In this issue of the journal, Tullmann and Dracup1 report on a survey of awareness of heart attack symptoms by older adults at risk for acute myocardial infarction. The good news is that these older adults were knowledgeable about the classic symptoms, such as chest discomfort and shortness of breath. The bad news is that more than one third of the individuals were unaware of atypical symptoms, which are more common in the elderly, and of treatment options.
In myocardial infarction, time is a major factor in determining the treatment outcome, and the authors correctly point out that delay drastically reduces the efficacy of reperfusion therapies such as primary angioplasty and thrombolysis. What can we do to reduce this delay?
The American Heart Association (AHA) is a voluntary health organization whose mission is to reduce disability and death from cardiovascular diseases and stroke. Public education is an important component of the mission, and the association has made concerted efforts for decades to publicize the warning signs of heart attack and stroke.
In 2001, the AHA and the National Heart, Lung, and Blood Institute (NHLBI) launched a new "Act in Time" campaign to increase the public's awareness of heart attack and the importance of calling 911 immediately, within 5 minutes of the onset of heart attack symptoms. The Act in Time campaign is based on the results of REACT (Rapid Early Action for Coronary Treatment), the first large-scale study to evaluate the effects of education on the time it takes individuals to recognize the warning signs of a heart attack and seek appropriate help. REACT demonstrated that relatively few patients call emergency medical services when experiencing chest pain, and that this could be improved by education. REACT also found that few are aware of the benefits of early treatment, in part because they have had little communication with their physicians about heart attack symptoms and survival.
As a part of the launch of the Act in Time campaign, the AHA and the NHLBI worked together to develop a standard language to describe the symptoms of myocardial infarction, and this standard language appears in all written and online materials of both groups (http://www.nhlbi.nih.gov/actintime/haws/haws.htm and http://www.americanheart.org/presenter.jhtml?identifier=3053#Heart_Attack). The launch of this initiative was accompanied by an editorial in Circulation written by Claude Lenfant and David Faxon and entitled "Timing is Everything: Motivating Patients to Call 911 at the Onset of Acute Myocardial Infarction".2 In this same issue of Circulation there was a "Cardiology Patient Page" on the warning signs of heart attack.3
In addition to these efforts at increasing public awareness, it is clear that there is another great opportunity for this critical education that is being missed. Patients with atherosclerotic vascular disease are at increased risk for both myocardial infarction and stroke, but healthcare providers treating patients at risk often do not think to educate them about the warning signs of both diseases. The reasons are unclear, but it is plausible to suggest that we feel that such education will carry the negative message that we are not certain that our treatment regimen will be successful. But we must be realistic, and patients will value our honesty. In the Tullmann and Dracup study, it is remarkable that individuals who had suffered a myocardial infarction did not have greater knowledge of warning signs than those who had not had an event, despite their greater level of risk. This education of heart attack or stroke survivors (and their families) is critical.
Knowledge of the warning signs of heart attack consistently outpaces knowledge about the warning signs of stroke. The American Heart Association conducted unaided awareness telephone surveys in 2000 and 2003; 1800 respondents, comprising a nationally representative sample of the U.S population, were asked "What are the signs or symptoms of a person having a stroke?" and "What are the signs or symptoms of a person having a heart attack?" In both surveys, approximately 85% of the sample correctly recalled at least one heart attack warning sign whereas fewer than 60% correctly recalled at least one stroke warning sign. And fewer than 25% could correctly name all the warning signs of stroke. Unaided awareness was highest among whites, females, and married persons. Awareness increased with increasing levels of education and with increasing household income. The need for targeted education is still highest among lower-income, lower-education level African American and Hispanic audiences, but it is needed for all.
To help increase the awareness of warning signs and the need to call 911 fast, new AHA materials are being developed. A pamphlet titled "Warning Signs and Actions: Our guide to quick action for heart attack, cardiac arrest and stroke emergencies," available in English and Spanish, is free to the public and can be requested by going to http://www.americanheart.org/presenter.jhtml?identifier=3007690
Two new programs are being launched in late 2004 to early 2005. The "Cardiovascular Disease: Patient Education Tool Kit" and the "Stroke: Patient Education Tool Kit" are designed for healthcare providers to help them promote prevention of heart attack and stroke in their offices and hospitals. Included in each of these kits is a patient education video that covers causes, warning signs, and effects of heart attack and stroke, as well as emphasizes the importance of prevention, early detection, and emergency treatment. Items such as bookmarks, magnets, and posters with warning signs will also be offered. Information on obtaining these kits will be on the AHA Web site http://www.americanheart.org (keyword toolkits) or by calling the toll free number 1-800-AHA-USA1.
An AHA cardiac rehabilitation program-Active Partnership-is also being updated and will include patient information on the warning signs of both heart attack and stroke. This program will be undergoing field-testing and evaluation in 2005.
Another new program is "Stroke: When Minutes Matter," a kit to help senior center program directors conduct a stroke educational event. The kit includes reproducible sheets, a 10-minute video, and stroke warning signs bookmarks. The messaging focuses on increasing senior citizens' awareness of stroke warning signs and the need to dial 911 when experiencing those warning signs.
Within the association, warning signs for heart attack and stroke are printed on the 70+ patient brochures and 50+ downloadable fact sheets in our portfolio. We have also developed materials for specific markets. One example is "Search Your Heart" for African Americans, and its Spanish version "De Corazon a Corazon". This faith-based program helps to address the disparity between the incidence of cardiovascular disease and stroke among African Americans and Hispanics/Latinos. The warning signs of heart attack and stroke are included in the program. There is also a "warning signs" button on AHA's home page (http://www.americanheart.org).
The association's Emergency Cardiovascular Care Department has developed English and Spanish brochures and wallet cards with the warning signs. These are distributed by affiliate and local offices at health fairs and other community events. Approximately 1.4 million of these were distributed in the past 12 months. In addition, in the past year 9.1 million people (5.5 million healthcare providers and 4.6 million public) were trained in an AED, first-aid, CPR, or emergency life support course. Materials for each of these include information on warning signs.
And finally, the Ad Council has joined forces with the American Stroke Association, a Division of the AHA, to launch a 3-year public service announcement campaign. The campaign's goal is to increase immediate stroke recognition and response. In early 2004, they launched a comprehensive print campaign, including billboard, magazine, and newspaper public service announcements, which focuses on stroke warning signs and the message of "Time Lost Is Brain Lost." This campaign also includes television and radio spots. One of the recently launched radio advertising campaigns targets African Americans, who are at greater risk for stroke than the general population.
As the authors of this article point out, and the AHA strongly supports, healthcare providers should work with their patients to educate them about the warning signs of heart attack and stroke-and the importance of calling 911 immediately. Educational materials like those mentioned above are helpful adjuncts. Patients and their families should be reminded that heart attack and stroke are life-and-death emergencies where every second counts, while being reassured that new medications and treatments unavailable in years past will help reduce morbidity and mortality-but best if given relatively quickly after the event.
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