"Good, Better, Best Never Let It Rest Until the Good is Better And the Better is Best"

Anonymous Old School House Poem

For Public Health reasons, the present day heart attack approach needs to be shifted from better to best. Heart attack need not kill 600,000 Americans each year if we could take another direction and begin to measure outcomes based on this new approach. Presently we report results in Heart Attack Care as a reduction in Acute MI mortality1 which is inaccurate and a very narrowed look at the overall heart attack problem. We even confuse the issue more when we report the results of thrombolytic trials in further reducing mortality but fail to point out that thrombolytic treated patients account for only 25-35% of all heart attack treated patients.

The best strategy for heart attack care is in preventing the heart attack from occurring. It is here where the mortality percent can approach zero and it is here where patients can become more motivated to change behavior and practice better lifestyles. How is this possible? In a recent article E. Lamfers MD, et al. reported on the "Effects of pre-hospital thrombolysis on aborting acute myocardial infarction"3 and concluded that "the assessment of the number of aborted myocardial infarctions may well be a better criteria then mortality for the efficacy of early thrombolysis". In the MITI Trial in which patients treated under 70 minutes had a miraculous 1.2% mortality, it was found that 40% of the patients had no rise in their necrosis markers.4 A full explanation for this has never been given but it has been assumed that reducing the time (of the occlusion) to treatment provides the patient a better chance to intercept a threatening acute ST elevation myocardial infarction and prevent damage from occurring.

There are two other ways in which patients with myocardial infarction can have their threatening MI's aborted. In our recent article entitled "Prodromal unstable angina in acute myocardial infarction: Prognostic value of short-term and long-term outcome and predictor of infarct size"5 , approximately 10% of the 206 patients in this GUSTO I Study had their threatening MI's aborted. Of these 10%, 4 out of 5 patients (80%) experienced prodromal unstable angina symptoms before developing their Acute MI. Perhaps the most important finding in this study was that the time to treatment was prolonged, not short (median 2.7 hours). Thus reduced time to treatment is not the only factor but that the prodromal presentation itself offers patients a chance to abort their threatening MI. A possible explanation for this observed prodromal phenomenon is that the stuttering chest symptom presentation may indicate that opening and closing of the coronary vessel is taking place explaining this preconditioning benefit seen in such prodromal MI patients.7-8 This would also help explain why patients with a prodromal presentation for 4 or more hours may have normal serum myoglobin levels indicating that damage has not yet taken place9. Such patients in effect may be similar to the MITI patients treated under 70 minutes. If so, this would necessitate care givers to be more aggressive in the treatment of patients presenting with prodromal (stuttering) presentations.

Finally another way to abort a threatening MI is to detect patients with prodromal unstable angina before they develop into patients with prodromal myocardial infarction. This was reported recently in the GUSTO II study in which 4,000 acute MI patients (with a 45% occurrence of prodromal symptoms) had a mortality of 6.2% whereas 8,000 unstable angina patients (with a 67% occurrence of such intermittent symptoms) had a mortality of 3.2%. Intervening early at the prodromal unstable angina stage has the potential to reduce the mortality by 50%. Infarctus Interruptus. Thus from a Public Health Cardiology Viewpoint we have come up with three ways to shift the paradigm of Heart Attack Care 10,11,12 to acute prevention.

ABORTED MI'S CAN OCCUR IN THE MECHANISM FOLLOWING SETTINGS

A. Early thrombolytic therapy ( <70 mins) reduced time to therapy b. prodromal mi stuttering pre-conditioning benefit c. prodromal unstable angina intervening before prodromal mi

however, the reduction to zero mortality in aborted patients presents a problem because presently we do not have a way to measure this effect when patients are saved from having a heart attack. to accomplish this it will be necessary to look at the total number of patients presenting with acute cardiac ischemia in any one hospital and measure performance that evaluates not only hospital mortality but also the threatening mi's aborted (saves)13. in effect, it may be that a hospital that has a poor 12% overall mi mortality may only have 20% of patients in this category and actually be saving 80% of patients from progressing to an acute myocardial infarction. william kannel, md, professor of medicine and public health at boston university once said "the day has to come when we consider heart attack in our patients as not the first indication for treatment but as a medical failure".

in summary, the "best public health practice" hospital in the future will need to offer to its community not only a comprehensive chest pain evaluation center that has the machinery to sort out patients with low probability of cardiac ischemia but also have an outreach community awareness program set up to practice "infarctus interruptus" by capturing patients in the community with prodromal heart attack symptoms14-19. from a public health cardiology viewpoint, it is better to intervene early and prevent the heart attack from occurring than to have the present day situation where patients enter with crashing acute myocardial infarction and their complications. thus, the best of public health heart attack care is yet to come........

*it has been reported in the literature over the last 75 years that 40-50% of patients with acute myocardial infarction have had prodromal chest symptoms before worsening symptoms brings them into the hospital.6

Bibliography

1. eugene braunwald, md, shattuck lecture - cardiovascular medicine at the turn of the millennium: triumphs, concerns and opportunities. n engl j med, 1997; 337: 1360-69.
2. braunwald, e, evidence-based coronary care (editorial) ann intern med 1997; 126:551- 553.
3. evert j.p. lamfers, md, ton e.h. hooghoudt, md et al. effect of prehospital thrombolyis on aborting acute myocardial infarction. the amer j of cardiology, vol 84, 928-30 october 15
4. weaver wd, cerqueira m, hallstrom ap, et al. (for the myocardial infarction triage and intervention project group): prehospital-initiated vs. hospital-initiated thrombolytic therapy. jama 270 (10): 1211-1216, 1993.
5. raymond d. bahr, md, e. victor leino, phd, and robert h. christenson, phd, prodromal angina in acute myocardial infarction patients: prognostic value of short- term and long-term outcome and predictor of infarct size. american heart journal, july 2000, volume 140, no. 1
6. eugene braunwald, md - acute myocardial infarction - the value of being prepared, n engl j med, january 1996, vol 334, no. 1: 51-52
7. mitchell w. krucoff, md, facc, fccp, durham va medical center, durham, north carolina, incidence, relevance and mechanism of cyclic changes in coronary flow before therapy for myocardial infarction: insights from continuous st-segment monitoring, clinician, vol. 17 no. 3, march 1999, p 16-17
8. agha w. haider, mbbs, felicita andreotti, md, phd, et al. early spontaneous intermittent myocardial reperfusion during acute myocardial infarction is associated with augmented thrombogenic activity and less myocardial damage. jacc, vol 26 no 3 september 1995:662-7
9. g.j. davies, s. chierchia, and a. maseri, prevention of myocardial infarction by very early treatment with intracoronary streptokinase. n engl j med, 1984; 311: 1488-1492
10. raymond d. bahr, md, introduction: the shifting pargadigm to earlier heart attack care, clinician, vol 13, no. 2, june 1995, p 4-6
11. raymond d. bahr, md, containing an infarct: preventing the heart attack in the first place, southern medical journal, january 1984, vol. 77, no. 1, 65-67
12. raymond d. bahr, md, the changing paradigm of acute heart attack prevention in the emergency department: a futuristic viewpoint? annals of emerg med, january 1995, 25:1, 95-6
13. raymond d. bahr, md, james tonascia, phd, editorial - measuring heart attack care performance: new indices and understanding, amer journal of emerg med, vol 14, number 1, january 1996, p 89-90
14. the strategy of chest pain units (in emergency departments), proceedings from the first maryland chest pain center research conference. a supplement to the maryland medical journal
15. raymond d. bahr, md, the concept and the development of chest pain emergency departments as a strategy in the war against heart attack. critical care nursing clinics of north america, vol 10, no. 1, march 1998
16. raymond d. bahr, md, chest pain centers:moving toward proactive acute coronary care, international journal of cardiology 72 (2000) 101-110
17. raymond d. bahr, md, access to early cardiac care: chest pain as a risk factor for heart attacks, and the emergence of early cardiac care centers, mmj, february 1992, 133-37.
18. raymond d. bahr, md, growth in chest pain emergency departments throughout the united states: a cardiologist's spin on solving the heart attack problem, coronary artery disease, october 1995, vol 6 no 10 p 827-30.
19. raymond d. bahr, md, acute outpatient care and comprehensive management of acute myocardial ischemia in chest pain emergency department, maryland medical journal, september 1995, vol 44 no 9, p 691-93.

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Clinton Seeks to Reduce Medical Errors and Promote Patient Safety
February 22, 2000 - Washington CNN THE PROBLEM

In an effort to reduce the number of medical mistakes that may be killing as many as 98,000 people annually, President Bill Clinton unveiled a series of initiatives Tuesday.

1. Set up a new center for quality improvement in patient safety. The 20 million dollar budget request for research into medical errors.
2. Mandatory reporting of hospitals through professional peer review, pharmacy and therapeutics committee etc..
3. Standards and guidelines to be incorporated into each hospital to prevent errors.
4. Create safe systems and safe environment in hospital.

THE SOLUTION

Heart Attack is the number one health problem in the nation with 600,000 deaths occurring each year.

Chest Pain Centers have been developed to improve heart attack care at the community hospital level in setting up a comprehensive triage system through the incorporation of guidelines and algorithms that are cost effective.

Observation Centers have been shown to reduce the number of missed MI patients being sent home as well as reducing the number of inappropriate costly admissions to the Coronary Care Units.

Chest Pain Centers and Observation Centers represent safety systems within hospitals to reduce errors in patients with heart attack.