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ESC Congress 2003: Cough for your life
September 02, 2003IMPORTANT: This press release accompanies both a presentation and an ESC press conference given at the ESC Congress 2003. Written by the investigator himself/herself, this press release does not necessarily reflect the opinion of the European Society of Cardiology
ESC Congress 2003: Cold comfort - Cough for your life
Background of the study: Sudden Cardiac Death (SCD) is defined as death resulting from sudden, abrupt, loss of heart function resulting from disturbances of cardiac rhythm (arrhythmias) in a person who may, or may not have been diagnosed with heart disease. It occurs dramatically, instantly or shortly after symptoms appear. Most SCD episodes are ultimately caused by ventricular fibrillation (VF). A precursor of SCD, Sudden Circulatory Arrest (SCA) may be transient or reversible; if treated promptly, it may not progress to SCD. Victims of SCD are on average about 50 to 60 years of age often during their most productive years and devastates unprepared families. According to the American Heart Association's (AHA) «Heart & Stroke Statistical Update 2001» over 200 thousand persons in the United States alone die each year of Ischaemic Heart Disease without being hospitalized. This corresponds to 200 SCD per 100,000 persons. Survivability of out-of-hospital VF episodes without permanent CNS damage is only 5-10%.
It is important to remember, that SCA IS NOT a synonym for, myocardial infarction (MI), which results from sudden coronary arterial obstruction that damages heart muscle. However SCD often complicates MI in the early minutes to hours after onset of chest pain when the heart is especially vulnerable to life-threatening arrhythmias. SCD also occurs in the absence of MI.
What causes the progression of SCA to SCD?
1. Two out of 5 victims are alone during SCA episodes. Since the onset of the loss of consciousness is very rapid, they usually don't have enough time to call for help. Unless the circulatory collapse is self-limited, survival requires bystander assistance with CPR and, if VF is present, defibrillation.
2. SCA interrupts circulation of blood. The brain, deprived of blood circulation, becomes irreversibly and progressively damaged after 5 to 6 minutes unless the circulation of oxygenated blood is restored. The average arrival time of emergency assistance exceeds that time window.
However, if victims of SCA episodes COULD maintain consciousness until circulation is restored or help (CPR) arrives, their chances of survival would greatly increase.
Self-resuscitative Cough-Cardiopulmonary Resuscitation.
In has been demonstrated in clinical settings, in the laboratory studies by Criley et al, and in the out-of-hospital settings by Petelenz, et al, that properly timed and performed coughs can, in cases of life-threatening arrhythmias allow the patient to maintain consciousness and even regain an effective cardiac rhythm. Extensive and convincing scientific bases for the ability of maintaining blood circulation in the absence of an effective cardiac rhythm was provided in the hemodynamic studies by Criley, Rosborough, and Niemann.
It had previously been noted in the 1960s by F. Mason Sones that patients undergoing coronary angiography could overcome transient episodes of heart slowing and/or marked decreases in arterial pressure by rhythmic, forceful coughing. These salutory effects of coughing were directly observed by continuous monitoring of arterial pressure and electrocardiogram (ECG). Criley et al in 1976 observed that patients with ventricular fibrillation (VF) or asystole (absence of heart beats) could maintain consciousness and near-normal blood pressure despite the absence of heartbeats. The mechanisms responsible for «Cough-CPR» were later extensively studied in animal experiments.
How does coughing support the circulation when the heart is in VF?
A heart in VF quivers ineffectually and circulation ceases. Rhythmic, forceful coughing causes abrupt upswings of pressure in the thorax, abdomen and all of their contents, including the heart, lungs, and blood vessels. Each cough is preceded by a deep inspiration that abruptly lowers the pressure in the thorax, drawing blood through the inert right heart chambers and into the pulmonary vessels by this vacuuming action. With the cough-induced abrupt rise in pressure, air is expressed out of the lungs through the airways and blood is expressed from the lungs through the inert left heart chambers and out of the thorax via arterial branches of the aorta. This pressurized arterial blood is selectively directed to vascular beds that have low-pressure veins.
It should be noted that the heart and all of the blood vessels in the thorax and abdomen are exposed to the abrupt rises in pressure caused by each cough, and for blood to flow through capillary beds there must be a higher pressure in the arteries than in the veins. The veins serving the brain are uniquely protected from cough-induced pressure surges because they are outside of the thorax and are protected by one-way venous valves in the jugular veins that snap closed with each cough. These venous valves prevent the transmission of pressure within the thorax to the jugular veins, providing the necessary low-pressure venous bed required for forward flow through the brain.
If we call the pressure raise phase of Cough-CPR «systole» the phase between coughs becomes «diastole». As noted previously, the negative intrathoracic pressure (vacuum) draws blood through the inert right heart chambers to the lungs in diastole. During between-coughs diastole, the pressure in the systemic arteries is maintained higher than that in the veins because of the rigid muscular tone in the arterial walls, so blood flows forward through the tissues. The magnitude of forward blood flow is proportional to the pressure difference between the arteries and the veins. Coronary blood flow also occurs in diastole because of the pressure difference between the coronary arteries and the low-pressure cardiac veins downstream from the arrested cardiac muscle.
How does coughing support the circulation in SCA not caused by VF?
Coughing can stimulate heartbeats through direct mechanical stimulation - possibly a small electrical discharge comparable to a «chest thump» - and has been shown to terminate supraventricular and ventricular arrhythmias. Our Doppler ultrasound studies demonstrate that coughing between normal heartbeats causes flow pulses in the brachial artery comparable to normal heartbeats by abruptly raising pressure in the arteries, while the venous beds outside the thorax (including the brain and upper extremities) are protected from these pressure surges by venous valve closure. Lastly, we have shown that 5-10 seconds of coughing can reduce markedly elevated left atrial pressure for several minutes in patients with mitral valve regurgitation.
Why, despite the overwhelming laboratory and clinical evidence of the effectiveness of Cough-CPR is this method not widely taught and used?
One reason is that most physicians are unaware of the effectiveness of Cough-CPR because the principal research was published more than 20 years ago. Another reason is the commonly held view that patients are not capable of recognizing the symptoms of imminent SCA and of performing an effective autoresuscitative cough.
In order to demonstrate that Cough-CPR is a practical solution under out-of -hospital conditions, we have conducted a study in 115 patients with ischaemic, valvar, congenital, and cardiomyopathic heart disease. These individuals were deemed to be at risk and were taught to recognize the prodrome of approaching SCA and to perform autoresuscitative coughs.
All patients participating in the study had previously experienced fainting, or were close to loosing consciousness as a result of ventricular tachycardia, atrial fibrillation or flutter, «sick sinus syndromes», bradycardia, asystole, blocks, or orthostatic hypotension. The patients were taught to recognize the syndromes of approaching fainting and trained performing resuscitative cough. The patients used resuscitative cough in 365 instances of perceived prodromal symptoms of fainting. As a result, the symptoms disappeared in 292 cases, and only in 73 cases further medical assistance was required. All patients survived until the follow up therapy was applied that included: 45 pacemaker implantations, 55 heart surgeries and 15 pharmacological interventions.
How difficult is it to perform auto-resuscitative cough?
The patient must: 1) learn to recognize the prodromal symptoms of SCA: "˘shortness of breath, "˘sudden nausea, "˘dizziness, "˘inappropriate sweating, "˘dark or blurred vision, "˘trembling hands and legs, "˘sudden weakness. 2) Be aware that the above symptoms may occur singly or in combinations and with varying intensity.
Teaching the resuscitative cough is straightforward: the patient should start with a single cough every 1 to 2 seconds in bouts of 5 coughs, repeating such training 3 times in the morning and 3 times in the afternoon. Depending on age and physical condition of the patient, the number of coughs per bout should be incrementally increased to 10, 20 or 30 coughs in each bout. The patient must learn to initiate the cough immediately after recognizing the prodromal symptoms.
Teaching patients to employ resuscitative cough, or Cough CPR, is simple and inexpensive, and routinely used at the Cardiology Center in Katowice. Continuing Cough-CPR research in our Center has been approved by the Ethical Commission of the Silesian Academy of Medicine and is focused on both physician and patient training.
In conclusion, we believe that:
1. Cough-CPR is a life saving procedure that enables surviving SCA under « out-of-hospital » conditions
2. Cough-CPR awareness
a. Cough-CPR should be widely promoted in the medical community.
b. Cough-CPR should be taught to patients with ischaemic heart disease who are at risk of SCA.
c. Cough-CPR should be taught to general public, as many people are not aware of their heart disease and their fainting may be the first and (most likely) also the last symptom of the disease, and, tragically, the end of life.
3. Cough-CPR is not intended to replace CPR by bystanders or emergency medical personnel, but is intended to abort SCA and/or serve as a bridge to allow the victim to summon help.
Tadeusz K. Petelenz
Cardiological Foundation - Katowice Ochojec, 7th Clinical Hospital of Silesian Medical School, Katowice, Poland
European Society of Cardiology (ESC)
It is important to remember, that SCA IS NOT a synonym for, myocardial infarction (MI), which results from sudden coronary arterial obstruction that damages heart muscle. However SCD often complicates MI in the early minutes to hours after onset of chest pain when the heart is especially vulnerable to life-threatening arrhythmias. SCD also occurs in the absence of MI.
What causes the progression of SCA to SCD?
1. Two out of 5 victims are alone during SCA episodes. Since the onset of the loss of consciousness is very rapid, they usually don't have enough time to call for help. Unless the circulatory collapse is self-limited, survival requires bystander assistance with CPR and, if VF is present, defibrillation.
2. SCA interrupts circulation of blood. The brain, deprived of blood circulation, becomes irreversibly and progressively damaged after 5 to 6 minutes unless the circulation of oxygenated blood is restored. The average arrival time of emergency assistance exceeds that time window.
However, if victims of SCA episodes COULD maintain consciousness until circulation is restored or help (CPR) arrives, their chances of survival would greatly increase.
Self-resuscitative Cough-Cardiopulmonary Resuscitation.
In has been demonstrated in clinical settings, in the laboratory studies by Criley et al, and in the out-of-hospital settings by Petelenz, et al, that properly timed and performed coughs can, in cases of life-threatening arrhythmias allow the patient to maintain consciousness and even regain an effective cardiac rhythm. Extensive and convincing scientific bases for the ability of maintaining blood circulation in the absence of an effective cardiac rhythm was provided in the hemodynamic studies by Criley, Rosborough, and Niemann.
It had previously been noted in the 1960s by F. Mason Sones that patients undergoing coronary angiography could overcome transient episodes of heart slowing and/or marked decreases in arterial pressure by rhythmic, forceful coughing. These salutory effects of coughing were directly observed by continuous monitoring of arterial pressure and electrocardiogram (ECG). Criley et al in 1976 observed that patients with ventricular fibrillation (VF) or asystole (absence of heart beats) could maintain consciousness and near-normal blood pressure despite the absence of heartbeats. The mechanisms responsible for «Cough-CPR» were later extensively studied in animal experiments.
How does coughing support the circulation when the heart is in VF?
A heart in VF quivers ineffectually and circulation ceases. Rhythmic, forceful coughing causes abrupt upswings of pressure in the thorax, abdomen and all of their contents, including the heart, lungs, and blood vessels. Each cough is preceded by a deep inspiration that abruptly lowers the pressure in the thorax, drawing blood through the inert right heart chambers and into the pulmonary vessels by this vacuuming action. With the cough-induced abrupt rise in pressure, air is expressed out of the lungs through the airways and blood is expressed from the lungs through the inert left heart chambers and out of the thorax via arterial branches of the aorta. This pressurized arterial blood is selectively directed to vascular beds that have low-pressure veins.
It should be noted that the heart and all of the blood vessels in the thorax and abdomen are exposed to the abrupt rises in pressure caused by each cough, and for blood to flow through capillary beds there must be a higher pressure in the arteries than in the veins. The veins serving the brain are uniquely protected from cough-induced pressure surges because they are outside of the thorax and are protected by one-way venous valves in the jugular veins that snap closed with each cough. These venous valves prevent the transmission of pressure within the thorax to the jugular veins, providing the necessary low-pressure venous bed required for forward flow through the brain.
If we call the pressure raise phase of Cough-CPR «systole» the phase between coughs becomes «diastole». As noted previously, the negative intrathoracic pressure (vacuum) draws blood through the inert right heart chambers to the lungs in diastole. During between-coughs diastole, the pressure in the systemic arteries is maintained higher than that in the veins because of the rigid muscular tone in the arterial walls, so blood flows forward through the tissues. The magnitude of forward blood flow is proportional to the pressure difference between the arteries and the veins. Coronary blood flow also occurs in diastole because of the pressure difference between the coronary arteries and the low-pressure cardiac veins downstream from the arrested cardiac muscle.
How does coughing support the circulation in SCA not caused by VF?
Coughing can stimulate heartbeats through direct mechanical stimulation - possibly a small electrical discharge comparable to a «chest thump» - and has been shown to terminate supraventricular and ventricular arrhythmias. Our Doppler ultrasound studies demonstrate that coughing between normal heartbeats causes flow pulses in the brachial artery comparable to normal heartbeats by abruptly raising pressure in the arteries, while the venous beds outside the thorax (including the brain and upper extremities) are protected from these pressure surges by venous valve closure. Lastly, we have shown that 5-10 seconds of coughing can reduce markedly elevated left atrial pressure for several minutes in patients with mitral valve regurgitation.
Why, despite the overwhelming laboratory and clinical evidence of the effectiveness of Cough-CPR is this method not widely taught and used?
One reason is that most physicians are unaware of the effectiveness of Cough-CPR because the principal research was published more than 20 years ago. Another reason is the commonly held view that patients are not capable of recognizing the symptoms of imminent SCA and of performing an effective autoresuscitative cough.
In order to demonstrate that Cough-CPR is a practical solution under out-of -hospital conditions, we have conducted a study in 115 patients with ischaemic, valvar, congenital, and cardiomyopathic heart disease. These individuals were deemed to be at risk and were taught to recognize the prodrome of approaching SCA and to perform autoresuscitative coughs.
All patients participating in the study had previously experienced fainting, or were close to loosing consciousness as a result of ventricular tachycardia, atrial fibrillation or flutter, «sick sinus syndromes», bradycardia, asystole, blocks, or orthostatic hypotension. The patients were taught to recognize the syndromes of approaching fainting and trained performing resuscitative cough. The patients used resuscitative cough in 365 instances of perceived prodromal symptoms of fainting. As a result, the symptoms disappeared in 292 cases, and only in 73 cases further medical assistance was required. All patients survived until the follow up therapy was applied that included: 45 pacemaker implantations, 55 heart surgeries and 15 pharmacological interventions.
How difficult is it to perform auto-resuscitative cough?
The patient must: 1) learn to recognize the prodromal symptoms of SCA: "˘shortness of breath, "˘sudden nausea, "˘dizziness, "˘inappropriate sweating, "˘dark or blurred vision, "˘trembling hands and legs, "˘sudden weakness. 2) Be aware that the above symptoms may occur singly or in combinations and with varying intensity.
Teaching the resuscitative cough is straightforward: the patient should start with a single cough every 1 to 2 seconds in bouts of 5 coughs, repeating such training 3 times in the morning and 3 times in the afternoon. Depending on age and physical condition of the patient, the number of coughs per bout should be incrementally increased to 10, 20 or 30 coughs in each bout. The patient must learn to initiate the cough immediately after recognizing the prodromal symptoms.
Teaching patients to employ resuscitative cough, or Cough CPR, is simple and inexpensive, and routinely used at the Cardiology Center in Katowice. Continuing Cough-CPR research in our Center has been approved by the Ethical Commission of the Silesian Academy of Medicine and is focused on both physician and patient training.
In conclusion, we believe that:
1. Cough-CPR is a life saving procedure that enables surviving SCA under « out-of-hospital » conditions
2. Cough-CPR awareness
a. Cough-CPR should be widely promoted in the medical community.
b. Cough-CPR should be taught to patients with ischaemic heart disease who are at risk of SCA.
c. Cough-CPR should be taught to general public, as many people are not aware of their heart disease and their fainting may be the first and (most likely) also the last symptom of the disease, and, tragically, the end of life.
3. Cough-CPR is not intended to replace CPR by bystanders or emergency medical personnel, but is intended to abort SCA and/or serve as a bridge to allow the victim to summon help.
Tadeusz K. Petelenz
Cardiological Foundation - Katowice Ochojec, 7th Clinical Hospital of Silesian Medical School, Katowice, Poland
European Society of Cardiology (ESC)
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