meeting. The logistics and the t i m e table of t h e negotiations, the most recent a d j u s t m e n t s , and the final draft of Bylaws j u s t recently a g r e e d upon, made it impossible to submit our revised application to ABMS in t i m e to be placed on the M a r c h a g e n d a 120 days in advance, as t h e ABMS Bylaws require. However, consideration is being given to h a v i n g one of the sponsoring boards m a k e a motion to set aside t h e Bylaws and vote on our a p p l i c a t i o n at the forthcoming ABMS m e e t i n g in Chicago. F a i l i n g t h a t , an a t t e m p t will be m a d e to e l i c i t a s t r a w vote among the ABMS m e m b e r s h i p to d e m o n s t r a t e two-thirds majority support. This evidence of support would m a k e it clear t h a t the long a w a i t e d approval will occur at the next r e g u l a r m e e t i n g of ABMS in September of 1979. W i t h e i t h e r of the above eventualities, A B E M will proceed to a c t i v e l y involve t h e r e p r e s e n t a t i v e s of the seven p r i m a r y boards in its actions, d e l i b e r a t i o n s and p r e p a r a t i o n s for t h e c e r t i f y i n g e x a m i n a t i o n . It is conceivable, b u t highly unlikely, t h a t n e i t h e r r e a l support or expression of support by an adequate m a j o r i t y of ABMS will be shown in the March meeting. In this case, A B E M should be in a position to proceed with its own e x a m i n a tion w i t h i n an a p p r o p r i a t e t i m e period. Yet, I feel confident t h a t with t h e support of t h e
seven major p r i m a r y boards we should have A B M S approval of our application by S e p t e m b e r of 1979 at the latest. I believe t h a t the o t h e r m e m b e r s of the n e g o t i a t i n g t e a m s h a r e this opinion. As I have expressed previously to the A C E P Council, I feel strongly t h a t we m u s t continue our e n d e a v o r to receive approval of certifying boards in e m e r g e n c y medicine, b u t w i t h i n the f r a m e w o r k of organized medicine. An i m p o r t a n t a d d i t i o n a l consideration is t h a t as problems of the t h i r d p a r t y r e i m b u r s e m e n t emerge, in my j u d g e m e n t , it will be i m p o r t a n t for e m e r g e n c y medicine to h a v e a recognized specialty certifying board. Readers should keep in m i n d t h a t despite w h a t appears to be a prolonged period of w a i t i n g and negotiating, all t h e other specialties who have sought the s a m e result, have required a s u b s t a n t i a l l y longer period of time to achieve it. I a m looking f o r w a r d to the auspicious event of the approval of A B E M as our College e m b a r k s on a second decade of life.
George Podgol;ny, MD President, ACEP President, ABEM
Prehospital Cardiac Arrest and Resuscitation: Evaluation and Alternative Strategies v a l u a t i o n of medical care is surely one of the most challenging, if not painful, duties of the h e a l t h professional. The e v a l u a t i o n of resuscitation from prehospital cardiac a r r e s t is no exception. In '~Epidemiology of Cardiac A r r e s t a n d Resuscitation in a S u b u r b a n Comm u n i t y " (8:2-5, 1979) E i s e n b e r g et al a n a l y z e d the resusc i t a t i o n s a t t e m p t e d by 33 s e p a r a t e g r o u p s in K i n g County, W a s h i n g t o n , to begin to develop a ~gold-standard" t h a t could be used as a m e a s u r e of the effectiveness of p a r a m e d i c p r o g r a m s in t r e a t i n g p r e h o s p i t a l cardiac arrest. Over an 1 8 - m o n t h period, 649 cardiac a r r e s t s occurred ( a n n u a l incidence 7.2/10,000). P r i m a r y h e a r t disease was found to be t h e cause in 81% and v e n t r i c u l a r fibrillation was p r e s e n t in 57%. Based on the success rate of Cobb et aP in c o n v e r t i n g p r e h o s p i t a l v e n t r i c u l a r fibrillation, E i s e n b e r g e s t i m a t e d t h e m a x i m u m incidence of lives saved to be 2/10,000 annually. This, then, was offered as a goal for successful resuscitation for an efficient p a r a m e d i c program. The p r i m a r y s u r v e i l l a n c e tool used to collect d a t a was a questionnaire. An e l e m e n t a l question in e v a l u a t i n g the results of h e a l t h care is w h e t h e r the d a t a base used to develop the "goal" will provide a s t a n d a r d t h a t will be applicable and acceptable elsewhere. E i s e n b e r g et al seemed satisfied with the e x t e n t to which t h e i r questionnaire m e c h a n i s m reflected t h e r e a l i t i e s of cardiac a r r e s t and r e s u s c i t a t i o n in K i n g County, and felt t h e i r d a t a and approach would be applicable to o t h e r s u b u r b a n communities. Yet, approaches to d a t a collection as well as differences in study p o p u l a t i o n s and access to medical care for cardiac c o m p l a i n t s m a y differ Substantially. For example, Cobb et a l l , 2 e s t i m a t e d t h a t n e a r l y One t h i r d of 18,000 requests for medical assistance in Seattle were from patients with cardiovascular disease while only 71 of 1,771 p a t i e n t s consecutively t r a n s p o r t e d by Pozen et al 2 had ischemic h e a r t disease. E s t i m a t e s have p u t the incidence of ~heart a t t a c k " d e a t h s at 28.6/10,000 in a ~'standard g e n e r a l population. ''3 Since more t h a n h a l f of these will t a k e place in the c o m m u n i t y , we m i g h t expect a n incidence of prehosp i t a l cardiac a r r e s t a b o u t twice t h a t observed by Eisen-
E
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berg et al. However, the researchers did point out t h a t t h e i r study population included only those patients for whom the emergency system was activated. D a t a has been offered to suggest t h a t successful resuscitation from p r e h o s p i t a l cardiac a r r e s t is related to 1) n u m b e r s of laypersons t r a i n e d in resuscitation; 1 2) frequency of layperson (bystander) s u p p o r t of the cardiac a r r e s t victim, 1 and 3) q u a l i t y of CPR provided by the bystander, s Lay persons m a y be - - or r a t h e r , m u s t be - - an i n t e g r a l p a r t of t h e p r e h o s p i t a l r e s u s c i t a t i o n effort. Successful r e s u s c i t a t i o n has been reported in 61% of cases in which CPR was i n i t i a t e d by a lay person w i t h i n one m i n u t e of cardiac arrest. ~ D a t a from a decade ago on t h e f r e q u e n c y of successful p r e h o s p i t a l r e s u s c i t a t i o n showed t h a t success r a t e s were often 10% or less. 7 The contribution of t h e l a y m a n m a y vary from one emergency care system to a n o t h e r while the competency of the prehospital care system m a y be e n t i r e l y comparable. How is one to account for this variable? To w h a t e x t e n t w i l l c o m m u n i t y e d u c a t i o n in the signs and symptoms of h e a r t a t t a c k and the importance of p r o m p t entry into t h e e m e r g e n c y care s y s t e m influence t h e frequency of prehospital cardiac a r r e s t and therefore t h e n u m b e r of p o t e n t i a l l y r e s u s c i t a t a b l e cardiac a r r e s t v i c t i m s ? We r e c o g n i z e t h a t a r r h y t h m i c d e a t h s occur e a r l y in t h e course of m y o c a r d i a l i n f a r c t i o n and t h a t m a n y are p r e v e n t a b l e w i t h e a r l y t r e a t m e n t . Since an effective education p r o g r a m m a y reduce p r e h o s p i t a l cardiac arrest, the success r a t e for p r e h o s p i t a l resuscitation by a n efficient p a r a m e d i c s y s t e m m a y also be reduced a n d an efficient p a r a m e d i c s y s t e m m a y a p p e a r to be doing its job less well. Surely an accounting of total cardiac arrests m i g h t avoid such a p o t e n t i a l m i s i n t e r p r e t a tion, but this merely underlines the reality that an overly simplistic index m a y be m i s l e a d i n g . O b v i o u s l y , t h e r e a s o n for t h e e x i s t e n c e of c o m m u n i t y - b a s e d m e c h a n i s m s for d e a l i n g with cardiac e m e r g e n c i e s is the fact t h a t b e t t e r t h a n half, p e r h a p s b e t t e r t h a n 65%, of those who die suddenly, p r e m a t u r e l y a n d unexpectedly do so in t h e k i t c h e n s , churches and shopping centers of t h e i r communities, not in the coron a r y care u n i t ) , s
JACEP
8:2 (February) 1979
In considering the applicability of the approach of E i s e n b e r g , '~success" i n prehospital r e s u s c i t a t i o n m a y well m e a n very different t h i n g s to different people. There are those, for example, who would emphasize reduction of overall cardiovascular mortality as opposed to salvage of the cardiac arrest victim, without d e n i g r a t i n g the importance of mobilizing a n d m a i n t a i n i n g an effective capability for caring for the cardiac arrest victim. We are becoming i n c r e a s i n g l y aware that coronary a r t e r i a l disease is b o r n in the c o m m u n i t y , n u r t u r e d there b e g i n n i n g with the n u t r i t i o n a l p a t t e r n s of the very young, s m o k i n g messages to teenagers~ c u l t u r a l a n d social pressures t h a t mold b e h a v i o r s , a m o n g a host of other factors. Controversy c o n t i n u e s as to the p o t e n t i a l i m p a c t of riskfactor r e d u c t i o n on coronary h e a r t disease incidence. Major clinical trials like the Multiple Risk Factor Interv e n t i o n T r i a l (MRFIT) 9 and the Beta-blocker Heart Attack T r i a l ( n a t i o n a l m u l t i - c e n t e r clinical t r i a l sponsored by the Heart, Lung and Blood Institute) are u n d e r w a y to test the potential of p r i m a r y and secondary i n t e r v e n t i o n on coronary h e a r t disease incidence. Yet, there is persuasive data a r g u i n g in favor of aggressive c o m m u n i t y action. It is clear, for example, t h a t y o u n g and middle-aged m e n who stop s m o k i n g have a major reduction in rates of coronary h e a r t disease as compared to those who cont i n u e to smoke.l°, 11 E v i d e n c e t h a t h e m o d y n a m i c a n d metabolic events associated with cigarette smoking m a y be m e d i a t e d b y c a t e c h o l a m i n e r e l e a s e , 12 a n d t h a t catecholamine release lowers.the threshold for ventricul a r f i b r i l l a t i o n l ~ , 14 as does c i g a r e t t e s m o k i n g , ~ h a s f u r t h e r s t r e n g t h e n e d the a r g u m e n t t h a t a cause-andeffect r e l a t i o n s h i p exists between cigarette s m o k i n g a n d coronary heart disease mortality. Strong evidence suggests t h a t m a s s - m e d i a e d u c a t i o n a l c a m p a i g n s directed at entire communities m a y be very effective in reducing r i s k of cardiovascular disease. 16 The fact t h a t three q u a r t e r s of those dying s u d d e n l y of cardiac causes had previously recognized hypertension, h e a r t disease or diabetes underscores the importance of secondary prevention and t h a t a high-risk group c a n be delineated for special education and t r e a t m e n t 2 7 Are we not b e i n g forced to face the reality t h a t a comprehensive approach to the problem of sudden death i n the c o m m u n i t y m u s t e v e n t u a l l y involve at least four steps: 1) identification a n d modification of cardiovascular risk factors, especially those k n o w n to be associated with sudden death; 2) identification of individuals k n o w n to be at high risk t h r o u g h a diagnosis of coronary h e a r t disease to optimize t r e a t m e n t and decrease t h e i r risk factors; 3) d e v e l o p m e n t of e f f e c t i v e t h e r a p y for arteriosclerosis a n d for t h e c o n t r o l of l i f e - t h r e a t e n i n g r h y t h m d i s t u r b a n c e s , a n d 4) effective t r e a t m e n t of myocardial infarction and cardiac arrest. Since n u m b e r s 1 to 3 m a y b e a r on t h e i n c i d e n c e of cardiac a r r e s t , perhaps their roles - - or lack thereof - - need to be considered in the e v a l u a t i o n of prehospital resuscitation efforts. CPR by e x t e r n a l cardiac compression and v e n t i l a t i o n was first described in 1960. TM Now, almost 20 years later, we have not yet developed its full potential for d e a l i n g with prehospital cardiac arrest, let alone a m e c h a n i s m for reliable e v a l u a t i o n of the effectiveness of a c o m m u n i ty-based emergency cardiac care system i n areas where one exists. Perhaps we m a y capitalize on the pique of public i n t e r e s t in hands-on life-saving, CPR t r a i n i n g and c o m m u n i t y e m e r g e n c y cardiac care systems to create
8"2 (February) 1979
p r i m a r y and secondary p r e v e n t i o n programs so that, 20 years from now, we are n o t c a u g h t looking back and wondering why we failed to see the brighter beacon. Finally, while the concept of the resuscitatable pat i e n t is an i m p o r t a n t one by which we may begin to judge the efficacy of a prehospital emergency cardiac care system, it pales by comparison with the potential of strategies for cardiac a r r e s t prevention. Still more appealing are programs t h a t hold promise for p r e v e n t i o n of arterial disease. At w h a t point in the c o n t i n u u m of effort a n d potential should the c o m m u n i t y - - and its h e a l t h p l a n n e r s and providers - - be satisfied? And need this question not be asked w h e n e v a l u a t i o n of prehospital cardiac arrest-resuscitation is b e i n g considered? Kevin M. McIntyre, MD Boston, Massachusetts
1. Cobb LA, Alvarez H, Copass MK: A rapid response system for out-of-hospital cardiac emergencies. M e d Clin N o r t h A m 60:283-290, 1976. 2. Pasco M, Fried DD, Voigt GG: Studies of ambulance patients with ischemic heart disease. II. Selection of patients for ambulance telemetry. A m J Public Health 67:532-535, 1977. 3. Sidel V, et al: Models for the evaluation of prehospital coronary care. A m J Cardiol 24:674-688, 1969. 4. Liberthson RR, Nagel EL, Hirshman JC, et ah Prehospital ventricular fibrillation. N E n g l J Med 291:317-321, 1974. 5. Kuller L: Sudden death in atherosclerotic heart disease: the case for preventative medicine. A m J Cardiol 24:617, 1969. 6. Lund I, Skulberg A: Cardiopulmonary resuscitation by lay people. Lancet 2:702, 1976. 7. Saphir R: External cardiac massage: Prehospital analysis of 123 cases and review of the literature. Medicine 47:73-87, 1968. 8. Nagel EL, Liberthson RR, Hirschman JC, et al: Emergency care. Circulation 51-52 (suppl III):111-216, 1975. 9. Paul O, for the MRFIT study group: The Multiple Risk Factor Intervention Trial (MRFIT): A national study of the primary prevention of coronary heart disease. J A M A 235:825-827, 1968. 10. Gordon T, Kannel WR, McGee D, et ah Death and coronary attacks in men after giving up cigarette smoking. Report from the Framington study. Lancet 2:1345-1348, 1974. 11. Wilhelmsson C, Vedin JA, Elmfeldt D, et ah Smoking and myocardial infarction. Lancet 1:415-420, 1975. 12. Cryer PE, Haymond MW, Santiago JV, et ah Norepinephrine and epinephrine release and adrenergic medications of smoking-associated hemodynamic metabolic events. N Engl J Med 295:573-577, 1976. 13. Verrier RL, Thompson PL, Lown B: Ventricular vulnerability during sympathetic stimulation: role of heart rate and blood pressure. Cardiovasc Res 8:602-610, 1974. 14. Verrier RL, Calvert A, Lown B: Effect of posterior hypothalamic stimulation on ventricular fibrillation threshold. A m J Physiol 228:923-927, 1975. 15. Bellet S, DeGuzman NT, Kostis JB, et ah The effect of inhalation of cigarette smoke on ventricular fibrillation threshold in normal dogs and dogs with acute myocardial infarction. A m Heart J 83:67-76, 1972. 16. Farquhar HW, Wood PD, Breitrose H, et al: Community education for cardiovascular health. Lancet 1:1192-1195, 1977. 17. Kuller L, Cooper M, Perper J: Epidemiology of sudden death. Arch Intern Med 129:714, 1972. 18. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closedchest cardiac massage. J A M A 173:1064-1066, 1960.
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seven major p r i m a r y boards we should have A B M S approval of our application by S e p t e m b e r of 1979 at the latest. I believe t h a t the o t h e r m e m b e r s of the n e g o t i a t i n g t e a m s h a r e this opinion. As I have expressed previously to the A C E P Council, I feel strongly t h a t we m u s t continue our e n d e a v o r to receive approval of certifying boards in e m e r g e n c y medicine, b u t w i t h i n the f r a m e w o r k of organized medicine. An i m p o r t a n t a d d i t i o n a l consideration is t h a t as problems of the t h i r d p a r t y r e i m b u r s e m e n t emerge, in my j u d g e m e n t , it will be i m p o r t a n t for e m e r g e n c y medicine to h a v e a recognized specialty certifying board. Readers should keep in m i n d t h a t despite w h a t appears to be a prolonged period of w a i t i n g and negotiating, all t h e other specialties who have sought the s a m e result, have required a s u b s t a n t i a l l y longer period of time to achieve it. I a m looking f o r w a r d to the auspicious event of the approval of A B E M as our College e m b a r k s on a second decade of life.
George Podgol;ny, MD President, ACEP President, ABEM
Prehospital Cardiac Arrest and Resuscitation: Evaluation and Alternative Strategies v a l u a t i o n of medical care is surely one of the most challenging, if not painful, duties of the h e a l t h professional. The e v a l u a t i o n of resuscitation from prehospital cardiac a r r e s t is no exception. In '~Epidemiology of Cardiac A r r e s t a n d Resuscitation in a S u b u r b a n Comm u n i t y " (8:2-5, 1979) E i s e n b e r g et al a n a l y z e d the resusc i t a t i o n s a t t e m p t e d by 33 s e p a r a t e g r o u p s in K i n g County, W a s h i n g t o n , to begin to develop a ~gold-standard" t h a t could be used as a m e a s u r e of the effectiveness of p a r a m e d i c p r o g r a m s in t r e a t i n g p r e h o s p i t a l cardiac arrest. Over an 1 8 - m o n t h period, 649 cardiac a r r e s t s occurred ( a n n u a l incidence 7.2/10,000). P r i m a r y h e a r t disease was found to be t h e cause in 81% and v e n t r i c u l a r fibrillation was p r e s e n t in 57%. Based on the success rate of Cobb et aP in c o n v e r t i n g p r e h o s p i t a l v e n t r i c u l a r fibrillation, E i s e n b e r g e s t i m a t e d t h e m a x i m u m incidence of lives saved to be 2/10,000 annually. This, then, was offered as a goal for successful resuscitation for an efficient p a r a m e d i c program. The p r i m a r y s u r v e i l l a n c e tool used to collect d a t a was a questionnaire. An e l e m e n t a l question in e v a l u a t i n g the results of h e a l t h care is w h e t h e r the d a t a base used to develop the "goal" will provide a s t a n d a r d t h a t will be applicable and acceptable elsewhere. E i s e n b e r g et al seemed satisfied with the e x t e n t to which t h e i r questionnaire m e c h a n i s m reflected t h e r e a l i t i e s of cardiac a r r e s t and r e s u s c i t a t i o n in K i n g County, and felt t h e i r d a t a and approach would be applicable to o t h e r s u b u r b a n communities. Yet, approaches to d a t a collection as well as differences in study p o p u l a t i o n s and access to medical care for cardiac c o m p l a i n t s m a y differ Substantially. For example, Cobb et a l l , 2 e s t i m a t e d t h a t n e a r l y One t h i r d of 18,000 requests for medical assistance in Seattle were from patients with cardiovascular disease while only 71 of 1,771 p a t i e n t s consecutively t r a n s p o r t e d by Pozen et al 2 had ischemic h e a r t disease. E s t i m a t e s have p u t the incidence of ~heart a t t a c k " d e a t h s at 28.6/10,000 in a ~'standard g e n e r a l population. ''3 Since more t h a n h a l f of these will t a k e place in the c o m m u n i t y , we m i g h t expect a n incidence of prehosp i t a l cardiac a r r e s t a b o u t twice t h a t observed by Eisen-
E
68/89
berg et al. However, the researchers did point out t h a t t h e i r study population included only those patients for whom the emergency system was activated. D a t a has been offered to suggest t h a t successful resuscitation from p r e h o s p i t a l cardiac a r r e s t is related to 1) n u m b e r s of laypersons t r a i n e d in resuscitation; 1 2) frequency of layperson (bystander) s u p p o r t of the cardiac a r r e s t victim, 1 and 3) q u a l i t y of CPR provided by the bystander, s Lay persons m a y be - - or r a t h e r , m u s t be - - an i n t e g r a l p a r t of t h e p r e h o s p i t a l r e s u s c i t a t i o n effort. Successful r e s u s c i t a t i o n has been reported in 61% of cases in which CPR was i n i t i a t e d by a lay person w i t h i n one m i n u t e of cardiac arrest. ~ D a t a from a decade ago on t h e f r e q u e n c y of successful p r e h o s p i t a l r e s u s c i t a t i o n showed t h a t success r a t e s were often 10% or less. 7 The contribution of t h e l a y m a n m a y vary from one emergency care system to a n o t h e r while the competency of the prehospital care system m a y be e n t i r e l y comparable. How is one to account for this variable? To w h a t e x t e n t w i l l c o m m u n i t y e d u c a t i o n in the signs and symptoms of h e a r t a t t a c k and the importance of p r o m p t entry into t h e e m e r g e n c y care s y s t e m influence t h e frequency of prehospital cardiac a r r e s t and therefore t h e n u m b e r of p o t e n t i a l l y r e s u s c i t a t a b l e cardiac a r r e s t v i c t i m s ? We r e c o g n i z e t h a t a r r h y t h m i c d e a t h s occur e a r l y in t h e course of m y o c a r d i a l i n f a r c t i o n and t h a t m a n y are p r e v e n t a b l e w i t h e a r l y t r e a t m e n t . Since an effective education p r o g r a m m a y reduce p r e h o s p i t a l cardiac arrest, the success r a t e for p r e h o s p i t a l resuscitation by a n efficient p a r a m e d i c s y s t e m m a y also be reduced a n d an efficient p a r a m e d i c s y s t e m m a y a p p e a r to be doing its job less well. Surely an accounting of total cardiac arrests m i g h t avoid such a p o t e n t i a l m i s i n t e r p r e t a tion, but this merely underlines the reality that an overly simplistic index m a y be m i s l e a d i n g . O b v i o u s l y , t h e r e a s o n for t h e e x i s t e n c e of c o m m u n i t y - b a s e d m e c h a n i s m s for d e a l i n g with cardiac e m e r g e n c i e s is the fact t h a t b e t t e r t h a n half, p e r h a p s b e t t e r t h a n 65%, of those who die suddenly, p r e m a t u r e l y a n d unexpectedly do so in t h e k i t c h e n s , churches and shopping centers of t h e i r communities, not in the coron a r y care u n i t ) , s
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8:2 (February) 1979
In considering the applicability of the approach of E i s e n b e r g , '~success" i n prehospital r e s u s c i t a t i o n m a y well m e a n very different t h i n g s to different people. There are those, for example, who would emphasize reduction of overall cardiovascular mortality as opposed to salvage of the cardiac arrest victim, without d e n i g r a t i n g the importance of mobilizing a n d m a i n t a i n i n g an effective capability for caring for the cardiac arrest victim. We are becoming i n c r e a s i n g l y aware that coronary a r t e r i a l disease is b o r n in the c o m m u n i t y , n u r t u r e d there b e g i n n i n g with the n u t r i t i o n a l p a t t e r n s of the very young, s m o k i n g messages to teenagers~ c u l t u r a l a n d social pressures t h a t mold b e h a v i o r s , a m o n g a host of other factors. Controversy c o n t i n u e s as to the p o t e n t i a l i m p a c t of riskfactor r e d u c t i o n on coronary h e a r t disease incidence. Major clinical trials like the Multiple Risk Factor Interv e n t i o n T r i a l (MRFIT) 9 and the Beta-blocker Heart Attack T r i a l ( n a t i o n a l m u l t i - c e n t e r clinical t r i a l sponsored by the Heart, Lung and Blood Institute) are u n d e r w a y to test the potential of p r i m a r y and secondary i n t e r v e n t i o n on coronary h e a r t disease incidence. Yet, there is persuasive data a r g u i n g in favor of aggressive c o m m u n i t y action. It is clear, for example, t h a t y o u n g and middle-aged m e n who stop s m o k i n g have a major reduction in rates of coronary h e a r t disease as compared to those who cont i n u e to smoke.l°, 11 E v i d e n c e t h a t h e m o d y n a m i c a n d metabolic events associated with cigarette smoking m a y be m e d i a t e d b y c a t e c h o l a m i n e r e l e a s e , 12 a n d t h a t catecholamine release lowers.the threshold for ventricul a r f i b r i l l a t i o n l ~ , 14 as does c i g a r e t t e s m o k i n g , ~ h a s f u r t h e r s t r e n g t h e n e d the a r g u m e n t t h a t a cause-andeffect r e l a t i o n s h i p exists between cigarette s m o k i n g a n d coronary heart disease mortality. Strong evidence suggests t h a t m a s s - m e d i a e d u c a t i o n a l c a m p a i g n s directed at entire communities m a y be very effective in reducing r i s k of cardiovascular disease. 16 The fact t h a t three q u a r t e r s of those dying s u d d e n l y of cardiac causes had previously recognized hypertension, h e a r t disease or diabetes underscores the importance of secondary prevention and t h a t a high-risk group c a n be delineated for special education and t r e a t m e n t 2 7 Are we not b e i n g forced to face the reality t h a t a comprehensive approach to the problem of sudden death i n the c o m m u n i t y m u s t e v e n t u a l l y involve at least four steps: 1) identification a n d modification of cardiovascular risk factors, especially those k n o w n to be associated with sudden death; 2) identification of individuals k n o w n to be at high risk t h r o u g h a diagnosis of coronary h e a r t disease to optimize t r e a t m e n t and decrease t h e i r risk factors; 3) d e v e l o p m e n t of e f f e c t i v e t h e r a p y for arteriosclerosis a n d for t h e c o n t r o l of l i f e - t h r e a t e n i n g r h y t h m d i s t u r b a n c e s , a n d 4) effective t r e a t m e n t of myocardial infarction and cardiac arrest. Since n u m b e r s 1 to 3 m a y b e a r on t h e i n c i d e n c e of cardiac a r r e s t , perhaps their roles - - or lack thereof - - need to be considered in the e v a l u a t i o n of prehospital resuscitation efforts. CPR by e x t e r n a l cardiac compression and v e n t i l a t i o n was first described in 1960. TM Now, almost 20 years later, we have not yet developed its full potential for d e a l i n g with prehospital cardiac arrest, let alone a m e c h a n i s m for reliable e v a l u a t i o n of the effectiveness of a c o m m u n i ty-based emergency cardiac care system i n areas where one exists. Perhaps we m a y capitalize on the pique of public i n t e r e s t in hands-on life-saving, CPR t r a i n i n g and c o m m u n i t y e m e r g e n c y cardiac care systems to create
8"2 (February) 1979
p r i m a r y and secondary p r e v e n t i o n programs so that, 20 years from now, we are n o t c a u g h t looking back and wondering why we failed to see the brighter beacon. Finally, while the concept of the resuscitatable pat i e n t is an i m p o r t a n t one by which we may begin to judge the efficacy of a prehospital emergency cardiac care system, it pales by comparison with the potential of strategies for cardiac a r r e s t prevention. Still more appealing are programs t h a t hold promise for p r e v e n t i o n of arterial disease. At w h a t point in the c o n t i n u u m of effort a n d potential should the c o m m u n i t y - - and its h e a l t h p l a n n e r s and providers - - be satisfied? And need this question not be asked w h e n e v a l u a t i o n of prehospital cardiac arrest-resuscitation is b e i n g considered? Kevin M. McIntyre, MD Boston, Massachusetts
1. Cobb LA, Alvarez H, Copass MK: A rapid response system for out-of-hospital cardiac emergencies. M e d Clin N o r t h A m 60:283-290, 1976. 2. Pasco M, Fried DD, Voigt GG: Studies of ambulance patients with ischemic heart disease. II. Selection of patients for ambulance telemetry. A m J Public Health 67:532-535, 1977. 3. Sidel V, et al: Models for the evaluation of prehospital coronary care. A m J Cardiol 24:674-688, 1969. 4. Liberthson RR, Nagel EL, Hirshman JC, et ah Prehospital ventricular fibrillation. N E n g l J Med 291:317-321, 1974. 5. Kuller L: Sudden death in atherosclerotic heart disease: the case for preventative medicine. A m J Cardiol 24:617, 1969. 6. Lund I, Skulberg A: Cardiopulmonary resuscitation by lay people. Lancet 2:702, 1976. 7. Saphir R: External cardiac massage: Prehospital analysis of 123 cases and review of the literature. Medicine 47:73-87, 1968. 8. Nagel EL, Liberthson RR, Hirschman JC, et al: Emergency care. Circulation 51-52 (suppl III):111-216, 1975. 9. Paul O, for the MRFIT study group: The Multiple Risk Factor Intervention Trial (MRFIT): A national study of the primary prevention of coronary heart disease. J A M A 235:825-827, 1968. 10. Gordon T, Kannel WR, McGee D, et ah Death and coronary attacks in men after giving up cigarette smoking. Report from the Framington study. Lancet 2:1345-1348, 1974. 11. Wilhelmsson C, Vedin JA, Elmfeldt D, et ah Smoking and myocardial infarction. Lancet 1:415-420, 1975. 12. Cryer PE, Haymond MW, Santiago JV, et ah Norepinephrine and epinephrine release and adrenergic medications of smoking-associated hemodynamic metabolic events. N Engl J Med 295:573-577, 1976. 13. Verrier RL, Thompson PL, Lown B: Ventricular vulnerability during sympathetic stimulation: role of heart rate and blood pressure. Cardiovasc Res 8:602-610, 1974. 14. Verrier RL, Calvert A, Lown B: Effect of posterior hypothalamic stimulation on ventricular fibrillation threshold. A m J Physiol 228:923-927, 1975. 15. Bellet S, DeGuzman NT, Kostis JB, et ah The effect of inhalation of cigarette smoke on ventricular fibrillation threshold in normal dogs and dogs with acute myocardial infarction. A m Heart J 83:67-76, 1972. 16. Farquhar HW, Wood PD, Breitrose H, et al: Community education for cardiovascular health. Lancet 1:1192-1195, 1977. 17. Kuller L, Cooper M, Perper J: Epidemiology of sudden death. Arch Intern Med 129:714, 1972. 18. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closedchest cardiac massage. J A M A 173:1064-1066, 1960.
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