National Heart Attack Alert Program Research Articles

In-Hospital ST-Segment–Elevation Myocardial Infarction

The clinical benefit of reducing the time between the onset of ST-segment–elevation myocardial infarction (STEMI) and coronary reperfusion has fueled the motivation of cardiologists and their emergency care colleagues for the past 2 decades.1 Prompt treatment with fibrinolytic therapy or primary percutaneous coronary intervention (PCI) leads to improved outcomes and important reductions in mortality.2 The development and optimization of systems of care to improve treatment times for STEMI patients has become a major initiative of the national cardiovascular organizations and regional healthcare networks. The National Heart, Lung, and Blood Institute’s National Heart Attack Alert Program introduced in 1991 to address care in the emergency department,3 the American College of Cardiology’s Door-to-Balloon Alliance launched in 2006 to optimize time to primary PCI in PCI-capable hospitals,4 and the American Heart Association’s Mission: Lifeline introduced in 2007 to address the continuum of care for STEMI patients from symptom onset to timely reperfusion to secondary prevention by developing systems of care5 have promoted and supported processes and protocols to improve time to treatment and the quality of care for patients with STEMI. National, regional, and local efforts have focused on organizing emergency medical systems (EMS), emergency departments, and hospitals to facilitate rapid diagnosis, triage, transport, and treatment with fibrinolytic therapy (when access to primary PCI is prolonged) or preferably timely primary PCI. These efforts and careful study of mechanisms that streamline patient flow and logistics of emergency care have resulted in a progressive reduction in the door-to-balloon times for primary PCI.6 Successful systems have addressed the problem at every stage, including empowerment of EMS and emergency department physicians to diagnose STEMI and to activate emergency interventional cardiology services, EMS transport of patients directly from the field to the catheterization laboratory, establishment of benchmarks for cardiac catheterization team readiness …

Implementation of Acute Myocardial Infarction Guidelines in Community Hospitals

To obtain information regarding the current use of guidelines and protocols and quality assessment practices for the management of ST-segment elevation myocardial infarction in Minnesota hospitals without cardiac catheterization laboratories. Structured surveys were mailed in 2003 to emergency department medical directors or nurse managers in 111 hospitals in Minnesota that did not have cardiac catheterization laboratories. Of the 111 hospitals surveyed, 104 (94%) responded. Sixty-three percent of responding hospitals have guidelines or protocols; 57% use standing orders for ST-segment elevation myocardial infarction. Thirty-three percent have neither. Of those with guidelines, protocols, or standing orders, 8% address triage and transfer criteria, 86% thrombolytics, 91% aspirin, and 71% beta-blockers. Fifty percent have quality assessment processes in place for ST-segment elevation myocardial infarction. Recommendations from the National Heart Attack Alert Program issued more than ten years ago and, more recently, the updated American College of Cardiology/American Heart Association Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction suggest development of emergency department and hospital-specific guidelines and protocols for ST-segment elevation myocardial infarction. Currently, only two thirds of community hospitals in Minnesota have these in place; when present, these guidelines are often incomplete and rarely address transfer criteria to hospitals with percutaneous coronary intervention capability. Quality assessment occurred in 50% of hospitals surveyed. Programs to help community hospitals develop and implement guidelines and quality improvement should be encouraged and supported.

Act in Time to Heart Attack Signs

Outcomes of reperfusion treatment for acute myocardial infarction (MI) can be dramatically enhanced if patients present early after symptom onset. Yet delayed presentation by patients with acute coronary syndrome (ACS) symptoms (including MI and unstable angina) remains a tenacious challenge. The "Act in Time to Heart Attack Signs" is a public education campaign sponsored by the National Heart, Lung, and Blood Institute's (NHLBI's) National Heart Attack Alert Program (NHAAP) that addresses early recognition and response to ACS symptoms by patients, providers, and the general public. The campaign's materials and messages are based on those used in a multicenter research program, the Rapid Early Action for Coronary Treatment (REACT), funded by the National Heart, Lung, and Blood Institute from 1994-1998. Materials are available for providers, patients, and the public discussing heart attack risk, common heart attack symptoms, the importance of seeking early care, common misconceptions about how heart attacks present, and the importance of accessing care by calling 9-1-1. There is a critical need for all healthcare providers to relay this lifesaving information to the patients seen in their practice settings.

Women's Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung and Blood Institute workshop: October 2-4, 2002: Section 6: key messages about acute ischemic heart disease in women and recommendations for practice.

Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB

The Diagnosis

The Diagnosis

Critical pathways for management of patients with acute coronary syndromes: An assessment by the National Heart Attack Alert Program

Background The use of critical pathways for a variety of clinical conditions has grown rapidly in recent years, particularly pathways for patients with acute coronary syndromes (ACS). However, no systematic review exists regarding the value of critical pathways in this setting. Methods The National Heart Attack Alert Program established a Working Group to review the utility of critical pathways on quality of care and outcomes for patients with ACS. A literature search of MEDLINE, cardiology textbooks, and cited references in any article identified was conducted regarding the use of critical pathways for patients with ACS. Results Several areas for improving the care of patients with ACS through the application of critical pathways were identified: increasing the use of guideline-recommended medications, targeting use of cardiac procedures and other cardiac testing, and reducing the length of stay in hospitals and intensive care units. Initial studies have shown promising results in improving quality of care and reducing costs. No large studies designed to demonstrate an improvement in mortality or morbidity were identified in this literature review. Conclusions Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes. (Am Heart J 2002;143:777-89.)

Underutilization of Evidence-Based Medications in Acute ST Elevation Myocardial Infarction

The TIMI 9 Registry set out to assess the management strategies and outcomes of an unselected group of patients with acute myocardial infarction presenting with ST segment elevation (STEMI). Demographic, procedural, and outcome data were collected from 840 consecutive patients with STEMI at 20 hospitals in United States and Canada between February and September 1994. Of them, 60% were treated with thrombolytic therapy, 9% with primary angioplasty, and 31% did not receive reperfusion therapy. Patients who did not receive reperfusion therapy were older, more likely female, and had a higher prevalence of prior myocardial infarction, congestive heart failure, higher Killip class on admission, and longer time from onset of symptoms to presentation. In evaluating the standard contraindications for fibrinolysis, approximately 10% in the thrombolytic group, 40% in the primary percutaneous coronary intervention (PCI), and 34% of those not receiving reperfusion therapy had at least one of these characteristics. Of those patients treated with fibrinolysis, only 20% met the National Heart Attack Alert Program goal of door-to-drug time < or =30 minutes. Likewise, of those treated with primary PCI, only 30% had PCI performed within < or =90 minutes. In-hospital mortality was significantly higher for patients not treated with reperfusion therapy (18.9%), compared with patients treated with fibrinolysis (7.6%) and those treated with primary PCI (10.5%) (P < 0.001). Thus, we found that reperfusion therapy was underused, with only 69% of patients with STEMI receiving this proven treatment, and of those only 25% treated within the recommended timeline. These data suggest that there is room for improvement in the management of these patients.

Overview: Diagnosing acute cardiac ischemia in the emergency department. A report from the National Heart Attack Alert Program

[Ornato JP, Selker HP, Zalenski RJ. Overview: diagnosing acute cardiac ischemia in the emergency department. A report from the National Heart Attack Alert Program. Ann Emerg Med. May 2001;37:450-452.]

National Heart Attack Alert Program Position Paper: Chest Pain Centers and Programs for the Evaluation of Acute Cardiac Ischemia

The National Heart Attack Alert Program (NHAAP), which is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), promotes the early detection and optimal treatment of patients with acute myocardial infarction and other acute coronary ischemic syndromes. The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations pertaining to the management of patients with acute cardiac ischemia. This position paper offers recommendations to assist emergency physicians in EDs, including those with chest pain centers, in providing comprehensive care for patients with acute cardiac ischemia. [Zalenski RJ, Selker HP, Cannon CP, Farin HM, Gibler WB, Goldberg RJ, Lambrew CT, Ornato JP, Rydman RJ, Steele P. National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia. Ann Emerg Med . May 2000;35:462-471.]

Critical pathways : a review. Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association.

Critical pathways, also known as critical paths, clinical pathways, or care paths, are management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency.1 As competition in the healthcare industry has increased, managers have embraced critical pathways as a method to reduce variation in care, decrease resource utilization, and potentially improve healthcare quality. Cardiovascular medicine in particular is an area in which critical pathways have been embraced. This is due in part to the high volume and high cost associated with cardiovascular diseases and procedures. In addition, the relatively mature guideline process has also contributed to the growth in use of critical pathways in cardiology. Although anchored in clinical guidelines, the critical pathway is a distinct tool that details processes of care and highlights inefficiencies regardless of whether there is evidence to warrant changes in those processes. Clinical guidelines, on the other hand, are consensus statements that are systematically developed to assist practitioners in making patient management decisions related to specific clinical circumstances.2 Although clinical guidelines can and should be used in pathway development, the majority of processes included in a pathway have not been rigorously tested and are generally not addressed in guidelines. Another term that should also be distinguished from critical pathways is clinical protocols. Protocols are treatment recommendations that are often based on guidelines. Like the critical pathway, the goal of the clinical protocol may be to decrease treatment variation. However, protocols are most often focused on guideline compliance rather than the identification of rate-limiting steps in the patient care process. In further contrast to critical pathways, protocols may or may not include a continuous monitoring and data-evaluation component. Critical pathway techniques were first developed for use in industry as a tool to …

Case report: reversal of an evolving myocardial infarction with intravenous thrombolysis

This case, in many ways, represents the ideal: a timely and effective administration of thrombolytic agents. The rarity of this situation reinforces the need for earlier recognition and treatment of infarction. In an analysis of time delays in thrombolytic therapy, 38% were attributed to in-hospital issues, 22% to patients' delays, 21% to problems with transportation, and 19% to reperfusion time. The National Heart Attack Alert Program calls for treatment within 1 hour of the development of signs and symptoms, including administration of thrombolytic agents within 30 minutes of the patient's arrival in the emergency department. That program seeks heightened awareness among hospital and prehospital providers and public education about seeking immediate treatment for chest pain. The prompt acquisition of additional ECGs and the subsequent rapid administration of a thrombolytic agent were the clinical essentials. This fact suggests the need to look for measures of quality other than simple "door to drug" times. "Data to drug" times may be another indicator of quality to address cases in which the initial ECG findings are not diagnostic. Furthermore, emergency departments may see more patients with impending infarction if public education campaigns are successful. This case emphasizes the need to obtain follow-up ECGs in light of the potential benefits from thrombolysis.

Evidence based approach to practice guides and decision thresholds for cardiac markers

There is substantial evidence for use of CK-MB, myoglobin, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) for diagnosis of myocardial infarction (MI) and risk stratification of the acute coronary syndromes. Timing of specimen collection, patient population, and decision limits are important considerations. Serial CK-MB measurement must be considered a benchmark of cardiac markers. The National Heart Attack Alert Program (NHAAP) determined that high quality clinical trials show that serial CK-MB measurements are very accurate for diagnosis of MI and have large clinical impact. Meta-analysis of CK-MB mass for retrospective MI diagnosis yielded a clinical sensitivity of 96.8 % and a specificity of 89.6 % for sampling at 12–48 hours. Numerous studies of myoglobin have demonstrated a high negative predictive value and high sensitivity 2–6 hours after presentation. The NHAAP group, however, rated performance of myoglobin as modestly accurate with small clinical impact. cTnI has a clinical sensitivity and specificity for diagnosis of MI in the range of 90 % and 97 %, respectively. However decision limits for cTnI may differ by up to 10-fold for different assays, indicating need for standardization. Meta-analysis showed that cTnT had a sensitivity of 98.2 % (CI: 97–99 %) for diagnosis of MI with lower specificity due to detection of minor myocardial injury. Both cTnT and cTnI are more useful for stratifying risk in acute coronary syndrome patients than CK-MB mass. The predictive ability of both cTnT and cTnI is optimized by sampling >6–12 hours after symptoms onset. But in unstable angina, the odds ratios for predicting outcomes of MI/short-term mortality with 12–24 hour sampling for cTnT was 2.7 the odds ratio for cTnI did not differ significantly at 4.2.

Consultation before thrombolytic therapy in acute myocardial infarction

The maximum benefit of thrombolytic therapy is obtained when drug is administered early after symptoms onset.1–4 Of all the delays impacting on time-to-thrombolytic treatment, in-hospital delay is often the longest.5,6 Despite recommendation of the National Heart Attack Alert Program that thrombolytic therapy be administered to eligible patients within 30 minutes of arrival at the emergency department,5 median door-to-drug time nationwide exceeds 45 minutes.7 Time-consuming emergency department protocols and practices may explain these unacceptable delays. One common practice is to request a “consultation” from another physician before initiating lytic therapy. This practice, at times of great value, may potentially delay clearly indicated treatment. Little is known about how often such consultation occurs and how it impacts on patient outcome. The aim of this study was to determine whether patients enrolled in the second National Registry of Myocardial Infarction (NRMI 2) for whom consultation was obtained before initiation of lytic therapy differ in presenting characteristics from their counterparts whose consultation was not obtained, to ascertain differences in time to treatment due to consultation, and to determine if time delays associated with consultation affect ultimate in-hospital outcome.

Thrombolysis in accident and emergency: The exception not the rule. Are we denying patients lifesaving treatment?

A recent report by Hood et al. (1998) that thrombolytic therapy was routinely available in only 35% UK Accident and Emergency (A&E) departments, raises some important issues about the role of A&E staff in the management of patients with acute myocardial infarction. Acute myocardial infarction is a common reason for emergency admission to hospital, and is associated with a considerable mortality. While most fatal events occur in the community, presumably because of fatal arrhythrnia, those patients reaching hospital alive have improved outcome if there is prompt restoration of coronary blood flow, usually through the administration of a thrombolytic agent. Moreover, the early mortality benefit appears to be maintained at 10-year follow-up (Baigent et al. 1998). That thrombolytic therapy is a time dependent intervention, more effective when given within the first 6 hours from symptom onset, and even more effective when administered within the first hour or two (Boersma et al. 1996) is well established. National guidelines recommend that suitable patients should receive treatment within 30 minutes of hospital arrival (the 'door to needle' time) (de Bono & Hopkins 1994), with more recent opinion suggesting that this target could be reduced to 20 minutes in well organized centres (European Society of Cardiology 1996). The lifesaving potential of this treatment is such that patients requiring thrombolytic treatment should probably be afforded the same priority as patients in cardiac arrest. Would A&E nurses accept the transfer of patients in cardiac arrest to the cardiac care unit (CCU) before definitive treatment was commenced? Of course not. That the majority of A&E departments do not provide thrombolysis was met with frank disbelief by an American colleague with whom this author recently discussed the Hood et al. (1998) paper. Many factors delay the administration of thrombolytic therapy, not least the actions of patients, carets and pro-hospital health professionals. Birkhead (1992) reported that the major component of delay in a six-centre survey occurred before the patient reached hospital. The focus of this paper, however, is on those delays occurring once the patient enters the hospital system. These are best described using the '4Ds' model developed in the USA (National Heart Attack Alert Program Co-ordinating Committee 1994) and have been adapted for use in the UK by Quinn & Thompson (1995). The 4Ds represent door (triage), data (time to first ECG recording), decision (to initiate thrombolytic therapy) and drug (the overall 'door to needle' time).

The National Heart Attack Alert Program: Progress at 5 Years in Educating Providers, Patients, and the Public and Future Directions.

The National Heart Attack Alert Program (NHAAP) was launched by the National Heart, Lung, and Blood Institute in 1991 with the goal of reducing morbidity and mortality from acute myocardial infarction (AMI) through the rapid identification and treatment of individuals with symptoms and signs of an AMI. To achieve this goal, the NHAAP established objectives for each of three phases of action where treatment delays can occur: in the hospital, the prehospital setting, and the patient/bystander arena. The NHAAP initially directed its educational efforts toward emergency department professionals. Recommendations for reducing delays in emergency department identification of patients presenting with heart attack symptoms were developed by a working group convened in late 1991. These recommendations were published in February 1994 in a peer-reviewed journal reaching more than 17,000 emergency physicians. The NHAAP worked in a partnership with its coordinating committee, representing 40 health professional, voluntary, and government organizations, to extend the reach of the report's recommendations to their members. Strategies for promoting the emergency department recommendations included publication of excerpts in newsletters and journals of the medical, nursing, and prehospital provider organizations represented on the NHAAP Coordinating Committee, and through symposia at annual meetings. Industry assisted with dissemination efforts and with implementing a continuous quality improvement program based on the paper's recommendations. The NHAAP also developed, with the Joint Committee on Accreditation of Health Care Organizations, a time-to-treatment indicator for thrombolytic therapy to be incorporated into their Indicator Measurement System (IMSystem). To track achievement of the objectives related to the Hospital Action Phase, national data sources for emergency department management of patients with AMI were evaluated at the 5-year point of the NHAAP. Data from a national registry showed that the median time from presentation at the emergency department to receiving thrombolytic therapy declined by about one third between 1992 and the last half of 1995. The percentage of all Medicare patients receiving thrombolytic therapy within the recommended 30 minutes after emergency department arrival nearly doubled between 1992 and 1995. Based on these and other results presented at the 5-year juncture of the program, the NHAAP Coordinating Committee assessed progress and identified new areas of focus for the next 5 years. Improvements in emergency departments' ability to identify and treat AMI patients progressed during the first 5 years of the NHAAP, when the program was highlighting this as a priority. This model is continuing to be used to address delays in the Prehospital Action Phase. Further research from a National Heart, Lung, and Blood Institute (NHLBI) community intervention trial will guide the program in its plans for full-scale public education to address the Patient/Bystander Recognition and Action Phase.

Factors influencing the time to thrombolysis in acute myocardial infarction. Time to Thrombolysis Substudy of the National Registry of Myocardial Infarction-1

The Time to Thrombolysis Substudy of the National Registry for Myocardial Infarction provided the opportunity to identify factors that delay thrombolytic treatment of patients with ST-segment elevation acute myocardial infarction. Forty-two participating registry hospitals volunteered for the Time to Thrombolysis Substudy. A case report form was developed to collect time points for emergency department arrival (door), recording of the electrocardiogram (ECG) (data), entry of the order to give a thrombolytic drug (decision), and initiation of the thrombolytic infusion (drug) as defined by the National Heart Attack Alert Program. The impact of mode of transportation to the hospital, sex, policy-driven cardiology consultation and/or contact of the primary care physician on door-to-drug time, and each component interval were determined in 1755 patients who were treated with recombinant tissue-type plasminogen activator (A1-teplase). The t test was used for comparison of means and the nonparametric sign test was used for medians. A minority of patients arrived at the hospital by ambulance, although more women (49.6%) arrived by ambulance than men (40.9%). However, women arrived at hospitals significantly later after onset of symptoms than men. It took half as long for patients arriving by ambulance to be seen by the physician than those who transported themselves to the hospital. It took longer for women to have the initial 12-lead ECG recorded than men. The decision to order a thrombolytic agent was delayed by 22 minutes and median door-to-drug time by 21 minutes in those patients who had a cardiac consultation over those in whom the drug was ordered and infusion was initiated by the emergency physician. Although the initial 12-lead ECG showed ST-segment elevation in 86% of patients who received the thrombolytic drugs, with no difference between men and women and no difference in the rate of cardiology consultation between men and women (77%), door-to-decision time and door-to-drug time were substantially longer for women having consultation than men. There was no significant difference in door-to-decision time between men and women when no consultation was performed, but it still took longer for a drug infusion to be initiated in women. Contacting the primary care physician delayed the decision to give a thrombolytic drug by 18 minutes and the administration of the drug by 20 minutes, but there were no differences between men and women. Preparation of the drug in the pharmacy resulted in significant delay compared with mixing it in the emergency department. Hospital practices and policies, including contacting the primary care physician prior to the initiation of a lytic drug, cardiology consultation, and preparation of the drug in the pharmacy rather than in the emergency department, significantly delay the goal of early treatment of patients with ST segment elevation acute myocardial infarction. Delays in hospital arrival for women are compounded by delays in the decision to treat them with a thrombolytic drug and initiation of the drug therapy in those women who receive consultation compared with men. Other delays in acquiring the first ECG and initiating the drug infusion in women are not explained.

Factors Influencing the Time to Thrombolysis in Acute Myocardial Infarction

Background: The Time to Thrombolysis Substudy of the National Registry for Myocardial Infarction provided the opportunity to identify factors that delay thrombolytic treatment of patients with ST-segment elevation acute myocardial infarction. Participants: Forty-two participating registry hospitals volunteered for the Time to Thrombolysis Sub-study. Methods: A case report form was developed to collect time points for emergency department arrival (door), recording of the electrocardiogram (ECG) (data), entry of the order to give a thrombolytic drug (decision), and initiation of the thrombolytic infusion (drug) as defined by the National Heart Attack Alert Program. The impact of mode of transportation to the hospital, sex, policy-driven cardiology consultation and/or contact of the primary care physician on door-to-drug time, and each component interval were determined in 1755 patients who were treated with recombinant tissue-type plasminogen activator (Alteplase). The t test was used for comparison of means and the nonparametric sign test was used for medians. Results: A minority of patients arrived at the hospital by ambulance, although more women (49.6%) arrived by ambulance than men (40.9%). However, women arrived at hospitals significantly later after onset of symptoms than men. It took half as long for patients arriving by ambulance to be seen by the physician than those who transported themselves to the hospital. It took longer for women to have the initial 12-lead ECG recorded than men. The decision to order a thrombolytic agent was delayed by 22 minutes and median door-to-drug time by 21 minutes in those patients who had a cardiac consultation over those in whom the drug was ordered and infusion was initiated by the emergency physician. Although the initial 12-lead ECG showed ST-segment elevation in 86% of patients who received the thrombolytic drugs, with no difference between men and women and no difference in the rate of cardiology consultation between men and women (77%), door-to-decision time and door-to-drug time were substantially longer for women having consultation than men. There was no significant difference in door-to-decision time between men and women when no consultation was performed, but it still took longer for a drug infusion to be initiated in women. Contacting the primary care physician delayed the decision to give a thrombolytic drug by 18 minutes and the administration of the drug by 20 minutes, but there were no differences between men and women. Preparation of the drug in the pharmacy resulted in significant delay compared with mixing it in the emergency department. Conclusions: Hospital practices and policies, including contacting the primary care physician prior to the initiation of a lytic drug, cardiology consultation, and preparation of the drug in the pharmacy rather than in the emergency department, significantly delay the goal of early treatment of patients with ST segment elevation acute myocardial infarction. Delays in hospital arrival for women are compounded by delays in the decision to treat them with a thrombolytic drug and initiation of the drug therapy in those women who receive consultation compared with men. Other delays in acquiring the first ECG and initiating the drug infusion in women are not explained. Arch Intern Med. 1997;157:2577-2582

Management of acute myocardial infarction

PREVIEWThe average time that elapses from a patient's first awareness of heart attack symptoms to start-up of specific reperfusion therapy is currently 4 hours. The National Heart Attack Alert Program wants to see this time reduced to 2 hours. Such dispatch would surely benefit patients, because when it comes to thrombolytic therapy, the sooner the better. Dr Ryan summarizes the new recommendations for handling patients with acute myocardial infarction rapidly and efficiently, from the 911 call and transport to the emergency department, through the important first 24 hours of hospitalization, to hospital discharge and long-term management.

The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction.

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

An Evaluation of Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department: A Report from a National Heart Attack Alert Program Working Group

[Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, Gibler WB, Hagen MD, Johnson P, Lau J, McNutt RA, Ornato J, Schwartz JS, Scott JD, Tunick PA, Weaver WD: An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: A report from a National Heart Attack Alert Program Working Group. Ann Emerg Med January 1997;29:13-87.]