National Heart Attack Alert Program
PROGRAM
DESCRIPTION
What is the origin of the National Heart Attack Alert
Program?
The National Heart Attack Alert Program (NHAAP) was
launched in June 1991. Along with the National Heart, Lung, and Blood
Institute's (NHLBI's) other national education programs, the National High
Blood Pressure Education Program, National Cholesterol Education Program,
National Asthma Education and Prevention Program, and NHLBI Obesity Initiative,
the NHAAP is located within the Institute's Office of Prevention, Education,
and Control.
Why is the NHAAP needed?
Death and disability from acute myocardial infarction
(AMI) or heart attack, continue to be a major public health problem. It is
estimated that there are 1.1 million heart attacks each year and approximately
515,000 die from AMIabout 51 percent were males and 49 percent were
females. Half of these deaths occur suddenly, within 1 hour of symptom onset,
outside of the hospital setting.
The current paradigm for treating patients with AMI is
early opening of the infarct-related artery through either pharmacological
(e.g., thrombolytic or clot-dissolving therapy) or mechanical (e.g.,
percutaneous transluminal coronary angioplasty or PTCA) intervention.
Thrombolytic therapy is associated with an overall 25
to 30 percent reduction in AMI mortality. In particular, studies have
demonstrated marked benefits from thrombolytic agents that were given within 1
to 2 hours after heart attack symptoms began. Although drug therapy has been
shown to reduce mortality from heart attacks if administered in the first 12
hours after symptom onset, the greatest reductions occur in patients who are
treated early (within 1 hour).
Yet these lifesaving/enhancing treatments are often
not made available to patients because theyand those around them,
including health care providers/systems in the community and in the
hospitalfail to recognize the symptoms and signs of a heart attack, and
respond quickly and appropriately. Health care provider, patient, and public
education are needed in the area of early recognition of individuals with heart
attack symptoms, the most appropriate response, and effective treatments. It is
estimated that 26 to 44 percent of patients delay longer than 4 hours in
seeking care for cardiac symptoms. Also, the care offered to heart attack
patients in emergency medical services systems throughout the United States is
extremely heterogeneous. In many if not most emergency departments, the
additive effect of multiple small time delays causes the tardy administration
of thrombolytic and other therapies for AMI. In fact, only a fraction of heart
attack patients eligible for benefiting from the latest therapies are actually
receiving such therapies.
What is the purpose of the NHAAP?
The NHAAP has the overall goals of, first, reducing
morbidity and mortality from AMI through rapid identification and treatment
and, second, heightening the potential for an improved quality of life for
patients and those around them. The Program's goal also includes early
recognition and response to individuals with symptoms and signs of acute
coronary syndromes, including unstable angina as well as both Q-wave and non-Q
wave myocardial infarction. The NHAAP further seeks to address the Healthy
People 2010 Objectives that relate directly to the Program's issues. These
objectives are:
- Increase the proportion of adults aged 20 years and
older who are aware of the early warning symptoms and signs of a heart attack
and the importance of accessing rapid emergency care by calling 9-1-1.
- Increase the proportion of eligible patients with
heart attacks who receive artery-opening therapy within an hour of symptom
onset.
- Increase the proportion of adults aged 20 years and
older who call 9-1-1 and administer cardiopulmonary resuscitation (CPR) when
they witness an out-of-hospital cardiac arrest.
- Increase the proportion of persons with witnessed
out-of-hospital cardiac arrest who are eligible and receive their first
therapeutic electrical shock within 6 minutes after collapse recognition.
What is the NHAAP's strategy?
The NHAAP has identified three phases where delay can
occur in the identification and treatment of individuals with a potential heart
attack:
Phase I: Patient and bystander recognition of the
symptoms and signs of AMI and their actions in response to these symptoms.
Phase II: Prehospital action by emergency medical
services providersthat is, the response to patients prior to their
arrival at the hospital.
Phase III: Hospital action by health care providers at
the hospital to identify and treat patients with the symptoms and signs of AMI.
What is the NHAAP Coordinating Committee?
A major component of the NHAAP is its Coordinating
Committee, which is composed of representatives from about 40 organizations.
This group provides input and feedback to the NHAAP about priority educational
needs and activities, and it disseminates program educational objectives,
messages, and materials to their organizations.
Member Organizations of the NHAAP Coordinating
Committee American Academy of Insurance Medicine American Association
for Clinical Chemistry, Inc. American Association of Critical Care Nurses
American Association of Health Plans American Association of
Occupational Health Nurses American College of Cardiology American
College of Chest Physicians American College of Emergency Physicians
American College of Occupational and Environmental Medicine American
College of Physicians American College of Preventive Medicine
American Heart Association American Hospital Association American
Medical Association American Nurses Association American
Pharmaceutical Association American Public Health Association
American Red Cross Association of Black Cardiologists Emergency
Nurses Association International Association of Fire Chiefs
International Association of Fire Fighters National Association of
Emergency Medical Technicians National Association of EMS Physicians
National Association of State Emergency Medical Services Directors
National Black Nurses' Association National Medical Association
Society for Academic Emergency Medicine Society of Chest Pain Centers and
Providers Society of General Internal Medicine
Federal Agencies
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention Department of Defense, Health
Affairs Department of Veterans Affairs Food and Drug Administration
Health Care Financing Administration Health Resources and Services
Administration National Center for Health Statistics National Heart,
Lung, and Blood Institute NHLBI Ad Hoc Committee on Minority Populations
National Highway Traffic Safety Administration
The NHAAP Coordinating Committee has three ongoing
subcommittees that meet in conjunction with the NHAAP Coordinating Committee
meetings:
- The Science Base Subcommittee: The purpose of the
Science Base Subcommittee is to review, on a regular basis, the state of the
art related to prevention of mortality and morbidity from AMI and to monitor
research related to early identification and treatment of AMI in the
patient/bystander, prehospital, and hospital arenas. As part of its
responsibilities, the subcommittee makes recommendations to the full
Coordinating Committee for future activities, including possible working groups
or expert panels to address relevant scientific issues. The subcommittee plays
an important part in monitoring the ever-changing scientific base that affects
program activities.
- The Health Systems Subcommittee: The goal of the
Health Systems Subcommittee is to facilitate the development of a framework
that supports the delivery of optimal and cost-effective care from symptom
onset to initiation of therapy for patients with symptoms and signs of acute
coronary syndromes. Its predecessor was the Access to Care Subcommittee
established as the first subcommittee of the NHAAP Coordinating Committee. The
Health Systems Subcommittee encompasses the three phases of action involved in
the rapid identification and treatment of individuals with symptoms and signs
of an AMI as originally conceptualized by the NHAAP Access to Care
Subcommittee: Phase 1, Patient/Bystander; Phase 2, Prehospital; and Phase 3,
Hospital. In addition, the Health Systems Subcommittee recognizes the community
as the ultimate coronary care unit and seeks to implement a framework or model
for an ideal health system in which all entities involved in some aspect of
caring for the individual with possible acute coronary syndromes, work
collaboratively to ensure a continuum of care for these patients. The Health
Systems Subcommittee's scope is all community-based health care delivery
systems (e.g., public, private, managed care), regardless of economic
reimbursement and including the uninsured. The need for pre-identified
indicators and outcomes to measure quality and impact of care, and use of new
technology to facilitate a seamless continuum of care for these patients, are
paramount to the subcommittee's charge.
- Education Subcommittee: The Education Subcommittee
is an ongoing subcommittee of the NHAAP Coordinating Committee. Its main focus
is identification of priority areas for health care provider, patient, and
public education in the area of rapid identification and treatment of patients
with symptoms and signs of acute coronary syndromes, including sudden cardiac
arrest. The subcommittee is also concerned with dissemination of this
information, to its target groups. Its specific objectives are to: address
professional education needs related to rapid identification and treatment of
patients with symptoms and signs of acute coronary syndromes, including sudden
cardiac arrest; recommend and/or organize, professional education
interventions/strategies for implementation by the NHAAP Coordinating Committee
organizations; recommend effective vehicles for dissemination of information to
patients and the public; review proposed educational messages and target
populations, based on the NHAAP science base and the Program objectives; review
educational materials developed for professionals, patients, and the public by
other groups; and make recommendations for tailoring of the products and their
distribution to the appropriate audience.
In addition, in 1992 the NHAAP convened the
Interagency Data Coordination and Program Evaluation Advisory Group, composed
of representatives from the following Coordinating Committee organizations that
are involved in ongoing data collection and research activities: the Agency for
Healthcare Research and Quality, American Heart Association, Health Care
Financing Administration, Health Resources and Services Administration,
National Association of State EMS Directors, National Association of EMS
Physicians, National Center for Health Statistics, National Highway Traffic
Safety Administration, and NHLBI. The ongoing advisory group was formed to work
with the program to (1) identify available data being collected from national
and state data systems that are relevant to the NHAAP's goals and objectives,
(2) determine what additional data are needed to support NHAAP planning and
evaluation activities, and (3) advise the NHAAP on development and
implementation of a program evaluation/data collection plan.
Priority Areas for 2002-2006
The NHAAP Coordinating Committee held its 10-year
meeting in June 2001 and reviewed progress to date in program activities and
relevant data trends. In addition, each of the Program's subcommittees
identified priority areas for its next five years of work. The consolidated
list of current priority areas is shown below:
- Widespread Dissemination and Implementation of
"Act in Time to Heart Attack Signs" Campaign Materials by NHAAP Coordinating
Committee Member Organizations.
To ensure the widespread dissemination
and Implementation of Act in Time to Heart Attack Signs Campaign Materials by
NHAAP Coordinating Committee Member Organizations.
- NHAAP Informatics Projects
To monitor
the NHAAP/National Library of Medicine informatics projects on use of
information technology to expedite the rapid identification and treatment of
patients with acute coronary syndromes for application outside of the research
setting.
- Conceptual Framework for Behavioral
Change
To review the recommendations from the American Heart
Association's January 2002 workshop on interdisciplinary approaches to reducing
treatment-seeking delay for patients with acute cardiovascular disease, as a
basis for possibly recommending a research initiative to one of the NHLBI
research divisions or other institute within NIH, if workshop data warrant such
a recommendation.
- Emergency Medical Services (EMS) Systems
Utilization
To identify the inappropriate barriers to accessing EMS for
patients with symptoms of an acute coronary syndrome and recommend approaches
to reducing barriers to improving system utilization.
- Evidence-Based Technologies
To promote
use of evidence-based technologies that positively affect the outcomes of
patients with acute coronary syndromes which are currently under utilized by
health care systems
- Quality Improvement
To review /shape
national quality improvement efforts related to management of patients with
acute coronary syndromes
- Effect of Health Information Portability and
Accountability Act (HIPAA)
To explore the implications of HIPAA on
health care systems and associated management of patients with acute coronary
syndromes
- Technologies and Protocols for Management of
Patients with Acute Coronary Syndromes (ACS)
To identify technologies
and protocols that assist in risk stratification, diagnosis, and early
treatment of patients with acute coronary syndromes (especially those with
non-ST elevation MI).
- Strategies/Technologies for Patient-Based and
Provider-Supported Solutions to Early Recognition of ACS
To apply
current strategies and new technologies to empower patients with
patient-based/provider-supported solutions to recognize and respond to symptoms
of acute coronary syndromes
- Explore the Establishment of an Acute Coronary
Syndromes Patient Surveillance Database in Emergency Departments
To
explore and promote the establishment of an acute coronary syndromes patient
surveillance database in emergency departments for capturing (real-time) acute
cardiac-related symptom-specific data and outcomes, superimposed on an existing
or planned surveillance database/system for monitoring cases/patients exposed
to weapons of mass destruction (biological/chemical/nuclear).
- Sudden Cardiac Death Focus
To establish
an ongoing focus on sudden cardiac death on the NHAAP Coordinating Committee's
Science Base Subcommittee agenda by monitoring and supporting the
Post-Resuscitative and Initial Utility in Life-Saving Efforts (PULSE) effort;
translating and disseminating the Public Access Defibrillation (PAD) Trial
results, and develop priorities for future cardiac arrest research.
Featured publications
National Heart Attack Alert Program Position Paper:
Chest Pain Centers and Programs for the Evaluation of Acute Cardiac Ischemia: A
writing group of the NHAAP developed a position paper on chest pain centers and
programs for the evaluation of patients with acute cardiac ischemia. The paper
offers recommendations to assist emergency departments, including those with
chest pain centers, in providing the highest standard of care for patients with
acute cardiac ischemia. This paper was published in Ann Emerg Med 2000;
35:462-471
Updated Evidence Report Evaluating Technologies for
Identifying Acute Cardiac Ischemia in the Emergency Department: An update of
the literature reviewing technologies for identifying patients with acute
cardiac ischemia in the emergency department, was prepared for the NHAAP, by
one of the Agency for Healthcare Research and Quality's Evidence-based Practice
Centers. A summary
and
full
report are available.
Critical Pathways for Management of Patients with
Acute Coronary Syndromes: An assessment by the National Heart Attack Alert
Program. National Heart Attack Alert Program Coordinating Committee Critical
Pathways Writing Group. In recognition of the potential impact of critical
pathways to improving the care of patients with AMI and other acute coronary
syndromes, a working group of the NHAAP developed a paper to review what is
currently known about critical pathways for evaluation of patients with acute
coronary syndromes and the potential opportunities for improving the care of
these patients. The paper was published in the Am Heart J 2002; 143:777-789
NHAAP approach to educating the public
Early advisors to the NHAAP recommended that the
Program defer public education about recognition of heart attacks until the
provider community had been more fully educated about the new paradigm of
reperfusion therapy and the importance of timely treatment for patients
experiencing an AMI. To that end, the NHAAP worked with one of its research
divisions in 1992, to develop an initiative to study the area of public
education and its impact on delay time. June 1993, the NHLBI released a request
for applications for the Rapid Early Action for Coronary Treatment (REACT)
study. The purpose of REACT was to evaluate the effect of community
intervention and public education on patient delay time and other outcomes.
These outcomes include use of the EMS system, emergency departments, and
thrombolytic therapy. They also include myocardial infarction case fatalities
and related indices. Applications were received in December 1993, and awards
were made in July 1994. The study compared 10 intervention communities with 10
control communities. The REACT study began in August 1994 and was completed in
the spring of 1998. The results were reported at the American Heart
Association's Scientific Sessions in November 1998. In September 2001, the
NHAAP launched a targeted public education campaign called "Act In Time to Heart Attack Signs," which
incorporates lessons learned from the REACT research program.
How can I get more information?
For more information on the NHAAP, contact:
National Heart Attack Alert Program NHLBI Health
Information Network P.O. Box 30105 Bethesda, Maryland 20824-0105
(301) 592-8573 phone (301) 592-8563 fax http://www.nhlbi.nih.gov
|