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Automatic external defibrillators (AEDs) are machines that are designed to be used by non-medical personnel in the event of a witnessed sudden collapse. The AED is connected to the chest of the patient and automatically detects the patient’s heart rhythm. If the AED detects a rhythm that requires an electric shock, the AED delivers the shock and monitors the rhythm until paramedics arrive. The time between collapse and delivery of the first shock is critical to survival. So it was hoped that home AEDs would help patients who are at very high risk of heart attacks.
A large study which will be published in the New England Journal of Medicine tomorrow studied 7,000 patients who had a recent heart attack but didn’t need an implantable defibrillator. They were randomized to two groups. One group received home AEDs, and the families were instructed that in the event of a witnessed collapse, the family member would use the AED, call paramedics and then do CPR. The second group did not receive AEDs, and the plan in the event of a witnessed collapse was to call paramedics and do CPR. The groups were followed for about a year and a half.
Disappointingly the groups did similarly, with about 2% of the patients dying in each group annually. Part of the reason that the group with AEDs didn’t do better is that they were used so infrequently. In a group of 7,000 patients, 123 cardiac arrests happened at home, and only 63 were witnessed. The AED was used on only 29 patients, and only 14 patients had rhythms for which shocks were delivered.
This bad news may actually be a victory for the medical care of heart disease. From other studies a decade ago, the authors of this study expected an annual death rate closer to 4% in this high risk group, but the medical treatment of heart disease has improved substantially in that time, with more aggressive goals for cholesterol lowering and more universal use of aspirin and proven blood pressure medications. So patients are surviving longer after heart attacks and fewer are in the desperate situation in which an AED can help.
So if you’ve had a heart attack, don’t invest in that external defibrillator. It’s a much better bet to take all the right medications and never need an AED.
Learn More:
The study in the New England Journal of Medicine: Home Use of Automated External Defibrillators for Sudden Cardiac Arrest
An editorial in the same issue: Can Home AEDs Improve Survival?
Patients paying doctors directly for their care is best for patients, best for doctors, and best for the country. Most of my patients know that this simple idea has been my obsession for the last few years. Initially, I thought this idea was just a good way to reorganize my practice. But now, with Medicare within a decade of insolvency, with decreasing numbers of medical students choosing primary care as a career, with increasing numbers of patients finding good primary care either unavailable or unaffordable, it is an idea that deserves broader attention.
Coincidentally two op-ed articles this week made the point that insurance for routine care is a big part of what’s wrong with American healthcare.
Tuesday, Jonathan Kellerman, a psychologist and a renowned author of mystery novels, wrote an op-ed in the Wall Street Journal comparing health insurance companies to the Mafia.
Today, the LA Times published an op-ed (by me!) asserting that customer service is better in most doughnut shops than in most doctors’ offices, and insurance interference is partly to blame. In it, I try to convince doctors to give up the insurance business model for simple retail medicine – the doughnut shop model.
I urge you to read both articles and pass them around to friends and colleagues, especially to physicians. Thank you for spreading my obsession.
Learn more:
“Dollars to Doughnuts Diagnosis” by Albert Fuchs
“The Health Insurance Mafia” by Jonathan Kellerman
Tangential Miscellany:
Happy Passover to all my Jewish readers!
Heart Disease, New Study, Prevention
New Feature
Ask the Doctor
I’ve read a lot in the news in the last two weeks scary stuff about Singulair. Should I stop taking it?
– Jeff K.
About two weeks ago the FDA released a communication that it was investigating the incidence of suicidal thinking and mood changes in patients taking Singulair, a medication used to treat asthma and nasal allergies. No connection between Singulair and these symptoms has been established. So there’s no reason to stop your medication, but obviously let your doctor know about any changes in mood or any thoughts of hurting yourself.
Please email me health-related questions that you think would be of general interest. Unless you ask me not to, I’ll identify you only by your first name and last initial.
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It’s Never Too Late to Treat High Blood Pressure
Preventive care in older patients is always a tricky balance. As patients get older, the conventional thinking goes, their life expectancy decreases, so there is less opportunity for preventive care to make a difference over many years. Also, older people tend to be more sensitive to medication side effects, so the likelihood of harm of any therapy is greater. For example, if lowering blood pressure only prevents strokes and heart attacks after many years, are older patients going to live long enough to benefit?
A study in the New England Journal of Medicine that will be published in the May 1 issue definitively answers that question. The study randomly assigned 3845 patients who were 80 or older and had high blood pressure to receive either blood pressure lowering medication or placebo. They were followed for an average of about two years.
Surprisingly, the patients on the blood pressure medications did quite a bit better without any increase in adverse effects from the medications. The patients on blood pressure medications had fewer strokes, heart attacks and death from any cause than those on placebo. For every about 60 patients taking medication instead of placebo for one year, one cardiovascular event was prevented. That’s much more benefit than was expected in this age range.
So don’t give up on your blood pressure because you think you’re too old to have to worry about it.
Learn more:
Despite many encouraging advances in the prevention, diagnosis and treatment of heart disease, heart attacks remain the largest cause of death in the US. Many of those heart attacks happen suddenly and cause a life-threatening abnormal heart rhythm called ventricular fibrillation. Patients frequently suddenly collapse, and without prompt restoration of a normal heart rhythm, survival is unlikely.
There are two critical factors that determine whether the patient will survive without serious brain injury. The first is the time from collapse to restoration of normal heart rhythm, which usually happens through the use of an electrical defibrillator. The second factor is whether the patient receives CPR during that time.
This is a very difficult subject to study since obviously patients can’t be randomized to different groups. (Who would sign up for placebo CPR?) The recommendations also have to be simple enough to be taught to the general public and then remembered and executed during a very stressful time. Despite these limitations, the recommended CPR procedure has undergone many revisions since I first learned CPR.
This week, the American Heart Association took another step in making CPR something that anyone can do. They removed the mouth-to-mouth breathing from the algorithm and just left the chest compressions. The reason is that in sudden collapse due to a heart attack the lungs are already inflated with air, and the blood is already oxygenated. So artificial respiration isn’t needed, just artificial circulation. These new recommendations also remove the potential for transmission of infection from mouth-to-mouth contact.
The new recommendations are incredibly simple. If you see someone collapse:
Learn more:
FOXNews article about the new CPR recommendations
New CPR recommendations on the American Heart Association website
Statistical trends from the Centers for Disease Control on the 5 leading causes of death in the US
Tangential Miscellany:
This week, the popular media all decided to debunk the myth that drinking 8 glasses of water a day has any health benefits, as you can read in these articles from Reuters, Chicago Tribune and Slate. My regular readers learned that last year.