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EHAC the Rosetta Stone

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Finding the Rosetta Stone of Heart Attacks

Dr. Ray Bahr is more than just the Founder of ACC Accreditation Services. His Early Heart Attack Care program is a benchmark of community outreach and education for heart disease.

This article was originally published in 2015, but the message still applies in 2018

Ever since the discovery that heart attacks take the lives of so many Americans each year (800,000) and elsewhere in the world, attempts have been made to find a solution to the heart attack problem. Well, I am happy to tell you that we are now positioning ourselves to do just that!

The science of heart attacks has enabled us to now know the pathophysiology of what takes place when an individual experiences a heart attack. When I began my training back in the 1960s, MIRU units were created in academic institutions (about 10 such) to study the problem. MIRU stood for Myocardial Infarction Research Units. To take advantage of their results and to take care of the heart attack patients, coronary care units (CCU) were set up in hospitals across the United States. These CCUs were set up throughout the hospital with no plan as to the best place to do this. Some were on the seventh floor, some on the fifth floor and, in the case of my own hospital, on the second floor. The care that was rendered was urgent - treating patients with cardiac arrest, congestive heart failure, arrhythmias, etc. - but patients treated in such units had to get into the CCUs before they received good care. No real effort was made outside to treat patients until they were admitted to these areas.

Outside of most CCUs was the emergency department, but this was not always a department where (it is now recognized)  as actually belonging to the specialty of emergency medicine. Back in the 1960s, it was known as the ER, or emergency room.  Previously, if the hospital had one, it was called the accident room. Most of these patients had been in an accident or were having surgical problems. Heart attack patients when they dared to enter such a unit had to have “real pain” or they would risk being scorned. The acronym GOMER was applied here “Get Out of My Emergency Room” unless you are suffering with severe pain. This was not the ideal place for patients with milder forms of chest pain or chest discomfort to present.

If you think about it enough, the best area to have placed the coronary care unit in the hospital would have been to do so in the emergency room and then to change the culture of the physicians treating such patients to accept all forms of chest pain presentation.  This would have been very difficult to do at this time. What did take place was the coming together of both emergency physicians and cardiologists to add a chest pain center in the ER to accommodate such patients. Even though, the scientific evidence was that 50% of heart attacks presented with early chest symptoms, the fear was that by informing and encouraging the public to come in early would have resulted in an over-saturation of such patients. Chest pain centers responded to this by adding an observation unit that through protocols was able to sort out patients with ischemia (15%) from those patients that could go safely home (85%).

As you can see, we took heart attack care from the coronary care unit of the hospital to the emergency department and now we would like to take it into the community. E. Braunwald MD has always stated that the ultimate coronary care unit was in the community. What he meant by this is that it is in the community where the heart attack begins, where it festers and where it will eventually rupture and develop a clot that will close the vessel and kill the patient. Where we need to be in heart attack care is as close to the community as we can get. How, now, are we doing this and making use of this Rosetta Stone information?

From day one, the concept of chest pain centers in the United States has been to develop a comprehensive system of heart attack care that would preferentially shift the paradigm of care to detecting patients with the earliest symptoms and preventing the heart attack from taking place. The strategy was to develop a standard of heart attack care that would take place in all 5000 hospitals in the United States so as to reach out and cover all areas. 

Chest pain centers now number over 700 in the United States and the trajectory looks like we should reach our target goal of 5000 hospitals over the next several years. What is so exciting at this point in time is identifying for the public the location of their nearest chest pain center where exists an observation  service that can efficiently and cost effectively let patients know if a heart attack is brewing or it is safe enough to go home.  In addition to this being a “teachable moment”, the patient will be more inclined to address their own risk factors.

Thus, heart attack care is now reaching the “heart” of the heart attack problem in that there is coming into existence a user-friendly strategy that is becoming more universal in scope. If so, we may well be on our way to finding the Rosetta Stone that will take heart disease out of first place where it has been for over 150 years.

Best of Luck in Saving A Life,
Raymond D.Bahr MD