NIH News Release
National Heart, Lung, and Blood Institute

Tuesday, July 4, 2000
4:00 p.m. EST
NHLBI Communications Office
(301) 496-4236

Education Study Increases Ambulance Use but Yields No Extra Improvement in Heart Attack Patient Delay Time

A community education study aimed at reducing patient delay time in seeking care for heart attack symptoms has shown increased use of the 9-1-1 emergency system but no extra improvement in delay time as a direct result of the campaign.

The study, which was sponsored by the National Heart, Lung, and Blood Institute (NHLBI), is published in the July 5 issue of the Journal of the American Medical Association.

The Rapid Early Action for Coronary Treatment (REACT) study is one of the first large-scale studies to evaluate the effects of community education on the time it takes people to recognize the warning signs of a heart attack and to seek appropriate medical help.

"Although the hoped-for improvements in delay time were not realized, the 20 percent increase in use of emergency medical services (EMS) is encouraging. An ambulance can bring medical care to the patient quickly, and patients who arrive at the emergency department in an ambulance get taken care of faster. Early treatment is vitally important for both survival and limiting damage to the heart muscle," said NHLBI Director Claude Lenfant, M.D.

According to Dr. Lenfant, the REACT findings will help guide the Institute and its National Heart Attack Alert Program in planning an education campaign to increase ambulance use in patients with heart attack symptoms and to help reduce the delay between the first symptoms of a heart attack and treatment, in communities where there is still a problem. REACT educational materials will be modified and updated before they are incorporated into a national educational program, which will be based on lessons learned from REACT and other relevant studies.

In the REACT study, which began in 1994, 10 communities in the United States received an 18-month-long education campaign which reached community members, health care professionals, heart disease patients and their families. Each of the 10 cities receiving the education program was compared to a similar city in its region which did not receive the program. Researchers collected information on heart attacks in hospitals in all 20 cities, and also conducted surveys of community members and heart attack survivors.

At the beginning of the study, patient delay time in all 20 cities averaged 2 hours and 21 minutes. According to the REACT investigators, this was a shorter patient delay time than was found in most previous research. During the study, delay time decreased in both the intervention and reference cities by nearly 5 and 7 percent respectively. However, the difference between the two groups of cities was not considered to be "statistically significant." The study investigators report that the lack of additional improvement in the cities involved in the educational program could be because average patient delays may have already shrunk to record low levels before the education program began.

"Although the REACT campaign appeared quite intense," write the investigators, "it must be viewed in the context of a constant barrage of information that virtually all citizens in communities throughout the United States receive. It is conceivable that, given this intensity of background information, a longer duration of an even more intense intervention might have been more effective in lowering delay time."

The 20 percent increase in ambulance use in patients hospitalized with a heart-related diagnosis was not accompanied by a significant increase in total visits to the Emergency Department by patients with chest pain. "This is a meaningful distinction and an important study result," said NHLBI scientist and REACT project officer Denise Simons-Morton, M.D., Ph.D. "The intervention increased ambulance use in an important patient population without overwhelming the Emergency system," she added.

According to REACT Steering Committee Chair Russell V. Luepker, M.D. of the University of Minnesota, School of Public Health, "Although the increased use of 9-1-1 was a secondary goal, it suggests that even short community campaigns can have a positive impact on heart attack-related behavior."

The REACT study was conducted by five field centers: The University of Alabama at Birmingham, the University of Massachusetts Medical School, the University of Minnesota, the University of Texas in Houston, and a combined site at the King County (Washington) Department of Emergency Medical Services and the Oregon Health Sciences University. The study communities were in ten states: Alabama, Louisiana, Massachusetts, Minnesota, North and South Dakota, Oregon, Texas, Wisconsin, and Washington. Study coordination and statistical analysis were performed by the New England Research Institutes in Watertown, MA.

To interview Dr. Russell Luepker, call 612-624-6362. To arrange an interview with Jeffrey Cutler, M.D., Director of NHLBI's Clinical Applications and Prevention Program, call the NHLBI Communications Office at 301- 496-4236..

More information about the National Heart Attack Alert Program is available online at