a special program of the National Emergency Medicine Association (NEMA)

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Week: 569.7 Guest: Dr. Raymond Bahr, Cardiology, St. Agnes Hospital, Baltimore, MD Topic: Chest Pain Emergency Room/EHAC Producer/Host: Steve Girard

NEMA: About half of the 500 thousand people who die of heart attacks each year have the power to prevent them. From small St. Agnes Hospital in Baltimore comes an aggressive program aimed at making it easier for someone experiencing chest discomfort to have it checked out...before heart attack strikes. It's the Chest Pain Emergency Room...developed by Dr. Raymond Bahr... whose newest attack on the problem is called EHAC, or Early Heart Attack Care....Dr. Bahr, what was the thinking behind the start of the CPER?

BAHR: We reasoned at the time that since the sudden death occurred shortly after the chest pain that if we had a place in a hospital that we could offer patients who are having chest pains... almost like a safe haven, like how on a sailboat you want to go someplace for a storm. Then we could get them in early and maybe prevent patients from having sudden death or crashing with a condition called ventricular fibrillation, which is an arrhythmia, a rhythm disturbance which occurs when a patient is having a heart attack or chest pain. And in most cases, when it occurs, the heart itself is in excellent condition except, electrically it just goes to pieces. And unfortunately, if you are outside the hospital and ten minutes go by...if you're in that condition, then the brain doesn't get blood supply. Then you knock off the higher centers of your brain, and if you don't die then you become more or less a, you know, a cripple, in terms of a vegetative state. So we reason that we want to do is offer patients in our community a safe haven when they were having chest pains, so we could prevent cardiac arrest from occurring. So we built the nations number 1...first chest pain center.

NEMA: And the chest pain center approach has spread around the world...it's become the impetus for a change in the form of prevention we attempt...

BAHR: We had to design other ways to deal with heart attack problem. One way is to look for ways of making a diagnosis of acute M.I., in the absence of the ST changes, which are usually the hallmark of a heart attack, and possibly to do a quick catheter. If the vessel's occluded, open that up. With that in mind, the question really that begs to be asked and answered is, "Why do we wait until the vessels occlude, weren't there some tell-tale signs before that "?... and yes there is, and that's what the entire program we presently are involved in is about. It's called EHAC, and it basically it stands for Early Heart Attack Care and it stands opposite the one end of the spectrum verses the other end which is CPR.

We say CPR is for the dead and EHAC is for the living. And that EHAC talks about heart attacks having beginnings, and this has been written up in the literature, and occurs in approximately 50% of the patients. When that occurs, it occurs over a course of time... hours to days to weeks. And if you intervene, you could actually prevent the crash... to an occluded vessel and the elephant sitting on the chest. We think that's where we should be, we should be getting out the message that the heart attacks have beginnings and the way to help reduce significant heart attack deaths in the United States is to engineer programs, at the community level, to attack that. And one way is to prepare hospitals to be more user friendly, in contrast to a GOMER mentality... which is 'get out of my emergency room' - unless she has severe pain... to one of 'thanks for coming in', and having a comprehensive triage plan that takes on all patients with chest pains, and sorts out patients into those with acute MI's, minor probability and low probability. And when that occurs then the hospital has the machinery for sorting out patients with low probability. And the chest pain centers that have evolved have been able to show that 80% of these patients can be sent home without necessarily being admitted to the hospital... and when that occurs, it gives the hospital the capability of sorting out low probability, and not admitting them and running up the cost of hospital beds.

NEMA: When that occurs, I know you believe it opens the door to the proper message to the community: that heart attacks need not kill if you are in touch with your body, and you know about early symptoms.

BAHR: And basically, these are: essential chest discomfort that's not perceived as pain n, because once its painful enough and you don't get in n... that's denial andprocrastination. But if you have essential chest discomfort, especially if it's intermittent, then its a tendency to put it on the back burner - we call it cerebral by-pass - and what happens is patients wait until it becomes severe, until the vessel occludes, and then there's an elephant sitting on the chest and then they panic to get into the hospital and be treated within one hour... and we know that's almost impossible. So, our program is an acute prevention program that alerts the community that heart attacks have beginnings, and that the place to be when you have these beginnings is in the hospital, where early care can stabilize the patient, find out where the blockage is, correct the blockage - and such patients can go home in less then 2 or 3 days with their life, their muscle, their vessel and the most importantly more motivated.

So essentially, over the years, chest pain centers have developed into comprehensive, systematic, ways of dealing with patients with chest pain. And the purpose is to sort these patients out, in a quick fashion, properly doing so without, in order to help patients who normally would be sent home that may have a heart attack or, perhaps admitting too many patients. In one study, 70% of patients admitted to CCU's turned out not to have heart attack and this was costing the nation 4 billion dollars. And, you know, it's incredible that 6-hundred thousand people die each year of a heart attack, that's more deaths in one year than all the soldiers killed in past wars. And it's important to realize the magnitude of the problem because heart attack really is the war home, and we should strategize just like we do with the war elsewhere. We should have a general, we should have a game plan, we should bring people together. And that's what the chest pain center concept and the movement is all about. It's a strategy to take heart disease out of first place before the end of the century. And so the chest pain centers have evolved to cut the strategy. And what takes place the next ten, fifteen years... I don't think any of us can predict or project, but we do know that we're well on the way to dealing more effectively and efficiently with the heart attack problem within the United States.

NEMA: Now over the years, the past several years since,since the St. Agnes CPER was, was established, it's kind of grown. Have you checked in and talked with other doctors at other facilities about it?

BAHR: We've had a number of chest pain symposiums, and the last time we counted there were over a thousand chest pain centers, represented in every state of the union. It's also across the world. We have many countries involved with chest pain centers and also the EHAC educational movement as well. We have a web site, www.EHAC.org and we're being hit 50,000 times a month. And it's a very popular site for educational as well as how to put together a chest pain center in a community hospital.

NEMA: Your remark about the cerebral by-pass was funny...but not too funny...

BAHR: I think a heart attack is more than a disease of the coronary vessel. I think it's a disease of human behavior. I think as adults, most adults are programmed from childhood up from their parents that when they've got some small discomfort, you bear it. You grin and bear it...and you put things away... you don't cry, you don't let people know you're in trouble, and you go on with your life and things like that. And not until you realize that, this disease kills and it kills by patients having symptoms and waiting until it becomes severe, will we ever, reduce the significant death and damages that takes place with it . We know that when we teach children and youth in the educational programs, they don't have the problems adults have, youth becomes care givers the very next day, that very day... "Dad, you've got to wear a seat belt"..." Mom, you can't smoke"... "Dad, you got chest pain? You go to the hospital". And they come at you 80 or 90 times within 10-seconds, and then finally you say, ..."enough's enough....I'm going to the hospital". So it's called the bug factor, that kids have a tendency to become very effective care givers within a short period of time. And adults have trouble - they're too busy with their lives to take time to check the symptoms out, hoping that it's not the big one. Once it's the big one, they're scared stiff ... this EHAC program is all about a way to avoid the big one, by getting checked out and going to a user friendly chest pain center.

NEMA: Dr. Raymond Bahr, in cardiology at St. Agnes Hospital in Baltimore...where the Chest Pain Emergency Room movement began... and now the EHAC program, Early Heart Attack Care...which emphasizes half of all heart attacks don't just happen...they have beginnings. Dr.Bahr says it's not an ethereal message: central chest discomfort that comes and goes...get it checked out. You could be saving your heart and life a lot of damage...and saving a lot of money in treatment, too.

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.

NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.NEMAhealth.org

...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.


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