By Vicki Meyer, BSN, RN, C4

Arkansas has the highest acute myocardial infarction (AMI) mortality rate in the nation, according to the Centers for Disease Control and Prevention – 80.2 deaths per 100,000 people, or 64 percent higher than the national average of 29.1 deaths. The Arkansas Behavioral Risk Factor Surveillance System (BRFSS) ranks Arkansas as having the second- to fifth-highest rate of risk factors in the nation that increase the probability of coronary artery disease and heart attack. These include:

  • Smoking
  • Diabetes
  • High cholesterol
  • Adult obesity
  • Physical inactivity
  • High blood pressure
  • Low fruit and vegetable consumption

Arkansas has a two-pronged approach to this problem, targeting medical professionals and the public. Medical professionals are encouraged to adopt evidence-based guidelines, best practices and educate their patients about preventive health care. Patient education is promoting healthy lifestyles, recognition of heart attack signs and usage of 911 during a medical emergency.

In September 2018, the Arkansas Department of Health (ADH) acquired the Chest Pain-MI Registry dashboard through the National Cardiology Data Registry (NCDR). The registry is a risk-adjusted, outcomes-based quality improvement program focusing exclusively on high-risk ST-Elevated Myocardial Infarction (STEMI)/Non-STEMI (NSTEMI) patients. The registry helps hospitals adhere to the American College of Cardiology’s clinical guideline recommendations and provides valuable tools to measure care, achieve quality improvement goals, improve patient outcomes and lower health care costs.

In Arkansas, the NCDR Chest Pain-MI Registry is called the Arkansas Heart Attack Registry (AHAR). AHAR is the ADH’s surveillance and quality improvement program for acute coronary syndrome. When STEMI and NSTEMI case data are routinely entered in this registry, the ADH team can provide surveillance, monitor care performance, and offer education and quality improvement technical assistance to hospitals to improve patient outcomes.

The ADH has recruited most of Arkansas’ primary coronary interventional (PCI) hospitals (receiving hospitals) and other PCI hospitals across Arkansas’ border, to join a collaborative effort focused on reducing the impact of heart attacks.

The goal of high-quality STEMI treatment is to achieve first medical contact with the patient to balloon within 90 minutes. It is vital that emergency medical services (EMS) and/or the non-primary coronary interventional hospital (transferring hospital), immediately recognize a STEMI on an electrocardiogram (ECG). EMS immediately notifies the nearest appropriate receiving hospital’s emergency department (ED) that a STEMI patient is en route and is to be transported immediately to the catheterization lab, bypassing the ED. AHAR will track each case’s adherence to the national guidelines for heart attack care.

Oversight for the AHAR is provided by the STEMI Advisory Council (STAC), a group of Arkansas-based interventional cardiologists, EMS professionals, nurses and public health officials. STAC analyzes registry data to identify areas for improvement and develop policies, procedures and pathways for the STEMI Systems of Care. STAC has approved the Arkansas STEMI Systems of Care Best Practice and Operations Manual, at healthy.arkansas.gov/programs-services/topics/stemi-advisory-council-stac.

The ADH’s “Dial Don’t Drive” campaign urges those with heart attack symptoms to call 911 immediately. About half of all heart attack patients drive themselves to the ED, not realizing the potential for cardiac arrest, causing an accident or not going to the appropriate hospital.

The public often views EMS as only a “quick ride” to the hospital. However, treatment begins in the ambulance, and EMS personnel know which facility is most appropriate to provide primary coronary intervention. Paramedics start treatment upon arrival at the patient’s location, assess vital signs, perform an ECG, start an IV and other life-saving treatments. Pre-hospital providers are essential to the chain of survival for heart attack patients.

The receiving hospital must be notified by EMS within five minutes of STEMI recognition. The receiving hospital can activate Code STEMI and call in the catheterization lab team: an interventional cardiologist, two nurses, and a cath-lab technician. Team members must arrive at the hospital within 30 minutes of activation time, so they’re ready before the patient arrives. The patient bypasses the ED, going directly to the catheterization lab to reduce time to treatment.

Public education efforts should emphasize that early recognition of heart attack symptoms equals early treatment and a better chance of survival. Heart attack warning signs can differ between men and women. Men usually experience classic warning signs; women can experience the classic symptoms, but often milder. Women may also experience indigestion, palpitations, dizziness, fatigue over several days, anxiety, sleep disturbances, nausea/vomiting or mild flu-like symptoms.

The American College of Cardiology Foundation designed a heart attack recognition program, the Early Heart Attack Care (EHAC). All Arkansas citizens are invited to go online, take the course and become a “deputy in heart attack” at dha.acc.org.
Becoming a “deputy” provides confidence in recognizing and treating people before heart damage occurs. EHAC is promoted on ADH’s Facebook (facebook.com/arhealthdept) and Twitter (twitter.com/ADHPIO) web pages.

For more information:

2013 ACCF/AHA Guideline for the Management of ST-elevation Myocardial Infarction: onlinejacc.org/content/accj/64/24/e139.full.pdf

2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: onlinejacc.org/content/accj/64/24/e139.full.pdf

2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: onlinejacc.org/content/accj/early/2017/09/14/j.jacc.2017.06.032.full.pdf

Ms. Meyer is employed with the University of Arkansas for Medical Sciences.

EDITOR’S NOTE: This article excerpted from The Journal of Arkansas Medical  Society,
February 2019.