Rapid Early Action For Coronary Treatment Research Articles

Patient Education to Reduce Prehospital Delay Time in Acute Coronary Syndrome

Reducing time from symptom onset to reperfusion therapy decreases infarct size and improves survival in patients with ST-elevation myocardial infarction (STEMI). National quality improvement initiatives, including the Door-to-Balloon (D2B) Quality Alliance, have successfully disseminated evidence-based strategies to reduce door-to-balloon time.1,2 Many hospital systems have achieved the targeted door-to-balloon time <90 minutes for 75% of patients with STEMI presenting directly to a hospital with percutaneous coronary intervention capability.3 However, prehospital delay from time of symptom onset to hospital arrival remains the largest portion of the total delay time and has been refractory to interventions aimed at improving patient responsiveness. Article see p 524 For patients with STEMI, longer prehospital delay is associated with higher in-hospital mortality even after adjusting for patient-, hospital-, and system-level variables including door-to-balloon or door-to-needle time.4,5 In the past 15 years, 2 randomized controlled trials have tested whether educational interventions to improve patient knowledge about acute coronary syndrome (ACS) symptoms and to promote patient action to call 9-1-1 would reduce prehospital delay time. Luepker and colleagues randomized 20 US cities to serve as controls or to receive 18 months of education targeting mass media, community and professional organizations, and patients and clinicians in the Rapid Early Action for Coronary Treatment (REACT) trial.6 The median prehospital delay time was 2.3 hours at baseline and decreased slightly (4.7% per year) during the 18 months in the intervention group; however, this trend was not significantly different to that observed in the control group ( P =0.54). The use of emergency medical services (EMS) increased modestly in the …

Severity of Myocardial Infarction

Cardiovascular disease constitutes a burden of epidemic proportion,1 and understanding its determinants is essential to designing effective interventions. Doing so requires the ability to track disease burden at the population level. In the United States, without national registries, community surveillance is the method of choice.2 Community surveillance studies are mostly retrospective by design, rely on diagnostic codes for case finding, and require a defined population in which events can be consistently and reliably captured and validated with standardized approaches. Applied to cardiovascular disease, community surveillance measures its burden in communities by tracking the incidence of events, their severity, and their mortality, thereby enabling the appraisal of the components of cardiovascular diseases in a given population.2 Because of the aforementioned methodological requirements, few surveillance studies exist in the United States. They include the Atherosclerosis Risk in Communities (ARIC) Study,3 the Minnesota Heart Survey,4 the Olmsted County Study,5 and the Worcester Heart Attack Study.6 The data from these studies indicate that, although deaths from coronary disease have declined, the incidence of myocardial infarction in the United States has remained mostly stable. Thus, the decline in mortality can be envisioned as reflecting an improvement in survival, which may be mediated by a declining severity of myocardial infarction. Article p 503 The article by Myerson et al7 in this issue of Circulation specifically addresses this important and understudied issue in ARIC between 1987 and 2002. They examined a large, multiracial population and relied on several indicators, including the composite Predicting Risk of Death in Cardiac Disease Tool (PREDICT) score to conclude that the severity of infarction declined over time. Indeed, the proportion of infarctions with major ECG abnormalities, ST-segment elevation, and Q waves decreased, as did biomarker values and the proportion of persons presenting with shock. …

Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

Creating an ideal system of care to address the care forpatients with ST-elevation myocardial infarction (STEMI) iscomplex from both the system’s and patient/family’s perspec-tives. In general, this care is unlike most other hospital care.It typically involves very fast and complex decision makingand, often, sudden transportation to another facility forpercutaneous coronary intervention (PCI). All of this occurswith a potentially critically ill patient and at a time when thefamily is often not immediately available. In this report, weaddress key perspectives from the patient and public point ofview of the current system of care for STEMI patients andhighlight the barriers and gaps that must be addressed by anideal system of care (Table 1).

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.

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Patients with chest pain calling 9-1-1 or self-transporting to reach definitive care: which mode is quicker?

ObjectiveWe examined differences in transport times for patients with chest pain who used private transportation compared with patients who used emergency medical services (EMS) to reach definitive medical care. MethodsThis was a retrospective cohort study with data used from the Rapid Early Action for Coronary Treatment (REACT) trial conducted in 20 US cities. Elapsed time to care was examined through the use of (1) decision to seek care to initial care (emergency department [ED] arrival versus EMS arrival on scene [n=1209]); (2) decision to ED arrival (for both groups [n=2388]); (3) time to thrombolytic therapy once admitted to the ED (for both groups [n=309]); and (4) decision to seek care to thrombolytic therapy (n=276). Elapsed travel times were ranked within Zip Codes and submitted to a nested analysis of variance model to determine if elapsed times were different between modes of transport. ResultsPrivate transportation (35 minutes) resulted in faster ED arrival than using EMS (39 minutes, P = .0014). However, if one considers EMS treatment to be initial care, calling 9-1-1 (6 minutes) resulted in much quicker care than patients using private transportation to the ED (32 minutes, P < .001). Transport by EMS resulted in a shorter elapsed time to thrombolytic administration compared with patients using private transportation when considering ED “door-to-needle” time (32 vs 49 minutes, respectively [P < .001]) or time from decision to seek care until administration of thrombolytic therapy (75 vs 92 minutes, respectively, [P = .042]). ConclusionsAlthough private transportation results in a faster trip to the ED, quicker care is obtained with the use of EMS.

Knowledge of heart attack symptoms in 20 US communities. Results from the rapid early action for coronary treatment community trial

Background. Effective treatment for patients with acute myocardial infarction is limited by patient delay in seeking care. Inadequate knowledge of heart attack symptoms may prolong delay. An intervention designed to reduce delay was tested in the Rapid Early Action for Coronary Treatment (REACT) Community Trial. In this report, the impact on knowledge of heart attack symptoms is presented. Methods. Twenty communities were randomized to intervention or comparison status in a matched-pair design. Intervention strategies included community organization, public education, professional education, and patient education. The main outcome measures were based on information regarding knowledge of symptoms collected in a series of four random-digit-dialed telephone surveys. Results. Knowledge of REACT-targeted symptoms increased in intervention communities. No change was observed in comparison communities. The net effect was an increase of 0.44 REACT-targeted symptoms per individual ( P < 0.001). The intervention effect was greater in ethnic minorities, persons with lower household incomes, and those with family or spouse history of heart attack ( P < 0.05). Conclusions. The REACT intervention was modestly successful in increasing the general public's knowledge of the complex constellation of heart attack symptoms. The intervention program was somewhat more effective in reaching disadvantaged subgroups, including ethnic minorities and persons with lower income. Despite these successes, the post-intervention level of knowledge was suboptimal.

U SE OF E MERGENCY M EDICAL S ERVICES FOR S USPECTED A CUTE C ARDIAC I SCHEMIA AMONG D EMOGRAPHIC AND C LINICAL P ATIENT S UBGROUPS : T HE REACT T RIAL

Objective. Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. Methods. A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged ≥30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9). Results. The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07–1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18–1.99, and adjusted OR 1.52, 95% CI 1.17–1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS use in those who were retired (adjusted OR 1.62, 95% CI 1.29–2.04) or had systolic blood pressure (SBP) at or below 160 mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26–1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88–2.97 for SBP <100 mm Hg). Conclusions. The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.

Part 7: The Era of Reperfusion

Part 7: The Era of Reperfusion

Impact of Community Intervention to Reduce Patient Delay Time on Use of Reperfusion Therapy for Acute Myocardial Infarction Rapid Early Action for Coronary Treatment (REACT) Trial

Reperfusion therapy for acute myocardial infarction (AMI) is a time-dependent intervention that can reduce infarct-related morbidity and mortality. Out-of-hospital patient delay from symptom onset until emergency department (ED) presentation may reduce the expected benefit of reperfusion therapy. To determine the impact of a community educational intervention to reduce patient delay time on the use of reperfusion therapy for AMI. This was a randomized, controlled community-based trial to enhance patient recognition of AMI symptoms and encourage early ED presentation with resultant increased reperfusion therapy rates for AMI. The study took place in 44 hospitals in 20 pair-matched communities in five U.S. geographic regions. Eligible study subjects were non-institutionalized patients without chest injury (aged > or =30 years) who were admitted to participating hospitals and who received a hospital discharge diagnosis of AMI (ICD 410); n = 4,885. For outcome assessment, patients were excluded if they were without survival data (n = 402), enrolled in thrombolytic trials (n = 61), receiving reperfusion therapy >12 hours after ED arrival (n = 628), or missing symptom onset or reperfusion times (n = 781). The applied intervention was an educational program targeting community organizations and the general public, high-risk patients, and health professionals in target communities. The primary outcome was a change in the proportion of AMI patients receiving early reperfusion therapy (i.e., within one hour of ED arrival or within six hours of symptom onset). Trends in reperfusion therapy rates were determined after adjustment for patient demographics, presenting blood pressure, cardiac history, and insurance status. Four-month baseline was compared with the 18-month intervention period. Of 3,013 selected AMI patients, 40% received reperfusion therapy. Eighteen percent received therapy within one hour of ED arrival (46% of treated patients), and 32% within six hours of symptom onset (80% of treated patients). No significant difference in the trends in reperfusion therapy rates was attributable to the intervention, although increases in early reperfusion therapy rates were noted during the first six months of the intervention. A significant association of early reperfusion therapy use with ambulance use was identified. Community-wide educational efforts to enhance patient response to AMI symptoms may not translate into sustained changes in reperfusion practices. However, an increased odds for early reperfusion therapy use during the initiation of the intervention and the association of early therapy with ambulance use suggest that reperfusion therapy rates can be enhanced.

Association between prepayment systems and emergency medical services use among patients with acute chest discomfort syndrome

Study Objective: Cost concerns may inhibit emergency medical services (EMS) use. Novel tax-based and subscription prepayment programs indemnify patients against the cost of EMS treatment and transport. We determine whether the presence of (or enrollment in) prepayment plans increase EMS use among patients with acute chest discomfort, particularly those residing in low-income areas, those lacking private insurance, or both. Methods: This study uses a subset of baseline data from the REACT trial, a multicenter, randomized controlled community trial designed, in part, to increase EMS use. The sample includes 860 consecutive noninstitutionalized patients (>30 years old) presenting with nontraumatic chest discomfort to hospital emergency departments in 4 Oregon/Washington communities. The association between prepayment systems and EMS use was analyzed using multivariable logistic regression. Results: Overall EMS use was 52% (n=445). Among EMS users, 338 (75%) were subsequently admitted to the hospital and 110 (25%) were released from the ED. Prepayment was not associated with increased EMS use in the overall patient sample. However, patients residing in low-income census block groups (median annual income <$30,000) were 2.6 times (95% confidence interval [CI] 1.4 to 4.8) more likely to use EMS when a prepayment system was available than when no system was present. No association was noted among higher-income block group residents. Among low-income block group residents lacking private insurance, prepayment systems were associated with 3.8 times (95% CI 1.2 to 13.4) greater EMS usage. Conclusion: Economic considerations may affect EMS system utilization among underinsured and low-income patients experiencing a cardiac event. Prepayment systems may increase EMS utilization among these groups. [Seipmann DB, Mann NC, Hedges JR, Daya MR, for the Rapid Early Action for Coronary Treatment (REACT) Study. Association between prepayment systems and emergency medical services use among patients with acute chest discomfort syndrome. Ann Emerg Med. June 2000;35:573-578.]

Components of variance in a group-randomized trial analysed via a random-coefficients model: the Rapid Early Action for Coronary Treatment (REACT) trial

Rapid Early Action for Coronary Treatment (REACT) was a multisite trial testing a community intervention to reduce the delay between onset of symptoms of acute myocardial infarction (MI) and patients' arrival at a hospital emergency department. The study employed a group-randomized trial design, with ten communities randomized from within matched pairs to each of two conditions. REACT also employed continuous data collection, based on surveillance of heart attack patients in community emergency departments. They analysed their data by comparing the mean slope for delay time in the ten intervention communities to the mean slope estimated in the ten control communities. Because no estimates of slope variation were available a priori, REACT was sized using approximations based on more traditional designs. In this paper, we present the slope and residual error variances as estimated from the REACT data and examine their influence on the power of the trial post hoc. We also examine the power of the trial as it would have been given a more traditional pretest-post-test design with analysis via a comparison of the net difference in condition means pretest vs post-test.

Components of variance in a group-randomized trial analysed via a random-coefficients model: the Rapid Early Action for Coronary Treatment (REACT) trial

Components of variance in a group-randomized trial analysed via a random-coefficients model: the Rapid Early Action for Coronary Treatment (REACT) trial

Factors That Influence Personal Perceptions of the Risk of an Acute Myocardial Infarction

Personal risk perceptions of acute myocardial infarction (AMI) affect people's preventive health behaviors as well as their beliefs during a heart attack episode. The authors investigated factors that are associated with personal risk perceptions of having an AMI. A random-digit-dial survey was conducted among 1294 respondents, aged 18 years or older, in 20 communities across the nation as part of the Rapid Early Action for Coronary Treatment (REACT) trial. Results of two mixed-model linear regression analyses suggested that worse perceived general health, more risk factors, and greater knowledge were associated with greater perception of AMI risk. The results also showed that women who answered, incorrectly, that heart disease is not the most common cause of death for women in the United States reported significantly lower risk perceptions than women who answered this question correctly. The findings in this study suggest that interventions need to target specific misconceptions regarding AMI risk.

Prehospital delay in patients hospitalized with heart attack symptoms in the United States: The REACT trial

Background The use of thrombolytic therapy for patients with myocardial infarction has been limited by patient delay in seeking care. We sought to characterize prehospital delay in patients hospitalized for evaluation of heart attack symptoms. Methods and Results The Rapid Early Action for Coronary Treatment (REACT) is a multicenter, randomized community trial designed to reduce patient delay. At baseline, data were abstracted from the medical records of 3783 patients hospitalized for evaluation of heart attack symptoms in 20 communities. The median prehospital delay was 2.0 hours; 25% of patients delayed longer than 5.2 hours. In a multivariable analysis, delay time was longer among non-Hispanic blacks than among non-Hispanic whites, longer at older ages, longer among Medicaid-only recipients and shorter among Medicare recipients than among privately insured patients, and shorter among patients who used an ambulance. Conclusions The observed pattern of differences is consistent with the contention that demographic, cultural, and/or socioeconomic barriers exist that impede rapid care seeking. (Am Heart J 1999;138:1046-57.)

Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction.

To inform intervention development in a multisite randomized community trial, the Rapid Early Action for Coronary Treatment (REACT) project formative research was undertaken for the purpose of investigating the knowledge, beliefs, perceptions, and usual practice of health care professionals. A total of 24 key informant interviews of cardiologists and emergency physicians and 15 focus groups (91 participants) were conducted in five major geographic regions: Northeast, Northwest, Southeast, Southwest, and Midwest. Transcript analyses revealed that clinicians are somewhat unaware of the empirical evidence related to the problem of patient delay, are concerned about the practice constraints they face, and would benefit from concrete suggestions about how to improve patient education and encourage fast action. Findings provide guidance for selection of educational strategies and messages for health providers as well as patients and the public.

Statistical Design of REACT (Rapid Early Action for Coronary Treatment), a Multisite Community Trial with Continual

Unusual problems in statistical design were faced by Rapid Early Action for Coronary Treatment (REACT), a multisite trial testing a community intervention to reduce the delay between onset of symptoms of acute myocardial infarction (MI) and patients’ arrival at a hospital emergency department. In 20 pair-matched U.S. communities, hospital staff members recorded delay time throughout a 4-month baseline period and the subsequent 18-month intervention period, during which one randomly selected community of each pair received a campaign of public and professional education. To exploit the continual nature of its data-collection protocol, REACT estimated the trend of delay time separately in each community by linear regression, adjusting for age, sex, and history of MI, and compared the ten adjusted slopes from intervention communities with those from control communities by a paired t-test. Power calculations based on the analytical model showed that with K = 600–800 cases per community, REACT would have 80% power to demonstrate a differential reduction of 30 min in mean delay time between intervention and control communities, as well as effects on a variety of secondary outcomes. Sensitivity analysis confirmed that the number of communities was optimal within constraints of funding and that the detectable effect depended weakly on the effectiveness of matching but strongly on K, helping the investigators set operational priorities. The methodologic strategy developed for REACT should prove useful in the design of similar trials in the future.