Decreasing Heart Disease and Sudden Cardiac Death for Kent County

1. Decreasing Heart Disease and Sudden Cardiac Death for Kent County Vanessa Bennett RN Nicole Conway RN Mary Jacobs RN Sarah Raden RN Ferris State University

2. Abstract • Heart disease is the number one cause of death not only in Kent County but in the United States as a whole. Preventive education is the key element to decreasing the risk of developing heart disease with advancing age. By targeting the younger population we are giving them the necessary tools needed to make healthier lifestyle choices and arming them with the knowledge of how and when to activate emergency response so we can also decrease Sudden Cardiac Death (SCD) • There are two types of risk factors for heart disease and these are modifiable and non-modifiable. • By assessing youth early, during a pre-participation exam, and well child visits these risk factors can be identified and monitored for the development of heart disease and prevention of SCD.

4. Introduction • Prevention of heart disease begins with the understanding of what causes the disease as well as how to identify both the modifiable and non-modifiable risk factors. By targeting the younger population ages 10-18 and providing them with the tools/information necessary to make healthier lifestyle changes it is possible to greatly reduce the prevalence of heart disease within Kent County. • By assessing young athletes early, during a pre-participation exam, family history evaluation, and well child visits these risk factors can be identified and monitored for the development of heart disease and there by lead towards prevention of sudden cardiac death. • In addition to understanding the causes of and prevention of heart disease among the younger population, it is also imperative to educate our youth in the identification of signs and symptoms of myocardial infarction, activation of emergency response systems, and the use of CPR and AED to improve the outcomes of those who may suffer a sudden cardiac arrest

5. Fennville Teen hits winning shot Then Dies • FENNVILLE, Mich. (WOOD) - The Fennville varsity basketball player who hit the game-winning layup in overtime on Thursday night -- lifting his team to a perfect 20-0 season -- collapsed on the court after the game, and later died at Holland Hospital. • Wes Leonard, 16, was a junior at the high school. • An autopsy revealed Wes Leonard died from "cardiac arrest due to dilated cardiomyopathy(enlarged heart)," Ottawa County's chief medical examiner Dr. David A. Start's office told 24 Hour News 8.

6. Etiology and Health Problem • Heart disease continues to be the leading cause of mortality in Michigan and Kent County (Michigan Department of Community Health, 2010). Heart disease is a generalized term to identify the different diseases the may affect the heart function. • One the illnesses’ that is categorized with in the term heart disease is Sudden Cardiac Death of the Youth (SCDY). SCDY can occur without any warning signs, and affects the younger population ages 1 to 39. The Michigan Department of Community Health (2010) defines SCDY as a cardiac or ill-defined cause of death occurring in the emergency room (ER), en route to the hospital, out of the hospital, or dead on arrival to the ER in a individual between the ages of 1 and 39 (p.2).  • Kent Counties leading cause of death for 2008 was heart disease with its number of deaths being 1,022 with a rate of 168.9 (Michigan Department of Community Health, 2011). Kent County age adjusted mortality rate for sudden cardiac death from 1999-2006 was 3.0-5.5 per 100,000 (Michigan Department of Community Health, 2009). • National benchmarks vary and are difficult to find, at this time, Kent County is on the moderately high scale in comparison to other Michigan Counties. According to the Michigan Department of Community health SCDY affects blacks more disproportionately (2009) with in the State of Michigan.

7. Modifiable and Non-Modifiable Risk Factors • The modifiable risk factors include smoking, alcohol and caffeine consumption, diet, inactivity, stress and weight management (American Heart Association, 2010). • By identifying these risk factors and making healthier choices will decrease of risk of developing heart disease or having a SCDY. Epidemiology and etiology of heart disease and SCDY has multiple factors most of which are preventable. • The non-modifiable risk factors include genetics, advanced age, race/ethnicity, sex and post-menopausal women. • According to the Michigan Department of Community Health (2010) as many as 40% of families with a victim of SCDY under age 40 have been identified as having a heritable disease (p.11). • By identifying a family history of heart disease can help identify, screen, and manage patients that could be at risks for SCD (Michigan Department of Community Health, 2010).

8. Bioecological Systems Theory • . Bronfenbrenners’s Ecological Systems Theory helps define the differences related to cardiac disease and possibly SCDY, this theory examines which personal characteristics and contextual variables such as peers, family, and community play a role in health behaviors (Gilmore, Harrell, Miles, & Hepworth, 2003). This theory also alludes to the positive impact nursing can play by proper application of community interventions.   This theory is now know as the Bioecological systems theory, in which: culture, society, global, school, religion, community, and family are all inputs which contribute to the child's output or behavior (Paquette, & Ryan, 2011).

9. Community and Nursing Involvement • The simple fact that knowledge is power leads this project into the community. There is a definite need for information to hit the public in regard to our younger populations; there is a lot of information out there about cardiac disease however the populations that are targeted appear to be those of the aging. • According to Wheeler et al. (2010) “In athletes with underlying but undiscovered heart disease, the risk for sudden cardiac death may be more than 100-fold higher than that of unaffected peers. Identification and appropriate treatment for these high-risk persons may substantially reduce their likelihood of dying suddenly” (p.276). • Other disciplines that may be asked to assist in the goal/outcome attainment would be from physicians to assist in cardiac screening that may require follow up. • Nurses for screening; pretest and posttest, body weight, fat, blood pressures, etc. • Teachers and educators, along with coaches and athletic directors, to set up a venue for education relating to SCD. • Social workers to assist with emotional needs for those at risk as well as to provide information to obtain the tools needed to improve health and wellness. • The American Red Cross, or other such entity; which would be willing to provide civilian training in CPR and AED use.

10. Prevention needed as a Resource • Prevention is the key to decreasing the number of deaths related to heart disease and SCD. • An example of primary prevention would be pre-participation sports screening for all athletes within the state of Michigan. Male athletes are more prone to die suddenly then female athletes (male: female ratio for SCD is 10:1) (Michigan Department of Community Health, 2010). • The purpose of pre-participation screens is to identify those athletes that may be high risk for having heart disease. There are currently no evidenced-based practice guidelines for screening the younger population for heart disease, more studies are needed to determine which screening tools are the most successful in determining which patients are more at risk for heart disease.

11. Present Community Groups • Kent County Health Department (2011) presently offers some classes geared towards education and health promotion: Walking into wellness, Cholesterol & Blood Pressure screening services, and Educational Services (nutrition, dining out, cholesterol, stress management, and child nutrition), these services can further expand on the education age group and focus.  Metro health also holds free screening for BP on Fridays. • Local Cedar Springs man gets to the heart of the matter. Gary Gust now 66 died for over two minutes before his heart was restarted by an AED, national statistics show fewer than 10 percent of people having an arrest outside the hospital make a recovery (Reens, 2011). “Grand Rapids Fire Department Battalion Chief Bart Perry hopes to jump-start that number as part of his recently pitched program that would train more people in CPR and place defibrillators in factories, office buildings, churches and other places where people congregate (Reens, 2011).” The second part of the plan is to use a texting system to call trained community members to the scene quickly. “There's obviously a big cost, but its well worth it,” Chalfoun said. “Its something that I’d hope this benevolent community will get on board with.” Gust marks his five year survival anniversary by buying his wife roses and Lori roses, Lori is the trainer whom used the AED and saved his life.

12. Planning • According to Freedman et al. (2009) “Overweight children (CDC 85th–94th percentile) are more likely than thinner children to have adverse levels of cardiovascular disease risk factors and to become obese adults” (p.755). • A result to this is that as children chance of a SCD event is increased, and by not addressing these issues early the risk will only increase over time. Inactivity and obesity in our children is quickly becoming an epidemic. • The First Community goal for Kent County is that the population of 10-18 year olds will have increased knowledge of cardiac disease and the link to obesity as a factor.

14. Healthy People 2020 • Developing Healthy People 2020s objective is to increase the proportion of adults aged 20 years older who are aware of the early warning symptoms and signs of a heart attack and the importance of accessing rapid emergency care by calling 9-1-1 (U.S. Department of Health & Human Services, 2011). • Due to the overwhelming number of children/athletes who have suffered SCD, it is important to also include a goal of knowledge of symptoms related to cardiovascular events/myocardial infarction and the use of activating the emergency response team and the use of CPR and AEDs. Across the age span. • The third goal to address in regard to knowledge of preventable risk factors affecting the younger populations early adolescent to age 30 that may lead to SCD; hypertension, hyperlipidemia, obesity, smoking/alcohol, stress management.

15. Objectives • By September 1, 2011 all Kent County Middle/High Schools will incorporate cardiac risk factors and disease prevention, including SCD, into the health education curriculum. • All middle/high schools in Kent County will have obtained an AED and trained faculty to use by December 1, 2012. • Beginning May 1, 2012 a county-wide Cardiovascular Health Summit will be held with information on surveillance, risk factor modification, and best practices. • Information regarding cardiovascular disease will be distributed quarterly to local health departments beginning January 2, 2012. • A comprehensive surveillance system for cardiovascular disease including a youth risk behavior surveillance system, weight monitoring of Kent County children and physical activity will be established by January 2012. • By January 2 of 2013, Kent County will have a 5% decrease in SCD in individuals age 10-18.

16. Interventions • To accomplish this, we will speak with the middle and high schools within Kent County to propose an addition to the health course to incorporate a unit dedicated to cardiac disease prevention and emergency response listed above and will be mandatory for all student athletes. • Prior to the course a pre- test will be given to students in the course to assess the initial knowledge and design a program to reach the target population. • Students will be educated in the importance of obtaining a family history to screen for possible links/risks of cardiovascular disease to decrease the SCD among children and adolescents. • “It is estimated that 40% of pediatric patients who suffer an SCD event may have unrecognized or underappreciated warning symptoms. Specifically, patients should be questioned about the history of syncope or seizureduring exercise, emotion, or startle; extreme fatigue associatedwith exercise (different from other children); and/or unusualor extreme shortness of breath during exercise, often mimickingexercise-induced bronchospasm.” • “Nearly all Americans believe that family health knowledge isimportant, but only one third of families have written a familymedical history to share with their relatives. In November 2004,the US Surgeon General launched a family-history initiative.A computerized checklist (available at: www.hhs.gov/familyhistory/download.html)can help families organize their history, especially duringfamily gatherings”

17. SCDY may have critical implications for the victims family, especially if the death was related to an inherited condition (Too Young to die). While there is still a need to better understand the problem of SCDY in Michigan, there are steps that can be taken now to improve: • -DETECTION of individuals at increased risk • -TREATMENT of those with predisposing conditions and • -INTERVENTION for victims experiencing sudden cardiac death • It should be noted that evidence-based guidelines for pre-participation screening of non-professional athletes currently do not exist, there for in the U.S. there are presently no universally accepted or mandated standards for screening athletes of this age, nor are there approve certification guidelines for the healthcare provider whom perform such exams. • National research on the best method of conducting pre-participation screening for athletes has led to inconsistent conclusions. • The American Heart Association and American College of Sports Medicine recommend that an athlete pre-participation evaluation include detailed family history and physical exam. • Heart screening test studied for student athletes www.boston.com/news/health/blog/2010/03/by_kay_lazar_gl.html. • This article discussed two studies that were completed about medical screenings for young athletes for the prevention of SCDY. The first study was completed by the Massachusetts General Hospital and Harvard University. They added an EKG screen to their physical exam and twice as many athletes with a unknown cardiac condition. They also determined that there were several false positives. Harvard added the EKG screen to their pre-participation screen for all athletes. • The second study was completed by Stanford University of Medicine discussed the cost of adding this the EKG exam to the pre-participation exam would be about 89.00 per athlete tested. There are estimates of approximately $ 2 billion per year to test all middle and high school athletes across the country.

18. . Pre-participation Screening of Young Competitive Athletes for Prevention of Sudden Cardiac Death. http://www.medscape.com/veiwarticle/585032_print This study was published in 2009 and discusses the need for EKG testing in young athletes provides the detection of different cardiac conditions that may have otherwise been missed by just a physical examination. This study was completed in Italy among middle and high school athletes. This study suggests that SCDY during sports is often the first and definitive manifestation of an underlying cardiovascular disease, which usually has a silent clinical course (Basso, Corrado, Schiavon, Pelliccia and Thiene, 2009). Knowing that many of the cardiac condition are silent by using a EKG is able to detect one of these conditions and get the individual the treatment necessary before something occurs. A screening test is not meant to get diagnostic; it separates apparently well persons who probably have a disease from those who do not (Basso, et. al, 2009). In conclusion this study suggest that pre-participation cardiovascular evaluation of competitive athletes essentially based on EKG seems, according to long term Italian experience, to be a lifesaving strategy that adequately meets the criteria for a good screening program : • 1. the risk of SCDY during sports represent a serious health problem • 2. EKG screening allows identification of still-asymptomatic athletes with at-risk cardiovascular diseases • 3. an effective management strategy exists on the basis of restriction of life threatening training/competition and subsequent clinical treatment and most importantly • 4. early detection and management of athletes favorably modifies the outcome of the underlying disease and leads to the reduction of SCDY. (Basso, et. al, 2009). • Pre-participation sports screening and physical along with a follow up-this is important in primary prevention, however there are not currently standards among how the test is given. • Provider education and public awareness of SCDY risk factors • Public awareness of cardiac symptoms and CPR/AED training • Emergency response protocols • Medical examiner protocols

19. . • All Kent County School educators and staff, and 9th and 10th graders will be trained in CPR and Automated External Defibrillators (AED), This will be achieved through training programs presented at the schools offered twice a year. This allows early intervention and defibrillation by personnel most likely to be at the site of arrest. Project ADAM will be the model used to implement teaching. Which was researched by Berger et al. (2004), and “Implementation of Project ADAM in high schools in the United States is potentially associated with an incremental cost-effectiveness ratio that is favorable” • Every School in Kent County will have an accessible AED with in one year, which will allow fast defibrillation of any student or adult suffering from a sudden cardiac event. Each School will be responsible for obtaining their AED. Information will be given to each school regarding grant applications and government money matching programs. Information like AEDgrant.com, Catalog of Federal Domestic Assitanc, Cintas Scholastic AED programWho, Philips HeartStart Giving Program, and local resources like Kiwanis Clubs, Lions Clubs, and Rotary International (Sudden Cardiac Arrest Foundation, 2011) will be provided to each school. • “The suggested preventive measures were categorized into five major areas: pre-participation sports screening and follow up; provider education and public awareness of SCDY risk factors; public awareness of cardiac symptoms and CPR/AED training; emergency response protocols; and, medical examiner protocols”

20. . • With parental permission, all Kent County high school students will be given a Youth Risk Behavior Surveillance questionnaire as part of their health/physical education curriculum. This is a voluntary and anonymous survey that includes high-risk health behaviors including diet, physical activity, drug use, alcohol consumption, and obesity.  • High-risk health behaviors which contribute to leading causes of morbidity and mortality such as heart disease often originate during childhood and carry into adulthood. • According to The Youth Risk Behavior Surveillance conducted by the CDC among high school students nationwide in 2007, “20.0% had smoked cigarettes during the 30 days before the survey, 35.4% had watched television 3 or more hours per day on an average school day, and 13.0% were obese.” Additionally, it was found that in the 7 days prior to the survey, that 65.3% of students failed to exercise as recommended, 78.6% did not consume the recommended servings of fruits and vegetables each day, and 33.8% reported consumption of at least one soda pop per day (Eaton et. al, 2008).

21. Evaluations • The Community Public health Nurse will measure how many employees and students are presently certified in CPR and AED use. The expected goal is to have a twenty five percent increase in certification with in one year. This will be measured by a secondary count of certified staff and students. (should we use a survey?) • AEDs will be at every school as counted by Community Health Nurse. • To determine the change in deaths related to SCD will be obtained by reviewing the death certificates for those whom passed away between the ages 10-18. • Completed YRBS questionnaires will be compiled at one local health department where results will remain on file for tracking of student behaviors. • These results will be factored into the development of health/physical education curriculum at all Kent County high schools. • These percentages will be calculated to determine the relationship from 2011 to 2013 to obtain either a decrease or increase in incidence of SCD.

22. AED Saved Huntley Boys Life Thirteen year old Brooks Beler was saved by CPR and an AED. He had known cardiomyopathy inherited from his father. These are the results from education and awareness, it is worth the cost. He is now scheduled to have a defibrillator inserted. “I want to thank my Teachers for helping me”

23. References • Berger, B.N., Whitstone, S.J., Frisbee, J.T., Miner, A., Dhala, R.g., Pirrallo, L.M., Utech., & Sachdeva. (2004). Cost-Effectiveness of Project ADAM A project to prevent Sudden Cardiac Death in High School Students. Pediatric Cardiology, 25(6),660-667. DOI: 10.1007/s00246-003-0668-z. Retrieved from http://www.springerlink.com/content/5kbr0j1bdfxx • CPR and First Aid Training. (2011). Kent Regional 4C CACFP CPR and First Aid Training PDF. Retrieved from http://search.yahoo.com/search?p=KENT+county+CPR+and+AED+training&ei=UTF-8&fr=moz35 • Eaton, D., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., & ... Wechsler, H. (2008). Youth risk behavior surveillance -- United States, 2007. MMWR Surveillance Summaries, 57(SS-4), 1-131. • Erb, Robin. (2010). Heart problems are a silent killer of children. Detroit Free Press Retrieved from http://www.michigan.gov/documents/mdch/Heart_problems_are_a_silent_killer_of_children_-_Detroit_Free_Press_10-13-10_343099_7.pdf • First Steps Kent County. (2011). Child poverty on the rise in West Michigan. Retrieved from http://www.firststepskent.org • Freedman, D., Dietz, W., Srinivasan, S., Berenson, G., & , Initials. (2009). Risk factors and adult body mass index among overweight children: thecbogalusa heart study. Pediatrics, 123. • Gilmer, M., Harrell, J., Miles, M., & Hepworth, J. (2003). Youth characteristics and contextual variables influencing physical activity in our adolescents of parents with premature coronary heart disease. Journal of Pediatric Nursing, 18(3), 159-168. Retrieved from libcat.ferris.edu.

24. . • Kann, L., Kinchen, S. A., Williams, B. I., Ross, J. G., Lowry, R., Grunbaum, J. A. and Kolbe, L. J. (2000), Youth Risk Behavior Surveillance — United States, 1999. Journal of School Health, 70: 271–285. doi: 10.1111/j.1746-1561.2000.tb07252.x • Kent County Health Department. (2011). Kent County Health Department Health improvements program. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Health_Promotion/walking.htm • Michigan Department of Community Health. (2009). Sudden cardiac death of the young (SCDY) surveillance and prevention project. Retrieved from http://www.michigan.gov/documents/mdch/SCDYReportfinalJan09_269478_7.pdf • Michigan Department of Community Health. (2011). Deaths and crude death rates for the ten leading causes of death, Kent County Health Department District and Michigan residents, 2008 and United States residents, 2006. Retrieved from http://www.mdch.state.mi.us/pha/osr/chi/Deaths/leadUS/Lhdus.asp. • Muecke, M. (1984). Community health diagnosis in Nursing. Public Health Nursing, 1(1), 23-25. • Mukerji, S., Hanna, B., Duquette, D., Bach, J.,Rosenman, K. (2010). Sudden Cardiac Death of the Young in Michigan: Development and Implication of a Novel Mortality Review System. Journal of Community Health, 35:689-697. DOI 10.1007/s10900=010-923-2. • National Center for Chronic Disease Prevention and Health Promotion, (2011). YRBSS:Youth risk behavior surveillance system. Retrieved from: • http://www.cdc.gov/healthyyouth/yrbs/index.htm • National Heart Lung and Blood Institute. (2010). NHLBI Working group screening for sudden cardiac death in the young. Retrieved from http://www.nhlbi.nih.gov/meetings/workshops/scd-young.htm

25. . • Paquette, D. & Ryan, J. (2011). Bronfenbrenner’s Ecological Systems Theory. Retrieved from http://pt3.nl.edu/paquetteryanwebquest.pdf • Reens, N. (2011, March 29). Heart of the matter. The Grand Rapids Press. pA3-4. • Robert M. Campbell, MDa, Stuart Berger, MDb Preventing Pediatric Sudden Cardiac Death: Where Do We Start? PEDIATRICS Vol. 118 No. 2 August 2006, pp. 802-804 (doi:10.1542/peds.2006-0564) • Sudden Cardiac Arrest Foundation. (2011). Funding Sources for Schools. Retrieved from http://www.sca-aware.org/schools/funding-sources. • Thomas, C. (2004) SMART Objectives. Retrieved from:http://www.managers-toolbox.com/SMART.htm • U.S. Department of Health & Human Services. (2011). Developing healthy people 2020. Heart Disease and Stroke. Retrieved from http:/healthypeople.gov/hp2020/Objectives.aspx • Wheeler, M., Heidenreich, P., Froelicher, V., Hlatky, M., & Ashley, E. (2010). Cost-effectiveness of preparticipation screening for prevention of. Annals of Internal Medicine, 152. Retrieved from www.annals.org • Wood TV 8. (2011). Fennville teen hits winning shot, dies. Retrieved from http://www.woodtv.com/dpp/news/local/sw_mich/Fennville-teen-hits-winning-shot-dies • Wong, K. (2011, March 15). AED saved Huntley Boys life. The Spirit of Montana News. Retrieved fromhttp://www.kulr8.com/news/local/Teachers-AED-Saved-Huntley-Boys-Life-118049624.html