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Re: Saving lives

Dear Editor,

Norris[1] reports that most out of hospital cardiac arrest occurs in the home, but that as patients usually have premonitory symptoms, there is an opening for education about these symptoms and how to act to avoid delay and subsequent mortality. Although there is clearly a need to educate the public at large to call an ambulance if they witness what could be a heart attack or cardiac arrest, less is known about what is effective in reducing individual delay time.

Our systematic review of interventions to reduce delay in patients with suspected heart attack[2] concluded that there was little evidence that community-wide media campaigns or one to one educational interventions reduced delay time.

Supporting evidence came mainly from before and after studies; no RCT provided positive results, suggesting a need for caution in attributing any reported effects to the actual intervention. The methodological quality of studies was generally poor and few studies reported mortality data. While most studies reported pre-intervention baselines, few had a reasonable post intervention follow-up-period (which should be measured in years not months). The best RCT[3] with a large sample in an 18 month intervention which included both a media campaign and a one-to-one intervention with people at higher risk was negative. Few studies reported the intervention in sufficient detail to draw any conclusions about which elements were effective.

We now know about many potential psycho-social, clinical and environmental factors that are associated with extended delay.[4] Most of the interventions that have been tested are educational and education alone has repeatedly been shown not to be an effective method for changing behaviour. It is seems likely that we need to spend more time designing cognitive-behavioural supportive interventions for patients, and importantly their family or carers, then assessing these in a well controlled RCT and using qualitative techniques to elicit which part, if any, of the intervention led to appropriate actions. Once validated an intervention might best be delivered through rehabilitation programmes, NSF clinics and discharge planning. As Norris et al have shown there is huge potential for saving lives.

Jill F Pattenden
Robert J Lewin
BHF Care and Education Research Group, Dept of Health Sciences,
University of York

References

1. RM Norris on behalf of the UK Heart Attack Study (UKHAS) Collaborative Group. Heart 2005; 91 1537-1540.

2. Kainth A, Hewitt A, Pattenden J, Sowden A, Duffy S, Watt I, Thompson D, Lewin R. A systematic review of interventions to reduce delay in patients with suspected heart attack. Emergency Medicine Journal. 2004;21:506-508.

3. Luepker RV, Raczynski JM, Osganian s et al. Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: the rapid early action for coronary treatment (REACT) trial. JAMA 2000; 284:60-67.