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CDC Telebriefing Transcript
Dr. George Mensah Discusses Sudden Cardiac Deaths

February 14, 2002

CDC MODERATOR: Hello. This is Kathy Harben with CDC's National Center for Chronic Disease Prevention and Health Promotion. Happy Valentine's Day.

Today's topic is State-Specific Mortality from Sudden Cardiac Death in the United States for the year 1999. Joining us is Dr. George Mensah, and that's spelled M-e-n-s-a-h. Dr. Mensah is chief of CDC's Cardiovascular Health Program. Also with us is Dr. Z.J. Zheng, and that is spelled--his first name is Z-h-i-J-i-e, last name Zheng, Z-h-e-n-g. He's the lead author and a CDC cardiac epidemiologist. Dr. Mensah will have a few comments and then we'll turn to questions.

DR. MENSAH: Thank you very much, Kathy. Good afternoon. As Kathy said, I am George Mensah. I am a medical doctor and a heart disease specialist, and chief of CDC's cardiovascular health program. I am joined by Dr. Zheng, who is also a medical doctor and a heart disease epidemiologist. He took the lead on this research work.

We want to thank you first for the opportunity to share with you some of the new information about the burden of heart disease and especially about the proportion of heart disease deaths that occur outside of hospitals or in emergency rooms in this country, and for the rest of this conference we are defining these deaths as deaths outside of hospitals or death in emergency rooms after sudden cardiac death.

Now just for a little background, as most of you know, cardiovascular diseases, including heart attack, stroke, and high blood pressure, kill nearly a million Americans every year, making it the leading cause of death among men and women in all racial and ethnic groups.

About 62 million Americans live with some form of cardiovascular disease. In fact, this year alone heart disease is expected to cost our nation about $329 billion in health care expenditures and lost productivity.

This week's morbidity and mortality weekly report includes findings from our latest study on sudden cardiac death or sudden heart disease death, as I defined. About 63.4 percent of heart disease deaths in 1999, that's more than 460,000 (inaudible), and nearly half of all heart disease deaths occurred outside of the hospital, according to the latest death certificate data from CDC's Center for National Health Statistics.

Leading the states with a high percentage of sudden cardiac deaths were Wisconsin. 72.9 percent of all heart disease deaths in that state were sudden, followed by Idaho, at 72.2 percent, Utah at 72.1 percent, Colorado at 71.3 percent, and Oregon at 71 percent.

Just for comparison, the states with the lowest percentages of sudden cardiac death still had percentages close to 60 percent. For example, Hawaii had 57.2 percent, Arkansas had 57.5 percent, New Jersey was 57.6 percent, Kentucky was 58.4 percent, and Oklahoma was 58.5 percent.

It's important to mention that women were more likely than men to die outside of the hospital. About 52 percent of women died before reaching the hospital, compared to 42 percent of men.

CDC and its partners are concerned about these sudden cardiac deaths and are working with partners of the American Heart Association and the American (inaudible) of Cardiology to raise awareness about the symptoms of heart disease, particularly heart attack, and to encourage people to seek immediate help.

Uncommon symptoms that the public and health care providers should watch for include breaking out in a cold sweat; having nausea and lightheadedness; but more common symptoms are chest discomfort or pain, a pain or discomfort in one or both arms or in the back, in the neck, the jaw, or stomach and, of course, shortness of breath.

Treatment of heart disease, including heart attack and cardiac arrest, is time-dependent. The earlier a patient is treated, the better the outcome. When an emergency occurs, the public should immediately initiate the chain of survival, call 911, attempt cardiopulmonary resuscitation or CPR, and use other (inaudible) external defibrillators when they're available until emergency personnel arrive.

People can reduce their chances of developing heart disease in the first place by being physically active, eating a diet low in fat and high in fruits and vegetables, and stopping or never starting smoking.

Currently CDC funds about 28 states to assess the burden of heart disease and stroke in (inaudible) and to develop partnerships to reduce that burden mainly through heart-healthy policies that encourage physical activity and good nutrition.

Thank you for listening, and we will be very happy to answer any questions that you have about these findings.

CDC OPERATOR: And, ladies and gentlemen, once again, if you do have a question, at this time please press the one. And we do have a question from the line of Ira Dreyfuss with AP Radio. Please go ahead.

QUESTION: This is a question relating to exercise. Being physically active can reduce the risk of all causes of mortality and coronary artery problems, but does CDC have a specific recommendation on physical activity for sudden death?

DR. MENSAH: This is Dr. Mensah. It's a very good question. You know, the Surgeon General's recommendation really is moderate levels of physical activity most of the days of the week, and frankly, that we can assume is what CDC supports, and we encourage, when we do educational activities, we encourage moderate levels of physical activity on most days of the week.

QUESTION: But does that mean specifically for cardiac, to reduce the risk of cardiac arrest?

DR. MENSAH: That's really difficult to say without having a specific study that looks at what parameters you give a patient and then assess the outcome. We do have some evidence in the literature, though, that in individuals who are above the 80th percentile of say physical activity in their population, their risk for sudden cardiac death is cut by more than half, and that's data from Seattle, Washington. But, again, we don't have at CDC any specific study that looks at exercise recommendations and the impact on sudden cardiac death.

CDC OPERATOR: Our next question is from the line of Kim Dixon with Bloomberg News. Please go ahead.

QUESTION: Hi. Thanks. I'm trying to find out or figure out some sort of comparison to this number, this number that 63 percent of all cardiac disease deaths are heart attacks, basically. Is this number increasing from previous years? And, if so, can you give me some sort of, you know, percent or some sort of basis to judge how things are changing?

DR. MENSAH: I think the first part that you mentioned is that these are not really all heart attacks. They are sudden deaths from--related to heart disease. It could be from heart muscle disease, it could be from arrythmia, so they are not all heart attacks.


DR. MENSAH: And the second part of your question was?

QUESTION: Was what is the comparison number? Are sudden cardiac deaths of the percentage of cardiac disease deaths, are they going up? I mean what's--the 63 percent, what was that five years ago?

DR. MENSAH: It's a very important question. One thing we say is there really isn't a very consistent pattern, although we know that if you look at the data for out-of-hospital deaths, and I think here what we have to be very clear, if you look at out-of-hospital deaths in 1989 and look at the trend through 1998, there has been an increase. We're talking by about 36 percent in 1989, about 41 percent around 1993, and 46 percent in 1998.

I should mention that this report was not a study that was specifically designed to look at this, so we cannot tell you whether this is a significant change or what are the determinants of that, but just looking at the proportion of out-of-hospital deaths alone, it looks like there has been an increase.

QUESTION: Is the proportion of out-of-hospital deaths due to sudden cardiac death?

DR. MENSAH: From this definition, yes. And, again, what we're calling the out-of-hospital sudden deaths are all the deaths that an be
related to the heart, meaning being certified on the death certificate as caused from the heart, and those deaths that were not in the hospital or, in this case, were not also in the emergency room.

The proportion in the emergency room has sort of gone down a little bit. We can't say that that's a significant change. If you look for comparison, in 1989, it was about 18 percent. It was still 18 percent or 18.7 percent in 1993, and about 16 percent in 1998.

So there there is less confidence in saying that there has been a significant change, but if you restrict it to only the out-of-hospital deaths, then that has increased.

QUESTION: Could you repeat the out-of-hospital numbers?

DR. MENSAH: The out-of-hospital numbers--

QUESTION: '89, '93, and '98?

DR. MENSAH: 1989 was about 37.8 percent, and 1991 was 38.6 percent. 1993 was about 39.2 percent, and actually this, I believe the full report in the morbidity and mortality publication would have the exact percentages also. The--in the previous publication that looked at sudden cardiac deaths from 1989 to '98, the trend is charted, and you would have those exact proportions.


DR. MENSAH: The most recent was 1998, and that was 46.7 percent for the out-of-hospital deaths.

QUESTION: Okay. Okay. All right. And do you have a hypothesis as to why that might be happening? Those are my last questions.

DR. MENSAH: Well, the--the one that we're most concerned about is access to care and also people acting in time when they have symptoms of heart disease. Again, this study was not designed to look at it, so it is not the best source for identifying the determinants of that change. But definitely if more people were to take very seriously what constituted the signs and symptoms or the early-warning signs of heart disease and heart attack, definitely the number of people dying outside of hospitals could go down, and you would see an increase in more people reaching the emergency room (inaudible) and people getting to care facilities much, much earlier.

QUESTION: Okay. Thank you.

DR. MENSAH: Thank you very much.

CDC OPERATOR: And we have a question from the line of Richard Donex with the National Public Radio. Please go ahead.

QUESTION: Okay. First, just to clarify something you mentioned a minute ago in response to the Bloomberg reporter's question. I missed something. When you talked about 18 percent in '89 and so, what were those referring to?

DR. MENSAH: Okay. Again, remember that sudden cardiac death has been defined very differently in the literature, and so we want to make sure that for this conference while we are talking about these numbers that we are talking about the same thing.

For the out-of-hospital deaths, they can be deaths in the emergency room or they can be people who get to the emergency room and are pronounced dead, or people who are found dead at room. And so the first percentages that I gave were the proportion of people who are either dead on arrival in emergency room or those who died in the emergency room, not in hospital. That--those were the 18.5 percent in 1989 and 16.7 percent in 1998. And there, there really isn't confidence in any trend, but the higher percentage is the proportion of deaths that are out of the hospital. So not in the emergency room and not dead on arrival, but in the--found dead at home or dying before they reach the hospital, and those were a much higher proportion with about 37.8 percent in 1989, and that's where there is a trend of an increase with 46.7 percent in 1998.

QUESTION: And that is significant (inaudible)?

DR. MENSAH: We have to say yes because usually on these data, since we are dealing with populations, we very often don't talk of statistical, they're sort of the real numbers, and so the 46.7 percent is different from the 36.--37.8 percent.

QUESTION: Okay. Now if I--thanks for clarifying it. If I can get to my question. Is one of the issues underlying here that--I seem to recall that women who have heart attacks may have atypical symptoms that may not be identified or recognized as cardiac symptoms. Is that one of the issues that you think is behind the fact that there are a high proportion of women with out-of-hospital deaths?

DR. MENSAH: You're absolutely right. We believe that that's one of the factors. And, again, you recognize that it's definitely a complex issue. It's not just the lack of recognition of the signs and symptoms. That's an important part, but also having access to medical care would be an important part.

The--one of the major reasons we are very interested in this is we think if we can do some education, not just patients and families, but also health care providers or professionals, we can make a big difference and reduce the disparity between what we see in women and what we see in men.

QUESTION: Is there something we should mention, though, in talking about these data with respect to women about how the symptoms may be different in women rather than men? So what--you know, what should women be alert to other than the classic chest pain and so on?

DR. MENSAH: Probably a two-part message. I think the most important thing to emphasize is that the symptoms for heart attack in the majority of cases are similar between men and women, and so chest discomfort, tightness or squeezing in the chest, these are very important. And there are more similarities than there are differences, but women are more likely to have the atypical type of symptoms and, in fact, that's the reason why we may miss more women, and those tend to be the nausea or pain in the neck and pain in the back, jaw pain.

But, again, I think it's important to emphasize that in the majority of cases, we need to pay attention to the common symptoms and treat both men and women in the same fashion, with the same level of urgency and immediacy.

QUESTION: May I just have one more? Are there other people waiting here?

I know that there's been overall for a couple of decades, at least, probably more, a decline in the cardiac--or cardiovascular mortality and heart-specific mortality. I haven't heard anything in very--about very recent years. Does that continue, and does it continue at the same rate?

DR. MENSAH: It has continued, and I think that's one of the successes of the health care system, the National Heart, Lung and Blood Institutes campaigns to increase awareness for blood pressure education, all of these have helped. The death rate, not the number of people dying, but the death rate for heart disease has continued to go down. The death rates for stroke have also continued to go down.

In the case of stroke, the rate at which it's been decreasing has been a bit slower in the past decade than the previous two, three decades. But so the trend for the nation is downward.

QUESTION: So for heart, it continues to decline at the same rates as it had been in the '70s and '80s, or is it also declining slower?

DR. MENSAH: In general, the rate of decline has continued, and even the most recent data have continued. The--for stroke, it's much clearer to demonstrate that the rate has slowed down, that it's still declining. So there is more of a change in the stroke mortality rate decline than there is in the coronary mortality decline.

It's really important to emphasize, though, that because the death rate is decreasing, that means more people are living with heart disease, and especially as we do a better job in preventing people from dying from a first heart attack, it means more and more people are living with damaged hearts, and so they are at increased risk for having heart failure, at increased risk of dying prematurely and dying suddenly.

So death is important, but it's only half the story, and there are far more people living, 62 million, as we mentioned, who are living with some form of heart disease.

QUESTION: Thank you.

DR. MENSAH: Thank you very much.

CDC OPERATOR: Our next questions are from the line of Ted Verdunsky with WABE, Atlanta. Please go ahead.

QUESTION: Dr. Mensah, I hope you can hear me on this phone. I'm recording on it. I'll ask my question and then click off.

This is to me, having to tell the story briefly, a story about minutes, where minutes count, and I'm wondering as part of the education message you're trying to get across, you said this can be used in an educational context, what is in there about the person making sure they leave a list of their medications around, like if they're on Coumadin or something like that, or their power of attorney, or cell phone numbers? I wonder how many more lives would be saved if these things were handy when the EMTs arrived?

DR. MENSAH: You're absolutely right. I think the more information the emergency personnel have about the patient, the more likely they are able to help them. So, in general, I think physicians and nurses and other health care providers try to do a good job in helping patients recognize the importance of that.

For the purposes of sudden cardiac death, though, the time issue is so important because every minute makes a huge difference. We're talking about a 10 percent decrease in the likelihood that you would survive after a cardiac arrest. And so even though knowing about the medications, knowing about previous medical conditions and surgeries are important, when someone is down and they don't have a pulse, and you can't arouse them from shaking and it's cardiac arrest, 911 is the best, and looking at their medications and their other history certainly would help, but that should come later.

So the message we're trying to get out is it's important to know the signs and symptoms, both for the patient themselves, but also for neighbors and families to recognize what are the signs of the cardiac arrest, and to dial 911 and to get help immediately.

CDC OPERATOR: And once again, ladies and gentlemen, if you do have a question, please press the one at this time.

We do have a follow-up from Richard Donex. Please go ahead.

QUESTION: Yes, just to follow up on what you said. Every minute that passes, there's a 10 percent decrease in survivability, is that what you said?

DR. MENSAH: That's correct. It's really--it's really pretty serious.

QUESTION: I think--don't we normally think that after three or four minutes without a pulse, that somebody is a goner?

DR. MENSAH: We would say that. I think if we know, as you recognize, sometimes the difficulty is knowing when the event really happened. If you find someone whose pulse (inaudible), it's never clear when it happened. So we always assume that it might have been sooner than we think, so we should still go ahead and call 911. But in general, the more time you waste, if you waste five minutes, that person's likelihood of surviving that cardiac arrest is already decreased by 50 percent. But I think what we do not want to say is for someone to make the assumption that perhaps the person has been pulseless or has been down for an hour or two so it's a lost cause. I think that may not be appropriate. Unless we know for a fact that this is--we're talking hours and hours and days, I think every time we see an opportunity for instituting either CPR or calling 911 and getting help immediately, I think we should do that.

QUESTION: And to Ms. Harvin, no further questions in queue.

CDC MODERATOR: Okay. It looks like we're getting close to the end of the half hour, then. If there are no more questions, we'll sign off.

CDC OPERATOR: And, ladies and gentlemen, that does conclude your conference for today. Thank you for your participation, and you may now disconnect.

Listen to the telebriefing

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