Too Many Heart Attack Victims Don't Call 911

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July 10, 2000 -- There's no mistaking what doctors call a "Hollywood heart attack" -- a man or woman clutches his or her chest and falls to the ground.

But when the symptoms are jaw pain, dizziness, sweating, and nausea -- or even mild chest and left arm pain -- many people either don't recognize that they're in serious trouble or don't want to believe it. They don't call an ambulance, and if they go to the emergency room, they are likely to drive themselves.

A survey in the July 11 issue of the journal Circulation reveals that of nearly 900 people seen in the hospital for chest pain, only about 23% used emergency medical service (EMS) transportation.

The combination of symptoms is confusing, says investigator N. Clay Mann, PhD. "The person thinks, 'Oh, this will pass; this is indigestion.' Or 'I just need to sit down for a while,'" he tells WebMD. Sometimes, too, people are embarrassed or afraid of making the wrong decision, and so they don't call for immediate help. People who took nitroglycerine, a commonly prescribed medication for patients with heart disease, were more likely to call an ambulance, leading Mann and his colleagues to believe that they were familiar with the symptoms and so knew what to do.

The authors surveyed 20 communities across the U.S. and found that even when people do realize they should go to the hospital, they still hesitate to call 911. Of those patients seen in emergency departments (EDs), about 60% had someone drive them to the hospital. Nearly 16% actually drove themselves.

"What people are missing is that the moment those paramedics arrive on their doorstep, treatment starts," says Mann, who is an associate professor at the University of Utah School of Medicine in Salt Lake City. "Oxygen, medications, monitoring, defibrillation [if their heart stops beating] ... are available immediately. And probably the most important point is [the paramedics] can call and warn the ED that [they're bringing in a person] with chest symptoms, so care on arrival is much quicker."

The authors also did random telephone surveys with nearly 1,000 people in the 20 communities and found that they were far more likely to call 911 for a family member or even a stranger who appeared to be having a heart attack than they would for themselves. This indicates that as bystanders, their intention was to do the right thing. However, a limitation of this survey was that the person answering the survey question was told the ill person was having a heart attack. There was no guesswork about symptoms.

The most troubling finding was that using emergency medical services was lower among people who called their doctors about their symptoms. Mann thinks it's likely these people were falsely reassured. It may be that "the phone call with the physician is reducing their anxiety to the point that they now can drive themselves. Or, the other option is that the physicians feel ... [that] they're well-versed in the patient's history, and they're saying, 'This is your third angina [chest pain] attack. Why don't you have your wife drive you in,'" Mann says. "I don't know which of those [possibilities] is true, but the cold hard facts are that 83% who called their doctor and ended up having a heart attack didn't call 911."

He and his colleagues are planning another survey that will ask patients more specific questions about phone calls with their doctors.

The current study demonstrates that the public must be educated about when and how to seek treatment, according to David A. Meyerson, MD, a cardiologist at the Johns Hopkins Medical Institutions and a spokesman for the American Heart Association (AHA). "The AHA would like people to understand that there are perhaps 1.2 million heart attacks occurring in the U.S. each year, and only 950,000 make it to the hospital. So 250,000 are dying before they get [there]." The earlier you get treatment, the more likely you will avoid damage, he says.

"People are embarrassed," Meyerson says. "They don't want to come to the emergency room complaining of something and find it to be indigestion. They're afraid they made the wrong decision. If the symptom[s] ... look like it is cardiac-related, we should urge them to seek early treatment."

Prompt treatment also may make a dent in the in-hospital deaths. "We now have the ability to turn off a heart attack in midstream with clot-dissolving medications or angioplasty," which involves using a tiny balloon that is inflated to flatten the clot in the clogged vessel. These treatments can preserve heart muscle function, preventing heart failure and reducing deaths, he adds.

"Time is muscle," Meyerson says. "The longer you wait, the more heart muscle dies."

Although the survey didn't ask people directly whether cost was a factor in their decision to call 911, it was noted that in areas that had either state-supported emergency medical services or a subscription service, the service was used twice as often as in areas that didn't have it.

"Cost could be a part of it," says David E. Wilcox, MD, FACEP, a spokesman for the American Academy of Emergency Medicine Physicians. He points out that some managed care programs have denied coverage if it was later learned that the person didn't have a serious problem.

To combat this, now at least 32 states have passed legislation to define "emergency" based on a layperson's interpretation, and a federal bill seeks to do the same. "If you have signs or symptoms that you interpret to be a potential emergency, and you go to the ED to have it checked out, the insurance company must pay for it," says Wilcox in an interview with WebMD. Wilcox also is medical director of ConnectiCare and a practicing emergency room physician at St. Francis Hospital in Hartford.

It's important to get the "prudent layperson" definition of emergency through the federal legislature, says Wilcox, because under the Employee Retirement and Income Security Act (ERISA), large companies that are self-funded do not fall under state law. So even though 32 states have passed the statute, big companies that account for about 40% of all employees in the country don't fall under it, he says.

"If you have a service that is free to you, [cost] is not a roadblock to using it," says Wilcox.

For more from WebMD, read how to recognize an emergency.

Vital Information:

  • In a recent study, researchers found that less than a quarter of emergency room patients with chest pain, a symptom of heart attack, used emergency medical transportation, with some even driving themselves to the hospital.
  • Among people who first called their doctors, emergency medical service use was lower, which worries researchers who think these people may be lulled into a false sense of security.
  • The benefits of using emergency medical services is that treatment begins upon arrival and the emergency department can be notified in advance, so care on arrival to the hospital can be quicker.
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