Heart disease affects millions across our country and the state of Arkansas. The there are many negative health effects of heart disease. They include death, heart failure, arrhythmias, and risk of future stroke or heart attack. These are life altering events that represent a significant health burden nationally and locally. Heart disease and stroke accounted for 14% of total health expenditures in 2013-2014, with an annual direct and indirect cost of over $300 billion. The diagnosis, acute care, and long-term treatments are costly and ccumulative¹. In Arkansas, the total hospitalization cost for heart disease exceeded $100 million in 2014². 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 MI 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 flow³.  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 chin⁴ 

The number of Arkansas per 100,000 population hospitalized is a simple representation of how many Arkansans require significant medical attention for an AMI. Data was derived from discharge information as reported by the The Healthcare Cost and Utilization Project. This metric helps to demonstrate the significance of the problem, as well as portray the burden it places on our healthcare system. 

The hospitalization rate has remained relatively stable nationally and in Arkansas, with a slight decline since 2012. However, the Arkansas rate remains higher. Most recently the national and Arkansas rates were 190.9/100,00 and 223.3/100,00 respectively.

Source: ¹ Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K., Haase, N., . . . Hong, Y. (2018). Heart Disease and Stroke Statistics—2008 Update. Circulation,137(12). doi:10.1161/circulationaha.107.187998

Source: ² Heart Disease Mortality Disparity Fact Sheet. Retrieved March 28,2018 from https://www.healthy.arkansas.gov/images/uploads/pdf/2018_Heart_Disease_Mortality_Disparity_Fact_Sheet.pdf

Source: ³Heart Disease Facts & Statistics. Retrieved from https://www.cdc.gov/heartdisease/facts.htm

Source: ⁴Angina (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 in Arkansas:

 
• 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 hospitalization 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 hospitalization rate.

The ADH and Arkansas Heart Attack Registry have also implemented multiple quality improvement initiatives that will contribute to lower hospitalization 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.