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http://www.nytimes.com/2002/09/23/health/menshealth/23BERG.html

A Cure for Sudden Cardiac Arrest, but Only if It's Close By

By LESLIE BERGER

t took David Gonzalez, a 66-year-old Bronx building superintendent, about 20 minutes to master the use of an automated external defibrillator, the medical machine designed for victims of sudden cardiac arrest that can literally shock someone back to life.

His hands trembled a bit and, working with a dummy in his building's recreation room, he put the chest pads in the wrong place. Quickly though, with reminders from his instructor, Mr. Gonzalez adjusted the pads and followed the machine's simple, step-by-step commands. "Shock advised," it said in one of those pleasant-yet-authoritative voices that could narrate a Disney monorail ride. "Stand clear!"

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"It's easy," he said afterward. "I'm comfortable using it."

Everyone seems to agree that today's generation of defibrillators are foolproof. Tucked inside neat, portable cases and weighing but a few pounds, the $2,500 computerized devices have only three buttons to press and that familiar voice to obey. Sixth-grade students learned to use them almost as well as paramedics, one recent study found.

As with so many modern predicaments, however, the issue is no longer about the technology but about how people use it. Researchers are now focusing on whether Mr. Gonzalez and others like him can remember what to do in an actual emergency, and whether it is possible — or even practical — to install enough devices to ensure that they will be available in the brief minutes in which they can make a difference.

About 460,000 Americans died in 1999 of sudden cardiac arrest, representing more than 60 percent of deaths from heart disease, according to a recent analysis by the Centers for Disease Control and Prevention. And only about half of them made it to a hospital before dying, the analysis said.

In sudden cardiac arrest, the heart's electrical signals malfunction and cause the main pumping chamber to quiver and stop. Heart attacks, in which arterial blockages choke off the heart's blood supply, usually produce pain or other symptoms that give victims a chance to seek help. But in cardiac arrest, the victim simply collapses without warning. Men are three times as likely as women to suffer sudden cardiac death through middle age, although the ratio evens out after 75.

THE most common cause of cardiac arrest is an abnormal heart rhythm called ventricular fibrillation, for which there is only one treatment: shocking the heart's nerves back to their normal rhythm, a process known as defibrillation. For best results, the technique must be done within three minutes. After that, the brain becomes too deprived of oxygen.

"I have the cure for sudden death: it's getting a defibrillator to the patient," said Dr. Douglas P. Zipes, a former president of the American College of Cardiology. "The problem is getting the device to the patient in an appropriate time interval. How can I facilitate getting the device to the patient?"

Some experts argue that there is a moral imperative to distribute defibrillators widely. Others argue that such efforts, however well-intentioned, could represent a colossal waste of money, given that 80 percent of sudden deaths occur in private homes, away from most defibrillators.

Concourse Gardens, a government-subsidized high-rise for the elderly, where Mr. Gonzalez lives and works, is 1 of 15 sites in New York City participating in a large experiment, called the public access defibrillation, or the PAD, trial. Nationwide, doctors and scientists in two dozen cities are overseeing volunteers at 1,000 public places, including shopping malls, discount chain stores, museums and health clubs.

They hope to learn not only how many lives might be saved, but also how many machines are needed at a given location, how much training is practical, how much money everything costs and whether, in the end, it makes financial sense. The vast, $20 million experiment, sponsored by the National Institutes of Health and the American Heart Association, is expected to continue through March.

Depending on the outcome, experts say, it is conceivable that the automated external defibrillator, now sold to individuals with a doctor's prescription, could become an over-the-counter device.

"It's not like a blood-pressure cuff, where all you're doing is making a measurement," said Dr. Myron L. Weisfeldt, the chairman of the Department of Medicine at Johns Hopkins University School of Medicine and a former president of the American Heart Association, who has helped lead the development of portable defibrillators. "You're talking about an instrument that, if properly used, in 10 seconds can save someone's life. That's a pretty dramatic treatment for someone to do if they're not a physician or health care professional.

"The real question," Dr. Weisfeldt continued, "is will a volunteer remember where the device is, what to do, how to use it when under the stress of someone actually in front of you who looks like they're dead? Or would it be better just to train people to call 911 and do CPR and let the ambulance people do the defibrillating?"

Some health professionals contend that the devices are so straightforward they should be mounted by every water cooler and first-aid kit.

"People think they can just call 911," said Richard A. Lazar, an expert on defibrillator law and policy based in Portland, Ore. "But the best E.M.S. systems have response times of four minutes or less to 90 percent of calls. My point is, even the best E.M.S. systems can't respond quickly enough."

The push to make defibrillators available to the public has followed years of research and refinement of the devices, which began as internal metal probes that came in direct contact with the organ during open-heart surgery.

Those evolved into manual external defibrillators, but they were bulky devices with huge chest paddles that required users to interpret an electrocardiogram and decide whether a shock was needed. Their invention paralleled the growing sophistication of emergency medicine and "the recognition that we need to start in the field," said Dr. Lynne D. Richardson, the vice chairwoman of emergency medicine at Mount Sinai Medical Center in New York and the principal investigator of the PAD trial here.

The Federal Aviation Administration, prompted in part by a lawsuit filed by the widow of a 28-year-old man who died on board a flight in 2000, last year ordered the nation's airlines to begin carrying defibrillators on all domestic and international flights. They have three years to comply. Several major airlines and many airports had already started using them.

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Last spring, the American Heart Association and the American College of Sports Medicine recommended that fitness centers set up defibrillators and train staff members to use them, especially if they have clients over 50 years old. Though there is no scientific evidence yet that says gyms have a higher incidence of sudden cardiac arrest, experts agree that exercise can be a trigger.

Town Sports International, the parent company of the New York Sports Clubs and their counterparts in Boston, Philadelphia and Washington, has begun seeking proposals from three manufacturers of defibrillators to equip all 130 of its gyms and train their staffs, an undertaking expected to cost hundreds of thousands of dollars. "It's not just the capital expenditure for the machines but the logistics of ongoing training and maintenance," said Frank J. Napolitano, a Town Sports executive. "It's much more complex than the public would think."

Dr. Al Hallstrom, the director of the PAD trial and a biostatistics professor at the University of Washington, agrees. Making sure the defibrillators are well-maintained and handy has been a challenge, he said. "We require our site coordinators to determine the location and viability of the machines on a monthly basis. Often, the first thing we find is that in many of the places, the machines are locked away in an office."

During retraining sessions, he continued, volunteers often forget where to put the chest pads. (If they are not in the right position, the shock will not go through the heart and defibrillate it.) Dr. Hallstrom also said that forgetting to call 911 had been another problem. (Phoning 911 and starting CPR are the first things someone should do before using a defibrillator.) "They get carried away by the device," he said.

Arguments against widespread use of defibrillators were bolstered earlier this month by an article in BMJ (formerly the British Medical Journal), in which the authors concluded that survival rates from sudden cardiac death in Scotland, where the study took place, would improve only marginally, to 6.3 percent from 5 percent, if the machines were made more available to the public because most cardiac arrests take place in the home and not close enough to the defibrillator locations.

"I think it's worth asking the question whether our health dollars are being well spent by doing this," said Dr. Stuart M. Cobbe, one of the study's authors. "Our feeling is that a better way of spending it would be improving the response times for mobile defibrillators and adding new responders, such as police or fire departments."

An additional question is whether the defibrillators should be set up in homes.

Next month, researchers in an $18 million study in the United States, Canada, Britain, New Zealand and Australia will start distributing defibrillators to 3,500 heart patients and train their partners to use them. Their survival rates will be compared with those of 3,500 other heart patients whose partners receive only CPR training.

Dr. Zipes, who is a professor at the Indiana University School of Medicine, has started a Neighborhood Heart Watch program in a section of Indianapolis to see if designated families with defibrillators and CPR training can respond to emergencies nearby. "When a 911 call comes in, it's immediately shunted to the house or apartment closest to where the event is taking place," Dr. Zipes said. He also said that the Scottish study affirmed his belief that installing the machines in homes is needed.

THAT'S why Dr. Richardson concentrated on apartment buildings for the trial in New York City. Getting through traffic and up high-rises make New York one of the worst places in the country to suffer sudden cardiac arrest. (The survival rate is less than 1 percent, Dr. Zipes and others said.) But finding a good mix of apartment dwellers willing to participate was not easy, according to Dr. Richardson and her assistant, Jennifer Holohan, a public health administrator who offered training at Concourse Gardens.

"Liability was the most common reason we were turned down," Dr. Richardson said. Wealthier residents, after they learned about the defibrillators, decided to buy their own rather than risk being placed in a control group that received only CPR training but no devices. More than one business executive plans to keep a defibrillator in his office and train his secretary to use it.

"This really resonates with middle-aged men," Dr. Richardson said.

On the other hand, at least one branch of a superstore is capitalizing on its participation in the trial to advertise itself as a "heart-safe store."

At the very least, Dr. Richardson suggested, the trial should help clarify the high-risk populations and the best places for defibrillators. "People are very attracted to the idea of a magic machine that can start your heart when it stops," she said. "But there's a limited pot of public dollars, and if we're putting defibrillators in pools, schools and day-care centers, we're not spending it on other things."