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Act Rationally With Heart Attack Symptoms
The Advocate
By Herb Denenberg, The Bulletin
You’d think by now everyone would know that if you have chest pain (or other heart attack symptoms such as shortness of breath) otherwise unexplained, you should call 9-1-1 and get emergency, urgent medical attention. But they don’t seem to act on that information, and that’s why tens of thousands of people experience heart attack symptoms such as chest pain and shortness of breath and don’t get emergency medical attention that might save their heart from permanent damage or perhaps even save their life.
That’s bad enough, but it gets worse. Studies have documented that attempts at public education on heart attack symptoms and the need to get prompt medical attention have produced no good results. A study in the journal Circulation: Cardiovascular Quality and Outcomes (October 6, 2009) states, “To date, community education on the topic have had disappointing results.” Studies have been carried out over about the last 20 years.
With the failure of community education in mind, a group of researchers decided to see what one-on-one counseling would do to get people to react immediately to heart attack symptoms. So, in the first of a kind study, the researchers studied 3,522 patients with documented heart disease. They were divided into two groups.
One group received face-to-face counseling by nurses with cardiology expertise on heart attack symptoms and the importance of getting emergency medical attention when such symptoms occur. This instructional meeting was followed by a telephone call one month later from the same nurse to reinforce the lesson. In addition, each patient at the conclusion of the face-to-face session was given “an advisory form that included the appropriate steps to take with onset of ACS [acute coronary syndrome] symptoms [i.e., symptoms of a heart attack].” The other group received no such special instructions.
The two groups were studied over a two-year period. The special instructions were proven to be ineffective. During the follow-up period, those experiencing heart attacks symptoms were no more likely to seek immediate and urgent medical attention whether in the group getting the special instructions or in the other group. In both groups the delay between symptoms and calling 9-1-1 was over two hours.
The study concluded, “The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from ACS [acute coronary syndrome] symptoms to arrival at the hospital continues to be a significant public health challenge.”
This study is instructive as it shows how complicated it is to fix the health-delivery system. It is easy to make grandiose claims about how much money can be saved by patient education. It is also easy to claim savings from early intervention combined with prevention. It is easy to claim future savings by eliminating waste, fraud and abuse. But these sweeping claims are usually made by rank amateurs who don’t know what they’re doing, don’t know how to accomplish their objectives, and who are taking flights into fantasy based on ignorance. This is illustrated perfectly by the proponents of ObamaCare who build legislative structures in the sky without foundation in facts or experience. The study also demonstrates again that there is a huge chasm between giving people solid information and getting them to act on it. In many situations, the brain seems to slow down or shut down altogether. One such situation apparently involves those having heart attack symptoms.
The study suggests even a small, incremental improvement in the health-care delivery system takes immense study and understanding of what is proposed. And it suggests when amateurs undertake to rush through 2000-page-plus pieces of legislation to comprehensively restructure the entire health system, you can be sure such proposals will end in catastrophe. In fact, when amateurs propose such rush-rush reform, you can be sure they have to be lunatics or close to it. And that’s one of the best, quick, and concise arguments against ObamaCare.
This study came to the attention of newsletter of the Cleveland Clinic, Heart Advisor, (December 2009) who had some important observations on its significance: “This suggests that heart patients need frequent reminders about symptom recognition and response …” This suggests cardiologists have to keep drilling patients on how to recognize and react to heart attack symptoms. Cleveland Clinic cardiologist Curtis Rimmerman, MD, the Gus P. Karos Chair in Clinical Cardiovascular Medicine and author of Heart Attack: A Cleveland Clinic Guide, also noted that hesitation in the face of heart attack symptoms is the biggest mistake a patient can make. The Cleveland Clinic has been rated No. 1 for heart care 15 years in a row by U.S. News & World Report, and is also considered one of the top hospitals in the U.S.
One of the many complexities of recognizing a heart attack is that they may be different for different groups. For example, men tend to have a different constellation of symptoms than women, much older people may have different symptoms than younger senior citizens, diabetics may have different symptoms than others, and those with pre-existing heart conditions may also have different symptoms. For example, Dr. Rimmerman explained that those who already suffer from occasional cardiac discomfort (angina pectoris) should be on the look out for somewhat different symptoms: “Heart attack discomfort can be similar, but more intense and unremitting. Heart attack discomfort is typically a central chest pressure, tightness or heaviness, unremitting and lasting for a period of minutes and beyond.” He added that the discomfort might be located outside of the chest, in the throat, jaw, teeth, neck, arms, or in the middle of the back between the shoulder blades. In fact, Dr. Rimmerman told me he once had a heart attack patient who had pain in a tooth, and of course, thought it was just a toothache, not a heart attack. And there’s no good way for the patient to decide on the cause of the toothache. Finally, to add one other complexity, some people have heart attacks without any symptoms.
If that doesn’t make it complicated enough, Dr. Rimmerman adds, “Everyone is different. The bottom line is if this discomfort is a new symptom for you, if it does not go away, you experience a sense of doom and gloom, it is unlike typical heartburn and should it radiate to one of those other areas, consider your heart is the source until proven otherwise.” I’ve read dozens of these lists of heart attack symptoms, and Dr. Rimmerman is the first I’ve found who makes the point of important individual differences in heart attack symptoms.
I’d add that you should not worry about being embarrassed if it turns out what you thought was a heart attack turns out to be something else or nothing. Doctors prefer you be safe rather than sorry and sooner rather than later. And remember that with all their tests and technology, doctors often have trouble deciding if there has been a heart attack, so don’t expect perfection of yourself.
Dr. Rimmerman added: “If you experience heart attack symptoms, time is muscle. The longer you wait, the more heart muscle may be irreversibly damaged and scarred. The stakes are high. Don’t presume it is heartburn and try medicating yourself at home. That could be a fatal mistake. Instead, assume it is your heart and seek prompt medical attention.”
Don’t assume a little delay is harmless. One study found that every half-hour delay reduces average life expectancy by one year. And you can appreciate the need for fast action when you take into account what is called “the golden hour.” The National Heart Attack Alert Program advocates a goal of one hour from heart attack symptoms to opening the coronary artery by angioplasty or stent placement. So, the typical heart attack victim waits until after the golden hour to get medical help.
Despite all the attempts to educate the public, the median prehospital delay has remained at 2.3 to 6 hours over time. More than three quarters of this delay time is related to patients waiting too long to seek emergency medical attention. Less than one quarter of the delay is related to transport time.
If you think these attempts at educating patients are almost hopeless, I hate to stress one other detail. This study focused on those who already had heart disease, and the message of urgent action in the face of heart disease symptoms did not get through to them. So, educating the general public on this matter is certain to be much more difficult.
You should also be familiar with the first aid for a heart attack. One important part of that first aid is to take an aspirin. Dr.Rimmerman said you should chew a full-strength (325 milligram) aspirin, and that would be the case even if that day you had already taken a baby aspirin or, say, a 325-milligram aspirin. That will help stop the clotting mechanism that is the mechanism of causing heart attacks. Dr. Rimmerman told me the 325 milligram dose is recommended for first aid as that is the most common size, and hence, the most readily available. However, he told me that 162 milligrams (two baby aspirin) would actually prevent clotting just as effectively when taken daily. Bayer told me that if chewed, a regular aspirin, an enteric-coated aspirin, or a chewable aspirin would be absorbed at the same rate. However, the enteric-coated aspirin might be harder to chew for some people.
Dr. Rimmerman also recommends having a list of all your medications and prior ECGs and other heart procedures you may have had. In addition, have a written medical history, including a list of allergies, if any. Dr. Rimmerman says, “Don’t rely on the hospital medical record system. Do your homework and be prepared.” This is good advice for anyone seeking medical care. If you present your medical information in written form, you improve your chances of getting the correct information in the hospital chart and other records and of getting that information in front of your doctors and other providers.
I’d add one other important piece of advice to that given by the Cleveland Clinic. Remember that those under stress often don’t think clearly, as indicated by the heart attack statistics related above. So, tell a member of your family or a friend of your symptoms, as they may encourage you make the right decision despite the stress-related problem of irrational thinking.
Herb Denenberg has served as Pennsylvania Insurance Commissioner, Public Utility Commissioner, and the Loman Professor of Insurance at the Wharton School of the University of Pennsylvania. He has served as consultant to many government agencies, has testified before Congress many times on health care and insurance issues, and has been involved in the revision of the insurance laws in four states and the District of Columbia. In 1973, he was elected to the Institute of Medicine of the National Academy of the Sciences. You can reach Herb at advocate@thebulletin.us.
That’s bad enough, but it gets worse. Studies have documented that attempts at public education on heart attack symptoms and the need to get prompt medical attention have produced no good results. A study in the journal Circulation: Cardiovascular Quality and Outcomes (October 6, 2009) states, “To date, community education on the topic have had disappointing results.” Studies have been carried out over about the last 20 years.
With the failure of community education in mind, a group of researchers decided to see what one-on-one counseling would do to get people to react immediately to heart attack symptoms. So, in the first of a kind study, the researchers studied 3,522 patients with documented heart disease. They were divided into two groups.
One group received face-to-face counseling by nurses with cardiology expertise on heart attack symptoms and the importance of getting emergency medical attention when such symptoms occur. This instructional meeting was followed by a telephone call one month later from the same nurse to reinforce the lesson. In addition, each patient at the conclusion of the face-to-face session was given “an advisory form that included the appropriate steps to take with onset of ACS [acute coronary syndrome] symptoms [i.e., symptoms of a heart attack].” The other group received no such special instructions.
The two groups were studied over a two-year period. The special instructions were proven to be ineffective. During the follow-up period, those experiencing heart attacks symptoms were no more likely to seek immediate and urgent medical attention whether in the group getting the special instructions or in the other group. In both groups the delay between symptoms and calling 9-1-1 was over two hours.
The study concluded, “The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from ACS [acute coronary syndrome] symptoms to arrival at the hospital continues to be a significant public health challenge.”
This study is instructive as it shows how complicated it is to fix the health-delivery system. It is easy to make grandiose claims about how much money can be saved by patient education. It is also easy to claim savings from early intervention combined with prevention. It is easy to claim future savings by eliminating waste, fraud and abuse. But these sweeping claims are usually made by rank amateurs who don’t know what they’re doing, don’t know how to accomplish their objectives, and who are taking flights into fantasy based on ignorance. This is illustrated perfectly by the proponents of ObamaCare who build legislative structures in the sky without foundation in facts or experience. The study also demonstrates again that there is a huge chasm between giving people solid information and getting them to act on it. In many situations, the brain seems to slow down or shut down altogether. One such situation apparently involves those having heart attack symptoms.
The study suggests even a small, incremental improvement in the health-care delivery system takes immense study and understanding of what is proposed. And it suggests when amateurs undertake to rush through 2000-page-plus pieces of legislation to comprehensively restructure the entire health system, you can be sure such proposals will end in catastrophe. In fact, when amateurs propose such rush-rush reform, you can be sure they have to be lunatics or close to it. And that’s one of the best, quick, and concise arguments against ObamaCare.
This study came to the attention of newsletter of the Cleveland Clinic, Heart Advisor, (December 2009) who had some important observations on its significance: “This suggests that heart patients need frequent reminders about symptom recognition and response …” This suggests cardiologists have to keep drilling patients on how to recognize and react to heart attack symptoms. Cleveland Clinic cardiologist Curtis Rimmerman, MD, the Gus P. Karos Chair in Clinical Cardiovascular Medicine and author of Heart Attack: A Cleveland Clinic Guide, also noted that hesitation in the face of heart attack symptoms is the biggest mistake a patient can make. The Cleveland Clinic has been rated No. 1 for heart care 15 years in a row by U.S. News & World Report, and is also considered one of the top hospitals in the U.S.
One of the many complexities of recognizing a heart attack is that they may be different for different groups. For example, men tend to have a different constellation of symptoms than women, much older people may have different symptoms than younger senior citizens, diabetics may have different symptoms than others, and those with pre-existing heart conditions may also have different symptoms. For example, Dr. Rimmerman explained that those who already suffer from occasional cardiac discomfort (angina pectoris) should be on the look out for somewhat different symptoms: “Heart attack discomfort can be similar, but more intense and unremitting. Heart attack discomfort is typically a central chest pressure, tightness or heaviness, unremitting and lasting for a period of minutes and beyond.” He added that the discomfort might be located outside of the chest, in the throat, jaw, teeth, neck, arms, or in the middle of the back between the shoulder blades. In fact, Dr. Rimmerman told me he once had a heart attack patient who had pain in a tooth, and of course, thought it was just a toothache, not a heart attack. And there’s no good way for the patient to decide on the cause of the toothache. Finally, to add one other complexity, some people have heart attacks without any symptoms.
If that doesn’t make it complicated enough, Dr. Rimmerman adds, “Everyone is different. The bottom line is if this discomfort is a new symptom for you, if it does not go away, you experience a sense of doom and gloom, it is unlike typical heartburn and should it radiate to one of those other areas, consider your heart is the source until proven otherwise.” I’ve read dozens of these lists of heart attack symptoms, and Dr. Rimmerman is the first I’ve found who makes the point of important individual differences in heart attack symptoms.
I’d add that you should not worry about being embarrassed if it turns out what you thought was a heart attack turns out to be something else or nothing. Doctors prefer you be safe rather than sorry and sooner rather than later. And remember that with all their tests and technology, doctors often have trouble deciding if there has been a heart attack, so don’t expect perfection of yourself.
Dr. Rimmerman added: “If you experience heart attack symptoms, time is muscle. The longer you wait, the more heart muscle may be irreversibly damaged and scarred. The stakes are high. Don’t presume it is heartburn and try medicating yourself at home. That could be a fatal mistake. Instead, assume it is your heart and seek prompt medical attention.”
Don’t assume a little delay is harmless. One study found that every half-hour delay reduces average life expectancy by one year. And you can appreciate the need for fast action when you take into account what is called “the golden hour.” The National Heart Attack Alert Program advocates a goal of one hour from heart attack symptoms to opening the coronary artery by angioplasty or stent placement. So, the typical heart attack victim waits until after the golden hour to get medical help.
Despite all the attempts to educate the public, the median prehospital delay has remained at 2.3 to 6 hours over time. More than three quarters of this delay time is related to patients waiting too long to seek emergency medical attention. Less than one quarter of the delay is related to transport time.
If you think these attempts at educating patients are almost hopeless, I hate to stress one other detail. This study focused on those who already had heart disease, and the message of urgent action in the face of heart disease symptoms did not get through to them. So, educating the general public on this matter is certain to be much more difficult.
You should also be familiar with the first aid for a heart attack. One important part of that first aid is to take an aspirin. Dr.Rimmerman said you should chew a full-strength (325 milligram) aspirin, and that would be the case even if that day you had already taken a baby aspirin or, say, a 325-milligram aspirin. That will help stop the clotting mechanism that is the mechanism of causing heart attacks. Dr. Rimmerman told me the 325 milligram dose is recommended for first aid as that is the most common size, and hence, the most readily available. However, he told me that 162 milligrams (two baby aspirin) would actually prevent clotting just as effectively when taken daily. Bayer told me that if chewed, a regular aspirin, an enteric-coated aspirin, or a chewable aspirin would be absorbed at the same rate. However, the enteric-coated aspirin might be harder to chew for some people.
Dr. Rimmerman also recommends having a list of all your medications and prior ECGs and other heart procedures you may have had. In addition, have a written medical history, including a list of allergies, if any. Dr. Rimmerman says, “Don’t rely on the hospital medical record system. Do your homework and be prepared.” This is good advice for anyone seeking medical care. If you present your medical information in written form, you improve your chances of getting the correct information in the hospital chart and other records and of getting that information in front of your doctors and other providers.
I’d add one other important piece of advice to that given by the Cleveland Clinic. Remember that those under stress often don’t think clearly, as indicated by the heart attack statistics related above. So, tell a member of your family or a friend of your symptoms, as they may encourage you make the right decision despite the stress-related problem of irrational thinking.
Herb Denenberg has served as Pennsylvania Insurance Commissioner, Public Utility Commissioner, and the Loman Professor of Insurance at the Wharton School of the University of Pennsylvania. He has served as consultant to many government agencies, has testified before Congress many times on health care and insurance issues, and has been involved in the revision of the insurance laws in four states and the District of Columbia. In 1973, he was elected to the Institute of Medicine of the National Academy of the Sciences. You can reach Herb at advocate@thebulletin.us.
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