Bade (Bah-day) Fatunde is a Cardiology Fellow at Mayo Clinic in Scottsdale, AZ passionate about EP, Sports cardiology, and prevention of sudden cardiac death. He loves writing, Yorùbá language/culture, and all things jazz. Bade is excited to grow as an AHA FIT blogger. Twitter: @BFatundeMD
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Moving from ‘Luck of the Draw’ to making BLS and Defibrillator availability basic

Olubadewa Fatunde, MD MPH

The AHA ReSS council had a fascinating 2021 meeting, including trials making us reassess the optimal temperature for patients following cardiac arrest (TTM2) and those investigating the potential new application of existing meds repurposed to cardiac arrest (e.g. Tocilizumab [IL-6 inhibitor] to reduce cytokine storm post-arrest, LPC-DHA to improve mitochondrial function). What really put these clinical trials into perspective was the plenary session, featuring actual survivors of sudden cardiac arrest discuss their experiences with the frustrating lack of established resources as they journey to find the new normal for their lives.

Perhaps the most memorable part of AHA 2021 was the harrowing account of Dr. Kevin Volpp, a cardiology and behavioral economics researcher at the University of Pennsylvania, reflect on his own sudden cardiac death experience. The morning of July 9, 2021 started as just a regular day. Volpp traveled to Cincinnati, Ohio to watch his daughter, Anna, play in a squash tournament. While dining with Anna, her Coach (Gina Stoker), and her Coach’s boyfriend (John White) the night before, Volpp suddenly became unresponsive, slumping his chair into the arms of White. Coach Stoker called 911. White, who is himself a squash coach at Drexel University, laid Volpp flat, could not find a pulse, and initiated bystander CPR. EMS arrived four minutes later. Ultimately, he received 14 minutes of CPR with three shocks from the automated external defibrillations before his circulation was restored. He was rushed to University of Cincinnati Hospital, where he was found to have a 99% blockage in his LAD artery, which was opened and stented (1).

Volpp, who had a strong family history of premature heart attacks, had been undergoing primary prevention measures including CAC screening, medications, and well exceeding the AHA’s minimum recommendation for weekly exercise, as he was training with Anna for an Ironman 70.3 triathlon (1). Sudden cardiac death does not always occur in those with a strong family history with plaque in their arteries. During his 3rd year of internal medicine residency, Dr. Anezi Uzendu suffered cardiac arrest while he was playing basketball, with no prior family history. Fortunately, through high quality CPR and persistent resuscitation (receiving a total of 13 defibrillation attempts before he was revived!)(2), he eventually recovered and completed both general and interventional cardiology fellowships.

Ultimately, the prompt recognition and initiation of the cardiac chain of survival that allowed Drs. Volpp and Uzendu to have good outcomes. Coach White credited Drexel University’s requirement that Coaches keep their training in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) active (1). BLS is the use of high-quality chest compressions (2 inches deep at 100-120 beats per minute) to maintain adequate circulation to the brain, before additional help can arrive to provide higher level of care (ACLS). Out of hospital cardiac arrest and recovery is far from normal across the country, occurring in less than 8% of individuals (3). Acknowledging the critical nature of illnesses causing cardiac arrest, why do so few survive? Low rates of education and implementation of bystander CPR and AEDs, two of the most important interventions linked to improving survival  by as much as 3-fold (3). These interventions are not independent, as defibrillator effectiveness increases, with increasing quality of CPR (optimal depth & speed) administered (4). In 2014, Dr. Monique Anderson and colleagues at Duke University found that, only 1.29-4.07% of the US population is certified in BLS—a shockingly low statistic for the number one cause of death in America (heart disease) (3, 5). Unfortunately, disparities are more likely in racial minority, older, rural, and Southern communities (5). Dr. Maryam Naim and colleagues found similar disparities in a pediatric population (6). Not surprisingly, average rates of bystander in America CPR are only 38.2% (7), with significant geographic variation (10-65%) (8) and lower rates of proper technique (compression depth of 2 inches and pace of 100-120 beats per minute (9). These findings are compounded by the fact that almost 90% of cardiac arrests occur in or near the home (10).

What’s the best method of increasing this? Anywhere from 71.5% to 85.3% of American high school seniors have their driver’s license (11). Many obtain this through taking driver’s education class in school. One long term solution would be providing BLS courses to all high schoolers, with the option to advance to ACLS certification for those interested. While logistics can be debated, this would increase the proportion of individuals ready to perform by stander CPR from the 70% of Americans who don’t feel prepared (10) to adequately administer CPR. For adults, there are many available BLS courses available. The AHA Knowledge Booster App is a fun and interactive resource for those who want to learn more, but don’t know where to start. There are several Spotify playlists of songs with a tempo of 100-120bpm (12-14), but “Staying Alive,” by the Bee gees seems to be the most enduring. Dr. Uzendu founded an organization—Make BLS Basic—that focuses on increasing bystander CPR rates in minority communities (15).

Increasing bystander CPR rates is only half of the prehospital equation. When bystanders perform CPR and use a defibrillator, the survival to hospital discharge approaches 50-60%, with improved survival and neurological outcome with earlier defibrillation of shockable rhythms (3). The meager rates of Automated External Defibrillator (AED) availability in public spaces are similarly shocking. In a Cleveland Clinic survey, only 27% of Americans reported an AED in their workplace. After his experience, Volpp posed the question, should national chains be required to install AEDs, given that most adults spend 15-20 (pre-pandemic) minutes a day in a restaurants or bar (1). To be sure, AEDs require maintenance (replacement of defibrillator pads & batteries) and untrained lay providers may struggle to use them effectively (3). Several cost-effectiveness analyses have found a benefit of widespread dissemination of public AEDs (16-18), though not all are as optimistic (19, 20).   AED Laws vary by state (21); there has also been federal legislation (22). The Sudden Cardiac Arrest Foundation states a goal of having an AED accessible within 90 seconds of any public area that people congregate (e.g. schools, state & federal buildings, casinos, etc.). We are far from this important goal.

I think the ultimate questions are: Should one’s survival following cardiac arrest depend on being with the right person at the right time or where you live, shop, eat, or pursue leisure? Will we accept the status quo? How can we improve rates of bystander CPR and AED availability to give everyone an equitable chance at surviving these life-threatening events, and a new lease on life? How can we better support SCA survivors during their recovery? Looking forward to answering these questions at future meetings.

 

References:

  1. Avril T. “A Penn professor’s heart stopped at restaurant that had no defibrillator. Few are equipped with the lifesaving devices.” Philadelphia Inquirer. 2021. https://www.inquirer.com/health/aed-defibrillator-restaurant-cardiac-arrest-20211213.html
  2. Uzendu A. From “delivered to the cath lab alive” to Interventional Cardiologist on call in 5 years. God is good. #CPRSavesLives. In: @DrUzendu, editor. 2021. https://twitter.com/DrUzendu/status/1465120531317989382
  3. Brady WJ, Mattu A, Slovis CM. Lay Responder Care for an Adult with Out-of-Hospital Cardiac Arrest. N Engl J Med. 2019;381(23):2242-51.
  4. Edelson DP, Abella BS, Kramer-Johansen J, Wik L, Myklebust H, Barry AM, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71(2):137-45.
  5. Anderson ML, Cox M, Al-Khatib SM, Nichol G, Thomas KL, Chan PS, et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med. 2014;174(2):194-201.
  6. Naim MY, Griffis HM, Burke RV, McNally BF, Song L, Berg RA, et al. Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES. J Am Heart Assoc. 2019;8(14):e012637.
  7. Promotion OoDPaH. Increase the rate of bystander CPR for non-traumatic cardiac arrests — PREP‑01. In: Promotion OoDPaH, editor.: Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/emergency-preparedness/increase-rate-bystander-cpr-non-traumatic-cardiac-arrests-prep-01/data
  8. Brown LE, Halperin H. CPR Training in the United States: The Need for a New Gold Standard (and the Gold to Create It). Circ Res. 2018;123(8):950-2.
  9. New Cleveland Clinic Survey: Only Half Of Americans Say They Know CPR [press release]. Newsroom: Cleveland Clinic, February 1, 2018 2018. https://newsroom.clevelandclinic.org/2018/02/01/new-cleveland-clinic-survey-only-half-of-americans-say-they-know-cpr/
  10. CPRBlog [Internet]. www.heart.org: American Heart Association. [cited 2021]. https://cprblog.heart.org/cpr-statistics/
  11. Ranzetta T. Question of the Day: What percent of high school seniors have a driver’s license? : Next Gen Personal Finance; 2019 [Budgeting]. Available from: https://www.ngpf.org/blog/budgeting/question-of-the-day-what-percent-of-high-school-seniors-have-a-drivers-license/.
  12. American Heart Association. Hands-Only CPR’s ‘Keep The Beat’ 100BPM Playlist: Spotify; 2015. https://open.spotify.com/playlist/18uMyHJHboUUCCwbtwdj3k
  13. nyphospital. Songs to do CPR to: Spotify. https://open.spotify.com/playlist/7oJx24EcRU7fIVoTdqKscK
  14. seigfriedb. CPR playlist (110 bpm). https://open.spotify.com/playlist/67BxVmgXqjr2lQqXKsyLxw: Spotify.
  15. Uzendu A. Make BLS Basic http://www.makeblsbasic.org2019 [Available from: http://www.makeblsbasic.org.
  16. Andersen LW, Holmberg MJ, Granfeldt A, James LP, Caulley L. Cost-effectiveness of public automated external defibrillators. Resuscitation. 2019;138:250-8.
  17. Nichol G, Huszti E, Birnbaum A, Mahoney B, Weisfeldt M, Travers A, et al. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54(2):226-35.e1-2.
  18. Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. 2010;55(16):1713-20.
  19. Atkins DL. Realistic expectations for public access defibrillation programs. Curr Opin Crit Care. 2010;16(3):191-5.
  20. Pell JP, Walker A, Cobbe SM. Cost-effectiveness of automated external defibrillators in public places: con. Curr Opin Cardiol. 2007;22(1):5-10.
  21. Roszak AR. CPR / AED Laws: Sudden Cardiac Arrest Foundation; [Available from: https://www.sca-aware.org/about-sudden-cardiac-arrest/cpr-aed-laws.
  22. State Laws on Cardiac Arrest and Defibrillators National Conference of State Legislatures [cited 22 Dencee. Available from: https://www.ncsl.org/research/health/laws-on-cardiac-arrest-and-defibrillators-aeds.aspx.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Channeling Health Care Delivery and Implementation Science in Cardiology for Improved Outcomes

Olubadewa Fatunde, MD MPH

The opening session for AHA21 was nothing sort of inspirational. In the opening session, a quote by Dr. Keith Ferdinand, Professor of Medicine and Chair of Preventative Cardiology at Tulane University, really stuck with me. The topic was how is the field of medicine adjusting in the midst of the challenges faced and inequities uncovered by the COVID pandemic? The simple answer: while positive strides have been made, there is much room for improvement. He then went on to expound about the importance of implementation science, as the best science in the world will do you no good if patients are unable to implement physical activity/dietary guidelines, understand when to take the appropriate medications, or receive preventive vaccines in time.

From the American experience with COVID, part of the difficulty in reaching the average American seems to be the emotional gap between patients and either healthcare institutions or providers. The weight evidence from the trials on COVID vaccines are clear on the efficacy and safety, particularly of the mRNA vaccines. However, delivering the messaging in a way the public will accept remains frustrating in many parts of the country. As a result, only 59% of the US population is fully vaccinated, while 68% have received at least one dose, ranking 51st in the world (1). The way we consume information is drastically different from earlier decades. In 2020, a Pew Research poll revealed more than eight-in-ten U.S. adults (86%) received news from a digital device compared to TV (68%), with those under 50 heavily skewed towards digital news consumption.(2) In this same poll, approximately 50% of adults consumed news from social media.(2, 3)  In contrast, in 2015, 75% of American adults had a PCP, dropping to 64% among 30-year-olds.(4)  During the last true global pandemic, that PCP was more likely to make a house call rather than see a patient 1 to 4 times a year.

The common thread for successful interventions seems to be meeting people where they are. Several panelists on the FIT session on navigating misinformation on social media, noted that as many receive news on socia media, they were motivated to explain new studies and correct misinformation on those platforms where people are likely to spend time and digest information. Admittedly, this effect is hard to measure, and many studies thus far are qualitative in nature. More concretely, two exciting trials presented at #AHA21 seem to shed some light on how we can mobilize these neural structures to improve the rates of uptake of proven behavioral & therapeutic modalities, to yield the morbidity and mortality benefits. Simply, how do we get patients to successfully take their indicated medications?

Dr. Jiang He of Tulane University presented the results of the China Rural Hypertension Control Project, an intervention in rural China utilizing nonphysician community health workers (CHW) supervised by local primary care physicians. These CHW—village doctors—were provided with basic medical training (e.g. standardized BP measurement) and tasked to deliver protocolized antihypertensive medications and counsel patients on medication adherence and lifestyle modification (5, 6). Patients were followed monthly and received discounted or free medications and home BP monitors. After 18 months, this cluster-randomized trial, yielded a 37.1% increase in achievement of goal BP control (< 130/80 mm Hg) of subjects living in intervention villages (57%) compared with those living in control villages (19.9%) (P < 0.001). The average drop in BP in the intervention group was greater by 15/7 mm Hg. (6) The use of community health workers is not a new phenomenon in developing countries. They are often trusted community members who receive training to help address community problems. The first use of CHW with no prior formal training to address problems with rural health was in China in the 1930s.(7) This model later spread to Latin America and Southeast Asia in the 1960s with varying levels of success. Certain countries—including Brazil, Bangladesh, and Kenya—have learned from these early struggles to build sustainable successful CHW models (7-9). Our colleagues in infectious disease have successfully integrated CHW to help tackle lack of adherence to Tuberculosis medications causing resistance, by CHW directly observing patients taking their medicines (DOTS).(10) In the US, CHW was recognized as a standard job classification by the US Department of Labor (US Bureau of Labor Statistics, 2010) for the first time in the 2010 census and continue to be underutilized. If the work of Dr. He and colleagues, can be translated to a form suitable to the US health system, this can hold great promise for prevention of the myriad problems stemming from uncontrolled hypertensions.

Dr. Alexander Blood, of Brigham and Women’s Hospital, provides a glimpse of what this may look like. Based on prior work led by Dr. Benjamin Scirica at the same institution(11), the program uses “navigators” to communicate with patients (via phone, text, and email), pharmacists to prescribe and adjust medication as necessary, as well as an algorithm to help educate patients, integrate data, and coordinate care. (12, 13)  As a result, systolic blood pressure was reduced by 10 mm Hg and LDL cholesterol by 45 mg/dL in approximately 10,000 participants enrolled. In an interview with TCTMD, Dr. Blood compared this program to Warfarin management, where the physician writes the initial prescription and the Pharmacy and Warfarin clinic maintain patient’s INR on a weekly basis. It is unlikely that quarterly or biannual visits will yield effective control in patients with poor health literacy. For patients that needed higher intensity care, they were referred to their physician (12, 13). An important aspect of this trial is the results were consistent in populations typically underserved by the medical system–Blacks, Hispanics, and non-English speaking populations. Dr. Blood noted, “…if you structure the way you’re reaching out to patients, engaging them, and communicating with them—if you’re intentional and equitable in the way you make that type of outreach—it’s possible to engage, enroll, and help patients reach maintenance at similar rates across these subpopulations that are traditionally underserved in medicine.” (12)

In summary, while amazing new discoveries & technologies continue to reshape what is possible in cardiology, it is equally important to apply the same ingenuity to scaling up what we already know works and meet people where they are, in order to guide them to best health that science can offer.

 

References:

  1. Hannah Ritchie EM, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) – “Coronavirus Pandemic (COVID-19)”. Published online at OurWorldInData.org. Retrieved from: ‘https://ourworldindata.org/coronavirus’ [Online Resource]. [Available from: https://ourworldindata.org/covid-vaccinations?country=USA.
  2. Shearer E. More than eight-in-ten Americans get news from digital devices2021. Available from: https://www.pewresearch.org/fact-tank/2021/01/12/more-than-eight-in-ten-americans-get-news-from-digital-devices/.
  3. Shearer E, Mitchell A. News Use Across Social Media Platforms in 20202021. Available from: https://www.pewresearch.org/journalism/2021/01/12/news-use-across-social-media-platforms-in-2020/.
  4. Levine DM, Linder JA, Landon BE. Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015. JAMA Intern Med. 2020;180(3):463-6.
  5. Sun Y, Li Z, Guo X, Zhou Y, Ouyang N, Xing L, et al. Rationale and Design of a Cluster Randomized Trial of a Village Doctor-Led Intervention on Hypertension Control in China. Am J Hypertens. 2021;34(8):831-9.
  6. Neale T. Village-Level Intervention Nets Big BP Control Gains in Rural China. TCTMD. 2021. https://www.tctmd.com/news/village-level-intervention-nets-big-bp-control-gains-rural-china [Accessed November 14, 2021]
  7. Perry H. A Brief History of Community Health Worker Programs. https://www.mchip.net/: USAID; 2013. p. 14.
  8. Lehmann U, Sanders D. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. School of Public Health, University of the Western Cape, Evidence and Information for Policy DoHRfH; 2007.
  9. Rosenthal EL, Wiggins N, Ingram M, Mayfield-Johnson S, De Zapien JG. Community health workers then and now: an overview of national studies aimed at defining the field. J Ambul Care Manage. 2011;34(3):247-59.
  10. Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing “DOTS-plus”. BMJ. 1998;317(7159):671-4.
  11. Scirica BM, Cannon CP, Fisher NDL, Gaziano TA, Zelle D, Chaney K, et al. Digital Care Transformation: Interim Report From the First 5000 Patients Enrolled in a Remote Algorithm-Based Cardiovascular Risk Management Program to Improve Lipid and Hypertension Control. Circulation. 2021;143(5):507-9.
  12. O’Riordan M. Pharmacist-Led Intervention Slashes LDL and BP in 10,000 Patients. TCTMD. 2021. https://www.tctmd.com/news/pharmacist-led-intervention-slashes-ldl-and-bp-10000-patients?utm_source=TCTMD&utm_medium=email&utm_campaign=Newsletter111321 [Accessed November 14, 2021]
  13. Blood AJ CC, Gordon WJ, et al. Digital care transformation: report from the first 10,000 patients enrolled in a remote algorithm-based cardiovascular risk management program to improve lipid and hypertension control. Presented at: AHA 2021. November 13, 2021.