Out-of-hospital cardiac arrest: The need for continuing education: Table 1

This editorial refers to ‘Impact of a public awareness campaign on out-of-hospital cardiac arrest incidence and mortality rates’†, by Z. Nehme et al., on page 1666. Cardiac death is still the most common cause of death in Europe.1 Approximately half of those deaths occur because of sudden cardiac arrest out-of-hospital.2 Recent articles have shown that outcomes of witnessed cardiac arrest have improved due to greater emphasis on resuscitation training, increased density of automatic external defibrillators (AEDs), better organization of emergency medical systems (EMS), and improved post-resuscitation care. There has also been reassuring information about the quality of life and functional outcomes after successful resuscitation from out-of-hospital cardiac arrest (OHCA).3 However, it is still unusual to see >10% of the victims leaving the hospital alive.4–6 An important point of discussion is the role of educating the layman about complaints possibly pointing to the occurrence of an episode of acute heart disease and the action that should follow. To evaluate the value of providing that information, an extensive public awareness campaign about those complaints and what to do was performed in the greater Melbourne area in Australia.7 Over a 10-year period, data were collected from 25 060 OHCA cases in a population of ∼4 million people in an area of 9990 km2. There was a yearly incidence of OHCA of 0.6/1000 inhabitants, with 62.4% unwitnessed, and 74.7% occurring at a private residence, figures comparable with those from the industrialized western world. During part of that 10-year period, the effect of a public awareness campaign on OHCA incidence and mortality rates was evaluated. Intensive media-directed public information was provided on the issue of sudden cardiac arrest, in an effort to make the layman aware of the necessity and required rapidity to find medical help in the case of complaints suspect for an acute heart ailment. As discussed by Nehme et al.,7 previous studies evaluating outcome of the value of layman information about cardiac complaints and the required immediate action gave mixed results. While some studies reported an increased use of the EMS after media information, it did not necessarily translate into a reduction of delays in seeking medical help. In their study, Nehme et al. found during the media-supported public awareness campaign a 15.2% reduction in the mean monthly incidence of OHCA, and a 16.6% reduction in death from OHCA. This reduction was also observed in the 2 months after the end of the public awareness campaign. A greater effect was found in males above 65 years, and a lower incidence of unwitnessed OHCA and in OHCA patients with initial non-shockable arrests. What can we conclude from this study? It shows that intensive mass media education about cardiac warning signs resulted in a substantial reduction in OHCA incidence and death, but only during the period of the public awareness campaign and shortly thereafter. Some questions remain. One would like to know if were there differences in the number of EMS calls during or shortly after public education and were results of the resuscitation attempt better during that time because of shortening of the time interval between onset of chest pain and call for EMS. Of the OHCA cases, 37% were women. They showed less of an impact from the public awareness campaign. It is known that women often have warning signs different from those in men. Also, they have a different age distribution of OHCA. Another point one would like to know is whether the effect of extensive and repeated education is the same or different in people with or without a cardiac history. To reduce OHCA and to improve outcome of a resuscitation attempt, education of the layman is important, not only about heart attack symptoms but also about what to do in the case of an OHCA. In many European countries, children now learn about this in school. This is part of our continuing efforts to build networks in the community of trained volunteers, with easy access to AEDs and optimal communication with EMS, resulting in improved survival after OHCA. The need to develop these facilities in the community is based upon our current inability to identify most of the OHCA victims before the event. Unfortunately, as indicated in Table 1, in spite of many efforts in that direction, we do not have risk assessment techniques with sufficient positive predictive accuracy to identify a significant portion of future OHCA candidates.8 The profile of the four categories of people dying suddenly out-of-hospital and our current ability to predict that risk before the event Hx, history; LVEF, left ventricular ejection fraction; SCD, sudden cardiac death. The profile of the four categories of people dying suddenly out-of-hospital and our current ability to predict that risk before the event Hx, history; LVEF, left ventricular ejection fraction; SCD, sudden cardiac death. Therefore, the key challenge in the case of an OHCA is to make the time interval between arrest and the start of the resuscitation attempt as short as possible. This is presently the only available option to increase substantially OHCA survival and decrease the incidence of cerebral damage with its long-term costs. A step forward is the increasing use of mobile health application solutions such as the ability to inform trained layman resuscitators by phone about the location of the victim and the nearest AED.9 However, as recently suggested, the best way to eliminate avoidable delays between OHCA and defibrillation would be to develop a wearable device that automatically alerts bystanders, and transmits the location of the victim to the nearest AED and to the EMS in case of an OHCA.10 To develop such an artefact-free reliable device will be quite a challenge. In order to make it successful in substantially reducing death from OHCA, it is obvious that such an arrest alarm device will require the necessary facilities in the community for rapid resuscitation such as readily available trained volunteers, adequate AED density, and wllingness of the EMS organization to support such an approach. As shown in the article by Nehme et al.,7 therefore, even in the presence of such a device, continuing information of the layman about warning signs of an acute cardiac ailment and the necessity of being trained in cardiac resuscitation remains crucial. In recent years we have seen the growing role of social media. The young no longer read newspapers or watch TV. This means that to create public awareness about OHCA we might also have to revise our methods of education and adapt them in relation to different age groups! Conflict of interest: none declared.