The Disparity of Care in SCA
11 August 2008, 9:45 AM EDT
"The disparity of care" in sudden cardiac arrest (SCA) response and prevention is a fancy way of describing a simple, yet unfortunate truth: white men are more likely to survive sudden cardiac arrest events and to be screened and treated with medical therapy to prevent sudden cardiac death than women or minorities.
SCAA hosted an "Ask the Experts" session with Dr. Kevin Thomas of the Duke University Medical Center, who responded to questions about this and related issues regarding improving cardiac health care for women and minorities. Dr. Thomas was a cardiovascular fellow and was honored with the Ralph Snyderman, MD, Graduate Medical Education Research Award while serving his residency at Duke. Since joining the Duke Medical staff, he has lead research in several areas related to the subject of health care disparities.
Read more about Dr. Kevin Thomas
Transcript
peppermintpatty:
I had my ICD installed in April 2008. I used to do a cardio work out at the gym in which I would push my heart rate between 134-150 for 30-45 minutes. Now I am on a Beta Blocker and my heart rate cannot reach the Cardio zone. My question is whether exercise at a lower heart rate has cardio benefit? If I never exercise at 135-150, will my heart become weaker. I notice that I do not have the stamina to do prolonged exercise. Its a problem for me, but is is a problem for my heart?
Dr. Kevin Thomas:
For many patients who have an ICD a beta blocker is an important medicine to strengthen the heart, prevent recurrent heart attacks, control blood pressure and to prevent abnormal heart rhythms. Exercising regularly is an important part in keeping your heart strong. Despite your heart not achieving the rates it did before the medicine was initiated you are still having significant cardiovascular benefit and it is unlikely your heart will weaken because of this observation. It is common to experience a decrease in your stamina when the beta blocker is initiated but that should improve once your body acclimates to the medication.
michaele:
My Mother recently died from SCA. Could she have been saved if someone knew CPR?
Dr. Kevin Thomas:
The answer to your question is not straightforward. SCA accounts for 335,000 deaths annually. 36-81/100,000 out of hospital cardiac arrests are treated by emergency medical services. So many SCA’s are unwitnessed and thus lead to poor outcomes.
Only 6% of SCA survivors live to be discharged from the hospital, so even if they are found and brought to the hospital survivors are relatively uncommon.
Given these considerations it is hard to know whether CPR or emergency services could have changed the outcome. During SCA time is of utmost importance and the quicker someone is found the better their chances of survival. The other variable is what caused her sca some conditions are more treatable and responsive than others.
It is important to recognize that your mother’s situation places you at higher risk and it is important to discuss this consideration with your doctor.
Only 6% of SCA survivors live to be discharged from the hospital, so even if they are found and brought to the hospital survivors are relatively uncommon.
Given these considerations it is hard to know whether CPR or emergency services could have changed the outcome. During SCA time is of utmost importance and the quicker someone is found the better their chances of survival. The other variable is what caused her sca some conditions are more treatable and responsive than others.
It is important to recognize that your mother’s situation places you at higher risk and it is important to discuss this consideration with your doctor.
Jack:
What percentage of SCA victims actually suffer a heart attack (MI)?
Dr. Kevin Thomas:
Myocardial infarction (heart attack) is one cause of sudden cardiac arrest.
According to the Heart Rhythm Society 75% of patients who die of SCA show signs of a previous myocardial infarction.
According to the Heart Rhythm Society 75% of patients who die of SCA show signs of a previous myocardial infarction.
Noreen G.:
I really don’t have a primary care physician. I see my OB-GYN for my annual check-up, and she also does a physical exam and standard lab work but not an EKG. My mother and father both had coronary artery disease, but I’ve always just assumed that it was due to poor eating and exercise habits. Do I need to consult with a heart specialist?
Dr. Kevin Thomas:
If you have a family history of coronary artery disease, particularly if it was diagnosed in your parents or other first degree relatives (mom, dad, brother or sisters) before the age of 55 that is a risk factor for you. In my opinion an EKG should be a part of your annual exam at least every 3-5 years. Many OB-GYNs are general practitioners but given your family history I would suggest having an internist see you annually to assess your risk and to perform the necessary screening tests not necessarily a cardiologist.
Mark:
I work at a community health clinic. Language barriers are a big issue, and we are often relying on children to interpret for their parents. The clinic has a policy of not allowing any “branded” material from medical corporations which might promote a certain brand of drug or company. If the AMA or the government really wanted to make a difference, developing a good library of information in some foreign languages would be of tremendous help. Do you have any thoughts on this?
Dr. Kevin Thomas:
Language concordance is paramount in providing high quality health care to minority populations. Unfortunately far too often there are situations such as those you describe. This is increasingly recognized as a problem and organizations such as CMS/JCAHO are requiring clinics and health systems to consider this issue and to provide better resources. The impetus for enforcing bi-lingual learning materials and staff resources must come from the stakeholders of the health system to ensure this change is widespread.
Mary L.:
I’m an African-American woman, active in the business community and my church. I sometimes feel inundated with messages about how African-Americans are at “higher risk” for a variety of health care issues (prostate cancer, breast cancer, heart disease, diabetes, etc.). Are we at “higher risk” or “under treated or under diagnosed?”
Dr. Kevin Thomas:
All of the above. African Americans are at higher risk for many of the conditions above and also diabetes mellitus, obesity, renal disease, and the list goes on. African Americans are also plagued by heath care disparities that manifest as lack of access to heath care providers, no insurance, less likely to receive care by subspecialists, and to receive the latest, newest medications and procedures. These disparities lead to worse health outcomes. That being said, there are opportunities for African Americans to improve their health by exercising more, improving eating habits, and focusing on a healthy lifestyle.
Linda:
My husband’s father died nearly 30 years ago at a young age (47). I did not know him and no one seems to have all the details of his death, but it has always been described as he died of a “massive heart attack in his sleep.” As I learn more about sudden cardiac arrest, I of course look at my husband and our three children and worry about their risks. All three of our boys play competitive sports. I have thought about getting them a cardiac screening but it doesn’t seem to be something other parents are doing and it has never been brought up by coaches or the school. My husband thinks I’m just being overly cautious so I would be interested in your thoughts.
Dr. Kevin Thomas:
The details of the death of your husband’s father are very important. If in fact he had SCA as a result of a myocardial infarction or heart attack that is very different than if he had SCA without evidence of heart blockages or a heart attack. In any event it is important that your husband have routine annual physical exams that tests him for diabetes, checks his cholesterol, and maintains a healthy lifestyle with exercise and good eating habits. In regards to your children, their risk is largely predicated on your husband’s and your genes. If your husband died suddenly that would place them at a greater risk, The issue of screening children who participate in competitive sports for cardiac abnormalities remains controversial. Overall the risk of SCA is extremely low (chance of occurrence is 1 out of 100,000).
The American Heart Association recommends a more cardiac-specific exam involving an EKG, echocardiogram or stress test for patients (even student athletes) who meet one of these criteria:
Personal history of syncope (fainting) or near syncope, excessive shortness of breath or fatigue, chest pain, hypertension, family history of unexplained or premature sudden cardiac death, hypertrophic obstructive cardiomyopathy or dilated cardiomyopathy, Marfan’s,Syndrome or Long QT Syndrome, an exam that detects a notable pathologic murmur, brachial-femoral delay, Marfan’s stigmata, or hypertension.
I also think it is important to have an Automated external defibrillator at all games.
The American Heart Association recommends a more cardiac-specific exam involving an EKG, echocardiogram or stress test for patients (even student athletes) who meet one of these criteria:
Personal history of syncope (fainting) or near syncope, excessive shortness of breath or fatigue, chest pain, hypertension, family history of unexplained or premature sudden cardiac death, hypertrophic obstructive cardiomyopathy or dilated cardiomyopathy, Marfan’s,Syndrome or Long QT Syndrome, an exam that detects a notable pathologic murmur, brachial-femoral delay, Marfan’s stigmata, or hypertension.
I also think it is important to have an Automated external defibrillator at all games.
Carolyn:
My sister has high blood pressure and her doctor says she’s a “borderline” diabetic. I’ve tried to get her in to see a specialist, but she insists that the general practitioner she has seen for almost 40 years is the only doctor she trusts. Maybe if he referred her to a specialist she would take his advice, but that hasn’t happened. Any advice?
Dr. Kevin Thomas:
Your sister’s situation brings up several important issues. Your sister seems to have a lot of trust and faith in her general practitioner which is an important part of her health care. Individuals who have that type of relationship with their physician tend to be more compliant with their medications and adherent to a healthy lifestyle. This is only helpful if her general practitioner is treating her appropriately and telling her the right things to do. With hypertension and borderline diabetes, her general practitioner should be capable of managing these diseases. A specialist is not always needed in these circumstances. Given that she has these risk factors it may be reasonable to refer her to a cardiologist for a cardiac work up if she is having symptoms or is at an increased risk of significant coronary disease based or her risk profile which her GP should be able to discern. If she is not following the recommendations of her GP I think it is unlikely a specialist would be more successful.
Jose:
Please help with some advice on how to talk to my wife about her health. She is 64-years old. She had what her doctor called a “minor” heart attack about three years ago. She has cut back on her smoking but still smokes, and rarely exercises. She says she “feels fine” but I can see that she is often out of breath after climbing a flight of stairs or similar activity. Since nagging about changing lifestyle habits doesn’t work and she doesn’t bring up these issues with her doctor, I’m hoping you have some other suggestions.
Dr. Kevin Thomas:
This is difficult; denial and is a common theme among many people. Perhaps you can motivate her by telling her how important it is for her to change her lifestyle because you want to have her around to enjoy life with of for her grandchildren or children if appropriate. Using other people is sometimes a good motivator. You need to be willing to exercise with her. She needs to stop smoking, as even one cigarette a day is dangerous. Also you may want to try support groups in the community or with friends. Testimonials are often very influencing hearing other individual’s story. Stay with it despite the frustration, your love and support will help in the end
Miguel:
As a 29 year-old, healthy male, what basic questions should I be asking my doctor about my heart and its health? I have a heart murmur, but want to be sure that I'm not at risk for other heart disorders. I think heart failure runs in the family -- my dad had a heart attack at age 49, but didn't have any indication that he was at risk.
Dr. Kevin Thomas:
Your father’s history certainly puts you at risk. Preventative maintenance will be key for you. You should be screened annually for cholesterol, diabetes and hypertension. You want to reduce the number of risk factors that you have for developing heart disease. And since you can’t change what happened to your Dad you must focus on the things you can change. Diet and exercise are important. Heart murmurs are typically fairly common in young patients and shouldn’t be a big concern, That withstanding if your physician is concerned about the character of your murmur a cardiac ultrasound (echocardiogram should be obtained.
Sandy:
As a student, sometimes it is difficult to eat a balanced, heart healthy diet. What are the best foods to eat to avoid potential "heart issues"?
Are there particular foods to avoid altogether?
Are there particular foods to avoid altogether?
Dr. Kevin Thomas:
I can appreciate your situation; busy with school and not a lot of financial resources, and it can be much more expensive to eat healthy. Try to avoid eating fried foods every day all things in moderation cut it back to 1 day every other week .Baked or steam foods are much healthier. Most college students get into trouble because they snack frequently. Snack on fruits and vegetables instead of candy bars, and potato chips. Trail mix is also a good alternative.
Lastly incorporate exercise into your regular routine.
Lastly incorporate exercise into your regular routine.
Norma:
My husband and I are in our early 50s. We participate in a HMO so don't have a strong relationship with any particular personal physician. We both have been given similar advice at our most recent annual check-up:
quit smoking, lose weight, exercise more and reduce sugar/salt in-take.
Blood pressure, cholesterol and blood sugar are "elevated" but nothing too alarming according to the doctor. I know you can't give specific medical advice to complete strangers, but I'm hoping you can give some general advice. Where do we start? Quit smoking first? Exercise? Diet? Trying to tackle it all at once seems too overwhelming. I think if my husband and I work together on a plan that is achievable, we are likely to be more successful, but I don't know how to proceed.
quit smoking, lose weight, exercise more and reduce sugar/salt in-take.
Blood pressure, cholesterol and blood sugar are "elevated" but nothing too alarming according to the doctor. I know you can't give specific medical advice to complete strangers, but I'm hoping you can give some general advice. Where do we start? Quit smoking first? Exercise? Diet? Trying to tackle it all at once seems too overwhelming. I think if my husband and I work together on a plan that is achievable, we are likely to be more successful, but I don't know how to proceed.
Dr. Kevin Thomas:
Not knowing the specifics of your respective test results I would offer the following.
Stopping SMOKING should be the highest priority. This is by far and away the worst thing about your health and should be stopped ASAP. There are now many ways to assist with this including using medication.
Exercise again is important. Start slow with walking a few times a week for 30 minutes and advance to 5 times a week which is currently recommended.
Diet can be an extremely effective way to lose weight, and improve your test results in all categories. Again try starting small cutting out all of the sugared drinks in your diet you will be amazed at the results
Good luck.
Stopping SMOKING should be the highest priority. This is by far and away the worst thing about your health and should be stopped ASAP. There are now many ways to assist with this including using medication.
Exercise again is important. Start slow with walking a few times a week for 30 minutes and advance to 5 times a week which is currently recommended.
Diet can be an extremely effective way to lose weight, and improve your test results in all categories. Again try starting small cutting out all of the sugared drinks in your diet you will be amazed at the results
Good luck.
That concludes our interview today. Thanks to Dr. Thomas and all our participants. This has been a great discussion.
