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National Heart Attack Alert Program


What is the origin of the National Heart Attack Alert Program?

The National Heart Attack Alert Program (NHAAP) was launched in June 1991. Along with the National Heart, Lung, and Blood Institute's (NHLBI's) other national education programs, the National High Blood Pressure Education Program, National Cholesterol Education Program, National Asthma Education and Prevention Program, and NHLBI Obesity Initiative, the NHAAP is located within the Institute's Office of Prevention, Education, and Control.

Why is the NHAAP needed?

Death and disability from acute myocardial infarction (AMI) or heart attack, continue to be a major public health problem. It is estimated that there are 1.1 million heart attacks each year and approximately 515,000 die from AMI—about 51 percent were males and 49 percent were females. Half of these deaths occur suddenly, within 1 hour of symptom onset, outside of the hospital setting.

The current paradigm for treating patients with AMI is early opening of the infarct-related artery through either pharmacological (e.g., thrombolytic or clot-dissolving therapy) or mechanical (e.g., percutaneous transluminal coronary angioplasty or PTCA) intervention.

Thrombolytic therapy is associated with an overall 25 to 30 percent reduction in AMI mortality. In particular, studies have demonstrated marked benefits from thrombolytic agents that were given within 1 to 2 hours after heart attack symptoms began. Although drug therapy has been shown to reduce mortality from heart attacks if administered in the first 12 hours after symptom onset, the greatest reductions occur in patients who are treated early (within 1 hour).

Yet these lifesaving/enhancing treatments are often not made available to patients because they—and those around them, including health care providers/systems in the community and in the hospital—fail to recognize the symptoms and signs of a heart attack, and respond quickly and appropriately. Health care provider, patient, and public education are needed in the area of early recognition of individuals with heart attack symptoms, the most appropriate response, and effective treatments. It is estimated that 26 to 44 percent of patients delay longer than 4 hours in seeking care for cardiac symptoms. Also, the care offered to heart attack patients in emergency medical services systems throughout the United States is extremely heterogeneous. In many if not most emergency departments, the additive effect of multiple small time delays causes the tardy administration of thrombolytic and other therapies for AMI. In fact, only a fraction of heart attack patients eligible for benefiting from the latest therapies are actually receiving such therapies.

What is the purpose of the NHAAP?

The NHAAP has the overall goals of, first, reducing morbidity and mortality from AMI through rapid identification and treatment and, second, heightening the potential for an improved quality of life for patients and those around them. The Program's goal also includes early recognition and response to individuals with symptoms and signs of acute coronary syndromes, including unstable angina as well as both Q-wave and non-Q wave myocardial infarction. The NHAAP further seeks to address the Healthy People 2010 Objectives that relate directly to the Program's issues. These objectives are:

  • Increase the proportion of adults aged 20 years and older who are aware of the early warning symptoms and signs of a heart attack and the importance of accessing rapid emergency care by calling 9-1-1.
  • Increase the proportion of eligible patients with heart attacks who receive artery-opening therapy within an hour of symptom onset.
  • Increase the proportion of adults aged 20 years and older who call 9-1-1 and administer cardiopulmonary resuscitation (CPR) when they witness an out-of-hospital cardiac arrest.
  • Increase the proportion of persons with witnessed out-of-hospital cardiac arrest who are eligible and receive their first therapeutic electrical shock within 6 minutes after collapse recognition.

What is the NHAAP's strategy?

The NHAAP has identified three phases where delay can occur in the identification and treatment of individuals with a potential heart attack:

Phase I: Patient and bystander recognition of the symptoms and signs of AMI and their actions in response to these symptoms.

Phase II: Prehospital action by emergency medical services providers—that is, the response to patients prior to their arrival at the hospital.

Phase III: Hospital action by health care providers at the hospital to identify and treat patients with the symptoms and signs of AMI.

What is the NHAAP Coordinating Committee?

A major component of the NHAAP is its Coordinating Committee, which is composed of representatives from about 40 organizations. This group provides input and feedback to the NHAAP about priority educational needs and activities, and it disseminates program educational objectives, messages, and materials to their organizations.

Member Organizations of the NHAAP Coordinating Committee
American Academy of Insurance Medicine
American Association for Clinical Chemistry, Inc.
American Association of Critical Care Nurses
American Association of Health Plans
American Association of Occupational Health Nurses
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Occupational and Environmental Medicine
American College of Physicians
American College of Preventive Medicine
American Heart Association
American Hospital Association
American Medical Association
American Nurses Association
American Pharmaceutical Association
American Public Health Association
American Red Cross
Association of Black Cardiologists
Emergency Nurses Association
International Association of Fire Chiefs
International Association of Fire Fighters
National Association of Emergency Medical Technicians
National Association of EMS Physicians
National Association of State Emergency Medical Services
National Black Nurses' Association
National Medical Association
Society for Academic Emergency Medicine
Society of Chest Pain Centers and Providers
Society of General Internal Medicine

Federal Agencies

Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
Department of Defense, Health Affairs
Department of Veterans Affairs
Food and Drug Administration
Health Care Financing Administration
Health Resources and Services Administration
National Center for Health Statistics
National Heart, Lung, and Blood Institute
NHLBI Ad Hoc Committee on Minority Populations
National Highway Traffic Safety Administration

The NHAAP Coordinating Committee has three ongoing subcommittees that meet in conjunction with the NHAAP Coordinating Committee meetings:

  • The Science Base Subcommittee: The purpose of the Science Base Subcommittee is to review, on a regular basis, the state of the art related to prevention of mortality and morbidity from AMI and to monitor research related to early identification and treatment of AMI in the patient/bystander, prehospital, and hospital arenas. As part of its responsibilities, the subcommittee makes recommendations to the full Coordinating Committee for future activities, including possible working groups or expert panels to address relevant scientific issues. The subcommittee plays an important part in monitoring the ever-changing scientific base that affects program activities.

  • The Health Systems Subcommittee: The goal of the Health Systems Subcommittee is to facilitate the development of a framework that supports the delivery of optimal and cost-effective care from symptom onset to initiation of therapy for patients with symptoms and signs of acute coronary syndromes. Its predecessor was the Access to Care Subcommittee established as the first subcommittee of the NHAAP Coordinating Committee. The Health Systems Subcommittee encompasses the three phases of action involved in the rapid identification and treatment of individuals with symptoms and signs of an AMI as originally conceptualized by the NHAAP Access to Care Subcommittee: Phase 1, Patient/Bystander; Phase 2, Prehospital; and Phase 3, Hospital. In addition, the Health Systems Subcommittee recognizes the community as the ultimate coronary care unit and seeks to implement a framework or model for an ideal health system in which all entities involved in some aspect of caring for the individual with possible acute coronary syndromes, work collaboratively to ensure a continuum of care for these patients. The Health Systems Subcommittee's scope is all community-based health care delivery systems (e.g., public, private, managed care), regardless of economic reimbursement and including the uninsured. The need for pre-identified indicators and outcomes to measure quality and impact of care, and use of new technology to facilitate a seamless continuum of care for these patients, are paramount to the subcommittee's charge.

  • Education Subcommittee: The Education Subcommittee is an ongoing subcommittee of the NHAAP Coordinating Committee. Its main focus is identification of priority areas for health care provider, patient, and public education in the area of rapid identification and treatment of patients with symptoms and signs of acute coronary syndromes, including sudden cardiac arrest. The subcommittee is also concerned with dissemination of this information, to its target groups. Its specific objectives are to: address professional education needs related to rapid identification and treatment of patients with symptoms and signs of acute coronary syndromes, including sudden cardiac arrest; recommend and/or organize, professional education interventions/strategies for implementation by the NHAAP Coordinating Committee organizations; recommend effective vehicles for dissemination of information to patients and the public; review proposed educational messages and target populations, based on the NHAAP science base and the Program objectives; review educational materials developed for professionals, patients, and the public by other groups; and make recommendations for tailoring of the products and their distribution to the appropriate audience.

In addition, in 1992 the NHAAP convened the Interagency Data Coordination and Program Evaluation Advisory Group, composed of representatives from the following Coordinating Committee organizations that are involved in ongoing data collection and research activities: the Agency for Healthcare Research and Quality, American Heart Association, Health Care Financing Administration, Health Resources and Services Administration, National Association of State EMS Directors, National Association of EMS Physicians, National Center for Health Statistics, National Highway Traffic Safety Administration, and NHLBI. The ongoing advisory group was formed to work with the program to (1) identify available data being collected from national and state data systems that are relevant to the NHAAP's goals and objectives, (2) determine what additional data are needed to support NHAAP planning and evaluation activities, and (3) advise the NHAAP on development and implementation of a program evaluation/data collection plan.

Priority Areas for 2002-2006

The NHAAP Coordinating Committee held its 10-year meeting in June 2001 and reviewed progress to date in program activities and relevant data trends. In addition, each of the Program's subcommittees identified priority areas for its next five years of work. The consolidated list of current priority areas is shown below:

  • Widespread Dissemination and Implementation of "Act in Time to Heart Attack Signs" Campaign Materials by NHAAP Coordinating Committee Member Organizations.
    To ensure the widespread dissemination and Implementation of Act in Time to Heart Attack Signs Campaign Materials by NHAAP Coordinating Committee Member Organizations.

  • NHAAP Informatics Projects
    To monitor the NHAAP/National Library of Medicine informatics projects on use of information technology to expedite the rapid identification and treatment of patients with acute coronary syndromes for application outside of the research setting.

  • Conceptual Framework for Behavioral Change
    To review the recommendations from the American Heart Association's January 2002 workshop on interdisciplinary approaches to reducing treatment-seeking delay for patients with acute cardiovascular disease, as a basis for possibly recommending a research initiative to one of the NHLBI research divisions or other institute within NIH, if workshop data warrant such a recommendation.

  • Emergency Medical Services (EMS) Systems Utilization
    To identify the inappropriate barriers to accessing EMS for patients with symptoms of an acute coronary syndrome and recommend approaches to reducing barriers to improving system utilization.

  • Evidence-Based Technologies
    To promote use of evidence-based technologies that positively affect the outcomes of patients with acute coronary syndromes which are currently under utilized by health care systems

  • Quality Improvement
    To review /shape national quality improvement efforts related to management of patients with acute coronary syndromes

  • Effect of Health Information Portability and Accountability Act (HIPAA)
    To explore the implications of HIPAA on health care systems and associated management of patients with acute coronary syndromes

  • Technologies and Protocols for Management of Patients with Acute Coronary Syndromes (ACS)
    To identify technologies and protocols that assist in risk stratification, diagnosis, and early treatment of patients with acute coronary syndromes (especially those with non-ST elevation MI).

  • Strategies/Technologies for Patient-Based and Provider-Supported Solutions to Early Recognition of ACS
    To apply current strategies and new technologies to empower patients with patient-based/provider-supported solutions to recognize and respond to symptoms of acute coronary syndromes

  • Explore the Establishment of an Acute Coronary Syndromes Patient Surveillance Database in Emergency Departments
    To explore and promote the establishment of an acute coronary syndromes patient surveillance database in emergency departments for capturing (real-time) acute cardiac-related symptom-specific data and outcomes, superimposed on an existing or planned surveillance database/system for monitoring cases/patients exposed to weapons of mass destruction (biological/chemical/nuclear).

  • Sudden Cardiac Death Focus
    To establish an ongoing focus on sudden cardiac death on the NHAAP Coordinating Committee's Science Base Subcommittee agenda by monitoring and supporting the Post-Resuscitative and Initial Utility in Life-Saving Efforts (PULSE) effort; translating and disseminating the Public Access Defibrillation (PAD) Trial results, and develop priorities for future cardiac arrest research.

Featured publications

National Heart Attack Alert Program Position Paper: Chest Pain Centers and Programs for the Evaluation of Acute Cardiac Ischemia: A writing group of the NHAAP developed a position paper on chest pain centers and programs for the evaluation of patients with acute cardiac ischemia. The paper offers recommendations to assist emergency departments, including those with chest pain centers, in providing the highest standard of care for patients with acute cardiac ischemia. This paper was published in Ann Emerg Med 2000; 35:462-471

Updated Evidence Report Evaluating Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department: An update of the literature reviewing technologies for identifying patients with acute cardiac ischemia in the emergency department, was prepared for the NHAAP, by one of the Agency for Healthcare Research and Quality's Evidence-based Practice Centers. A summary and full report are available.

Critical Pathways for Management of Patients with Acute Coronary Syndromes: An assessment by the National Heart Attack Alert Program. National Heart Attack Alert Program Coordinating Committee Critical Pathways Writing Group. In recognition of the potential impact of critical pathways to improving the care of patients with AMI and other acute coronary syndromes, a working group of the NHAAP developed a paper to review what is currently known about critical pathways for evaluation of patients with acute coronary syndromes and the potential opportunities for improving the care of these patients. The paper was published in the Am Heart J 2002; 143:777-789

NHAAP approach to educating the public

Early advisors to the NHAAP recommended that the Program defer public education about recognition of heart attacks until the provider community had been more fully educated about the new paradigm of reperfusion therapy and the importance of timely treatment for patients experiencing an AMI. To that end, the NHAAP worked with one of its research divisions in 1992, to develop an initiative to study the area of public education and its impact on delay time. June 1993, the NHLBI released a request for applications for the Rapid Early Action for Coronary Treatment (REACT) study. The purpose of REACT was to evaluate the effect of community intervention and public education on patient delay time and other outcomes. These outcomes include use of the EMS system, emergency departments, and thrombolytic therapy. They also include myocardial infarction case fatalities and related indices. Applications were received in December 1993, and awards were made in July 1994. The study compared 10 intervention communities with 10 control communities. The REACT study began in August 1994 and was completed in the spring of 1998. The results were reported at the American Heart Association's Scientific Sessions in November 1998. In September 2001, the NHAAP launched a targeted public education campaign called "Act In Time to Heart Attack Signs," which incorporates lessons learned from the REACT research program.

How can I get more information?

For more information on the NHAAP, contact:

National Heart Attack Alert Program
NHLBI Health Information Network
P.O. Box 30105
Bethesda, Maryland 20824-0105
(301) 592-8573 phone
(301) 592-8563 fax

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