Hot Tip: Have Your Heart Attack In Seattle

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Even under the best of circumstances, not all patients are equally treatable. Cardiac arrest—or the cessation of the heart's activity—may occur for a variety of reasons. In about 30 percent of cases, the cause is a heart attack. Roughly 25 percent of the time, the culprit is ventricular fibrillation, a type of arrhythmia in which uncoordinated electrical activity in the heart makes the heart muscle tremble rather than contract properly. Other causes include infection, trauma and drug overdose.

The best chances of survival come when cardiac arrest is caused by ventricular fibrillation and someone is there to witness the patient's collapse, so that treatment can be started right away. Thanks to the widespread availability of defibrillators in ambulances, airplanes, airports and even casinos, cardiac arrests in those venues have become more survivable. "Personnel are trained in the use of defibrillators, and they can get to you within five minutes," says Sanders. "In these settings, survival rates for ventricular fibrillation are as high as 45 percent." The machine measures electrical activity in the heart to verify that the problem is ventricular fibrillation. Then, when you push a button, the device delivers an electric shock to get the heart pumping again.

A new treatment protocol developed by Dr. Gordon Ewy, head of the University of Arizona's Sarver Heart Center, also appears to boost survival substantially for ventricular fibrillation, at least where witnesses are present to call for help. Instead of working to restore both heartbeat and breathing, EMTs focus primarily on the heart. "The vast majority of adults in cardiac arrest have a heart problem, not a lung problem," Sanders explains. "Simply getting the blood circulating again by providing uninterrupted chest compressions is the most important treatment." Ewy, Sanders and colleagues published a study in JAMA in March, showing the results when EMTs in two Arizona towns were trained in the new technique. "Before adopting our protocol, 4.7 percent of patients survived," Sanders says. "Afterwards, that increased to 17.6 percent." Another study in the Annals of Internal Medicine this month showed that the same approach more than doubled survival in two Wisconsin counties, from 20 to 47 percent. More importantly, it boosted "neurologically intact" survival from 15 to 39 percent.

It's not only EMS teams who can take advantage of this new approach to resuscitation. For bystanders who happen to witness someone going into cardiac arrest, the equivalent is "hands-only" CPR, where you continuously give the patient chest compressions to pump blood, without taking time to breathe into the patient's mouth. An online demonstration is available at www.heart.arizona.edu/publiced/lifesaver.htm.

Even with the best of techniques, not everyone can ultimately be saved. Nichol's study deliberately excluded 8,622 patients who were not treated because of their own written requests (known as "advance directives"), terminal illnesses or the request of the family. And other cases are hopeless from the start. A second study in JAMA this week laid out new rules for helping to identify the futile cases. These include situations in which all of the following are true: there was no witness to the event (so help was delayed), no bystander attempted to perform CPR, no defibrillator was used and the cardiac arrest occurred before EMS arrived (as opposed to happening in the ambulance). Applying these guidelines can save EMTs countless hours of working on patients who have no chance of making it home alive. By the same token, they can give emergency teams a better sense of when it's worth it to keep trying.

As Nichol says, not long ago, cardiac arrest meant certain death. Now, as he puts it, "cardiac arrest is a treatable condition"—provided you live in the right town.

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Posted By: aint2sure @ 10/18/2008 12:28:50 AM

I walked into the ER of the Baptist Hosptial in Prattville, Alabama a few years ago and told the gal behind the counter I was having an heart attack. She told me to fill out some forms, take a number, and they'd call me when it was my turn. Alabama's better....oh yeah...go on believing that!
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Posted By: daniRN @ 09/26/2008 5:49:48 PM

cedar-sweetie: Its great that you survived your ordeals, but the situation you describe is one of the considerations of living in a rural area. Emergency medical services are not always immediately on-hand in the rural setting; that should be as much a consideration as your property taxes, education and school resources, employment opportunities, and cost of living. Rural areas and small towns often do not have the resources to staff full-time EMS; often they are staffed by basic EMT professionals or first responders only who work on a part-time or even volunteer basis and have to cover a large area within their particular rural setting. As for your other comments: often it is too late. In the medical field, this is termed futility. If a patient has had an unwitnessed arrest, no pulse, no respirations, and no heart rhythm, it is absolutely futile in almost all cases to attempt resuscitation of any kind. Even with a witnessed arrest, the odds are small that the patient can be resuscitated to prior neurological functioning. I cannot speak for you, but I do not want to be resuscitated to live in a persistently vegetative or severely neurologically impaire state; nor would I allow that for my husband, my mother, my father, or even my own children.
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Posted By: cedar_sweetie @ 09/26/2008 12:09:25 AM

Sept. of 2004, I had open heart surgery, to repair a damaged heart. They did all kinds of things, including a new mechanical valve.Two weeks later, I had a heart attack.We live in a very small town, and at the local clinic we were told to wait for the ambulance, but after finding out it would take about half an hour to get there, my husband said I'm not waiting.He drove me to a town about 22 miles away, and on the way, we picked up the local police, and met the ambulance about 1/2 way there.We didn't stop, and had a caravan to the ER, and I think had we waited, it would have been too late.Once there, I got the proper care, and survived.Agreed that an EMT staff can be the turning point, but sometimes it just doesn't work out that way.Had we had our ambulance and EMT's there, it would have been better, and care could have been given sooner, but sometimes you just have to do it yourself.
On the other side, sometimes the first responder to a situation can be a virtual lifesaver.I did CPR and breathing for a gent that was down, and no one would do anything for him.He had no pulse, no breath,and had already voided his bladder.He was revived, and some years after, his wife still kept in touch.So I disagree with the premise of it's too late.It's never too late to try.We are both survivors, and thank God for the folks that helped!