National Heart Attack Alert Program

The new treatments and the synergistic effect of time on their effectiveness, coupled with ongoing patient and system delays, gave the impetus for the National Heart, Lung, and Blood Institute's (NHLBI's) consideration, in the late 1980s, of establishing a national education program dedicated to coordinating efforts to improve emergency care for patients with acute MI and their outcomes (9). The NHLBI launched the National Heart Attack Alert Program (NHAAP) in June 1991, with the first meeting of its Coordinating Committee comprised of approx 40 healthcare providers, voluntary, and federal liaison representatives involved in some aspect of care of the acute MI patient in the hospital or in the community. The NHAAP's overarching goal is to promote early identification and treatment of patients with acute MI and to reduce the incidence of (and improve survival from) sudden cardiac death in the community. The scope of program was expanded in 1997 to include all patients with acute coronary syndromes, i.e., unstable angina, as well as acute myocardial infarction. Paramount to the program's goal is the reduction of delays associated with each of three phases ultimately leading to rapid treatment of these patients. At the time the NHAAP was started, patient-associated delays were noted to be the most significant component of total delays ranging from 2.5-6 h in reported studies. Delays related to the emergency medical services (EMS) system response and transportation of the patient to the hospital were also noted, and also very disturbing was delays in the early identification and treatment of patients suitable for reperfusion therapy once the patient arrived in the emergency department. Hospital delays were found to be in the range of 60-90 min in several well-conducted clinical trials. It became evident that the magnitude of delay in the emergency department was not appreciated by most physicians until times from patient arrival to treatment were actually recorded (11).

It was also apparent that patient-mediated delay was an area that was not well understood, yet represented one of the most significant (and challenging) components of delay. Furthermore, early program advisors felt that the existing understanding of the design and implementation of efficient and cost-effective public education campaigns was not sufficient to warrant such a national effort at that time. They were also concerned that EMS and hospital emergency departments would be overrun by patients who responded to an improperly developed public education campaign (11).

On the advice of its early advisors, the NHAAP stimulated the Rapid Early Action for Coronary Treatment (REACT) research program at the NHLBI, to examine the impact of community-wide education regarding symptoms of a heart attack and the importance of accessing EMS. The NHAAP deferred immediate public and patient education efforts pending the results of REACT.

The NHAAP Coordinating Committee and the program's early advisors recommended that, while research was underway that would ultimately inform the NHAAP's public education "arm," it was imperative to first address delays associated with the emergency medical community who would be responding to patients who ultimately present in response to a public education campaign. Thus, during its first nearly 8 yr, the NHAAP focused largely on educating healthcare providers, notably in emergency departments and EMS systems, about the importance of rapid recognition and treatment of individuals with symptoms and signs of a heart attack. The NHAAP published issue papers and reports highlighting: (i) the rapid identification and treatment of acute MI patients in the emergency department setting (12); and (ii) EMS issues that potentially impact on rapid recognition and treatment of these patients (13-15). In addition, the program reviewed the diagnostic performance and clinical impact data for a number of technologies used in diagnosing patients with acute cardiac ischemia in the emergency department (16-19). Subsequently, it issued a position paper on chest pain centers and programs (20) and convened a symposium with the National Library of Medicine and the Agency for Health Care Policy and Research to explore the role of new information technology in expediting the recognition, diagnosis, and treatment of patients with acute MI (21). To address patient delay pending development of a public educational campaign, the NHAAP published a review paper on patient and bystander factors associated with treatment-seeking delay (22), as well as recommendations directed to providers for educational strategies to reduce prehospital delay in their patients at high risk for a heart attack (23,24). In 1998, the NHAAP released a report that described the community as the "ultimate coronary care unit", and encouraged all settings, where patients may present with a cardiac emergency, to plan for a timely and effective response (25).

This chapter reviews the three fundamental areas where timely identification and treatment of patients with an acute MI are critical to their outcomes as identified by NHAAP, and addresses the implications for policies and educational efforts by providers, institutions, and communities.

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