Coronary heart disease, often referred to simply as heart disease, includes a spectrum of causes that all lead to eventual blocking of the important arteries on the heart. These blood vessels provide oxygen-rich blood to the heart, allowing it to effectively pump blood to the body. In patients with heart disease, these vessels are occluded. Most commonly this occlusion is due to a process called atherosclerosis.  In atherosclerosis, a plaque builds up inside the arteries causing occlusion of the blood flow¹.  When the occlusion becomes significant enough, the heart tissue can be damaged, through a process called ischemia resulting in an acute myocardial infarction (AMI) or heart attack. Coronary artery occlusion, whether partial or full, causes ischemia leading to angina. Angina is chest pain or discomfort that is highly variable in presentation. It is often described as pressure with pain radiating down the arm or towards the chin². 

Heart disease is very common nationally, with 735,000 Americans experiencing a heart attack annually. This startling statistic is worsened with the fact that heart disease is responsible for 1 in 4 American deaths¹. In Arkansas, heart disease was the leading cause of death in 2016 according to the CDC³. 

The prevalence of heart disease is closely linked to the prevalence of its risk factors. Hypertension, high cholesterol and smoking are key risk factors, and 49% of Americans have at least one. Additionally, diabetes, obesity, poor diet, and physical inactivity all increase the risk of heart disease and future heart attacks¹. Diabetes, obesity, poor diet, and physical inactivity occur at rates of 14.8%, 35%, 30.1%, and 75.7%, respectively^4,5. One of the most concerning aspects of heart disease is it's relationship with heart attacks also known as acute myocardial infarctions (AMI). 

In an AMI the blood vessels that provide oxygen-rich blood to the heart become occluded, preventing the heart muscle from effectively pumping blood to the body. In patients with heart disease, these vessels are occluded. Most commonly this occlusion is due to a process called atherosclerosis.  In atherosclerosis, a plaque builds up inside the arteries causing occlusion of the blood flow⁶.  When the occlusion becomes significant enough, the heart tissue can be damaged, through a process called ischemia resulting in an AMI. Coronary artery occlusion, whether partial or full, causes ischemia leading to angina. Angina is chest pain or discomfort that is highly variable in presentation. It is often described as pressure with pain radiating down the arm or towards the chin⁷. 

AMI mortality rate includes all Arkansans that died directly due to an acute myocardial infarction reported as deaths per 100,000 individuals. This rate is a simple yet powerful indication as to the effectiveness of Arkansas's management of patients experiencing an AMI. This rate is compared to the national average for the same period of time. 

The Center for Disease control has demonstrated a national trend of decreasing mortality rate from AMI since 2010. This is reflected above, and this decrease in rate is currently down to 28.1 per 100,000 Americans. Unfortunately, Arkansas has not experienced a similar improvement. As the national rate decreases, the Arkansas AMI mortality rate has remained in the 70 per 100,000 Arkansans, with a recent increase to 84.3 in 2017.  

Source: ¹Heart Disease Facts & Statistics. Retrieved from https://www.cdc.gov/heartdisease/facts.htm

Source: ²Angina (Chest Pain). Retrieved from https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain

Source: ³  Stats of State of Arkansas, Retrieved March 28, 2019 from https://www.cdc.gov/nchs/pressroom/states/arkansas/arkansas.htm

Source: ⁴ State Briefs. Retrieved March 28, 2019, from https://www.stateofobesity.org/states/ar/

Source: ⁵Overweight and Obesity. Retrieved March 28, 2019, from https://www.cdc.gov/obesity/stateprograms/fundedstates/pdf/arkansas-state-profile.pdf

Source:⁶ Heart Disease Facts & Statistics. Retrieved from https://www.cdc.gov/heartdisease/facts.htm

Source:⁷Angina (Chest Pain). Retrieved from https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain

The following groups and organizations have been pivotal in the efforts to improve STEMI outcomes:
• American College of Cardiology 
• Arkansas Department of Health Tobacco Cessation and Prevention Branch 
• Arkansas Department of Health Trauma Branch – Stroke and STEMI Section 
• Arkansas Department of Health Chronic Disease Branch 
• Heart Disease and Stroke Prevention Coalition 
• STEMI Advisory Council

Reducing mortality rate for acute myocardial infarction (AMI) requires heart disease prevention as well as proper treatment of AMI when prevention is not sufficient. AMIs are precipitated by many risk factors. Some risk factors are non-modifiable which include age, sex, ethnicity, and family history. Other risk factors are modifiable, and can be actively targeted to decrease risk of AMI. These include: smoking, obesity, physical inactivity, high cholesterol, high blood pressure, smoking, and diet. It has been shown that smoking cessation, exercies, statin use, blood pressure control, and dietary changes directly causes a decrease in MI¹.  In patients that do experiences an AMI, the mortality rate can depend on how well they are treated. If a patient does not recieve proper and timely care, as outline later in this scorecard, they have an increased risk of a poor outcome².

However, some patients do not have access to the healthcare. This is often due to lack of insurance. According to the American Heart Association, 7.3 million patients with coronary vesel disease are uninsured. Without acess to healthcare, patients are unlikely to recieve the preventative treatments that are available. Additionally, they may be less likely to seek treatment in the case of an MI³. 

Source:¹ Mensah GA, Wei GS, Sorlie PD, et al. Decline in Cardiovascular Mortality: Possible Causes and Implications. Circ Res. 2017;120(2):366–380. doi:10.1161/CIRCRESAHA.116.309115

Source:² Karl Heinrich Scholz, Sebastian K G Maier, et al. Impact of treatment delay on mortality in ST-segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT-STEMI trial, European Heart Journal, Volume 39, Issue 13, 01 April 2018, Pages 1065–1074, https://doi.org/10.1093/eurheartj/ehy004

Source:³Access to Care retrieved from: https://www.heart.org/en/get-involved/advocate/federal-priorities/access-to-care

The Arkansas Department of Health (ADH)  boasts a Chronic Disease Council which has been created to address hypertension, diabetes, obesity, and other chronic diseases that are a significant burden for Arkansans. Many of these chronic diseases are important risk factors for AMI. Decreasing the incidence and prevalence of such chronic diseases will put fewer Arkansans at risk of AMI in the future, and lower the mortality rate.

The ADH and Arkansas Heart Attack Registry have also implemented multiple quality improvement initiatives that will contribute to lower mortality rates for Arkansas that suffer a STEMI.  These include:

(a) launching the Arkansas Heart Attack Registry which has resulted in the participation of 26 Percutaneous Coronary Intervention (PCI) capable hospitals in the program

(b) providing 12-lead EKG equipment for 6 providers serving 15 Arkansas counties to increase EMS capacity in assessing and managing STEMI patients

(c) creating a STEMI best practices operations toolkit to increase adherence to the latest evidence-based treatment guidelines

(d) developing a STEMI pilot program in the northeast and southern regions aimed at improving care coordination between EMS and hospitals

(e) providing online STEMI education on evidence-based practice for all physicians, nurses and pre-hospital providers in the state

(f) coordinating a multi-channel community awareness campaign to help Arkansans know the signs and know the importance of dialing 9-1-1 when heart attack is suspected.

The Arkansas Heart Attack Registry is in the planning and early implementation phase. In the future, the ADH STEMI Section plans to conduct hospital site visits to provide technical and quality improvement assistance registry data to help staff identify and close gaps in patient care.