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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 4  |  Page : 223-229

An observational study of out-of-hospital cardiac arrests reported in Indian print media


1 Consultant Cardiologist, Srinivasa Heart Centre, Warangal, Telangana, India
2 Department of Emergency Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
3 Division of Cardiology, University of Alabama, School of Medicine, Birmingham, Alabama, USA
4 Department of Pharmacology, Jayamukhi College of Pharmacy, Warangal, Telangana, India
5 Medical Student, Mamata Medical College, Khammam, Telangana, India

Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. Srinivas Ramaka
Consultant Cardiologist, Srinivasa Heart Centre, Warangal, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_52_19

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  Abstract 


Background: Newspapers in India often report incidents of cardiac arrest. Media reports are a source for raising awareness of cardiac arrest and cardiopulmonary resuscitation (CPR) among the public. This study is aimed at evaluating the reports of cardiac arrest published in Indian newspapers. Materials and Methods: This is an observational study of cardiac arrests reported in Indian newspapers between January 2001 and June 2019. The study included reports containing the word “cardiac arrest” referring to a cardiac arrest event in India. Data of demographics, location, time, clinical characteristics, performance of CPR, and survival using the Utstein template were extracted from the newspapers. Reports of out-of-hospital cardiac arrest (OHCA) were selected for analysis. Results: One thousand seven hundred seventy-nine reports of cardiac arrest were reviewed and 1703 reports were selected after excluding 76. Of these, 279 reports did not specify whether it was an in-hospital cardiac arrest (IHCA) or OHCA. Of the remaining 1424 reports, 377 reports were IHCA and 1047 were OHCA. One thousand forty-seven OHCA cases were selected for analysis. The study noted male preponderance and a median age of 51–60 years. OHCA commonly occurred in residential locations, followed by public buildings, other places, and street/highways. Prior risk factors, heart disease, and symptoms were reported in some reports. Of 15 subjects who received CPR, 11 were reported to have survived. Although demographic data are reported in the majority, there is poor reporting of clinical and resuscitation details. Conclusions: The study gives a glimpse of OHCA in India and emphasizes the need for elaborate reporting of data on cardiac arrest. The crucial role of media is recognized.

Keywords: Cardiac arrest, cardiopulmonary resuscitation, newspaper reports, out-of-hospital cardiac arrest, survival from out-of-hospital cardiac arrest and India, Utstein template


How to cite this article:
Ramaka S, Murthy VS, Nanda NC, Sindgi VM, Mohammed AS. An observational study of out-of-hospital cardiac arrests reported in Indian print media. J Indian coll cardiol 2019;9:223-9

How to cite this URL:
Ramaka S, Murthy VS, Nanda NC, Sindgi VM, Mohammed AS. An observational study of out-of-hospital cardiac arrests reported in Indian print media. J Indian coll cardiol [serial online] 2019 [cited 2020 Mar 28];9:223-9. Available from: http://www.joicc.org/text.asp?2019/9/4/223/280351




  Introduction Top


Mass media are an important source to improve health literacy in the country.[1] The most common platforms for mass media are newspapers, magazines, radio, television, and the Internet. Newspapers serve as a valuable source of health-related information to the lay public. One such example of health literacy which impacts community participation is knowledge of cardiovascular disease (CVD).[2] Reports of cardiac arrest are often reported in the lay press. Being an important public health problem, they generate immense interest among the readers. Dissemination of accurate information by the newspapers and other media will influence the public perception of cardiac arrest, resuscitation, and outcomes.[3] Such newspaper reports serve to motivate the lay public to learn cardiopulmonary resuscitation (CPR) skills and contribute to resuscitation quality outcomes. There are evidence-based data to prove that immediate bystander CPR increases survivals in out-of-hospital cardiac arrest (OHCA).[4]

The burden of CVD in India is increasing. Reports of sudden cardiac arrest are often reported in Indian media. The Indian Readership Survey data released for the first quarter of 2019 reveal that the overall readership of newspapers is increasing (Media Research Council). While there is an overall increasing readership of newspapers in all languages, English newspaper readership has been increasing more.[5]

Currently, the data on cardiac arrest, especially OHCA, are limited in India. There have been few studies published,[6],[7] including a recently completed regional study Warangal Area Out-of-Hospital Cardiac Arrest Registry-WACAR (unpublished data). Comprehensive national data on OHCA are lacking. The data from media reports provide a glimpse of OHCA in India. A study published from the United Kingdom reviewed the details of cardiac arrests reported in the lay press adopting the Utstein template.[8] However, there have been no reported studies so far from Indian media based on an internationally accepted Utstein template.[9],[10]

Aims and objectives

The study aims at evaluating the reports of OHCA as reported in print media (particularly newspapers in India) with Utstein template – portrayal of cardiac arrest, demographics, and patient and resuscitation characteristics.


  Materials and Methods Top


Study design

This is an observational study of a cohort of cardiac arrests reported in selected Indian English newspapers.

Setting

There has been an attempt in securing national data on OHCA. There is no single source or agency in India through which all media reports can be collected. Only English newspapers with websites and data available for public domain were accessed for reports of cardiac arrest.

Participants

Subjects from reports of cardiac arrest in various locations in India were included in the study.

Sources of data

Newspaper reports from Indian newspapers in English language with a wide circulation. They were retrieved from the archives during 2001–2019 from the websites of The Hindu, The New Indian Express, The Times of India, The Hans India, and The Pioneer.

All the articles are screened for eligibility. Initially, those reports with a search word “cardiac arrest” were retrieved. Articles eligible for inclusion included persons sustaining cardiac arrest at several Indian locations. Reports with no reference to a possible cardiac arrest were excluded. Articles in different newspapers of the same cardiac arrest victim were searched for any additional information, and only the best report was included. Those due to obvious possible noncardiac causes such as trauma were excluded. Data related to Utstein variables were extracted from these reports. Data of OHCA subjects were selected for analysis.

Variables

Demographics

  1. Gender: Male, female, or unknown
  2. Age range: 0–20, 21–30, 31–40, 41-50, 51–60, 61–70, 71–80, 81–90, and 91–100. Coronary artery disease (CAD) is the common cause for OHCA. CAD in <45 years of age of subjects is labeled as “young CAD.” CAD in <55 years in males and <65 years in females is labeled as “premature CAD”[11]
  3. Location: Whether the arrest location is in-hospital or out-of-hospital. If OHCA, the categories of location noted: residence/home, public building, street, place of recreation/ground, transport center, educational institution, health-care facility, industrial or workplace, and others
  4. Witnessed: By a layperson or health-care professional
  5. Etiology/clinical characteristics: Based on the Utstein definition, the cause of cardiac arrest is presumed to be of cardiac origin unless it is known to be caused by trauma, drowning, respiratory, or other causes as determined by the rescuers
  6. Performance of CPR: Whether CPR was performed or not and details of the arrival of emergency medical services (EMS)
  7. Defibrillation: Details of availability and utilization of an automated external defibrillator (AED) and EMS
  8. Outcomes: Details of survival and management.


Statistical analysis

Data entry was done using MS Excel. Statistical analysis was done using MedCalc Statistical Software version 19.1.5 (MedCalc Software bv, Ostend, Belgium; https://www.medcalc.org;2019). Frequencies were calculated for descriptive data.


  Results Top


A total of 1779 reports of cardiac arrest were reviewed from January 2001 to June 2019. Of these, 76 reports which reported more than once in different newspapers and those which did not meet the inclusion criteria were excluded. Of the 1703 reports, only 1424 had in-hospital or out-of-hospital information. After excluding 377 reports of in-hospital cardiac arrest (IHCA), 1047 reports of OHCA were selected for analysis.

In 37 subjects, the identity of the subject was not reported. They were labeled as “unknown name” [Flow Chart 1 and [Table 1].
Table 1: Baseline data of out.of.hospital cardiac arrest subjects

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Demographics

The study noted male preponderance with a median age group being 51–60 years (27.78%) [Figure 1] and [Figure 2]. The mean age was 54.1 years. The mean age of OHCA was higher in females compared to males.
Figure 1: Age range versus the number of subjects of out-of-hospital cardiac arrest

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Figure 2: Age range and number of males versus females

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Of the 889 subjects (males – 782 and females – 107) in whom age was reported, 225 (25.3%) are <45 years and 664 (74.7%) were above 45 years.

Of 782 males, 398 (44.8%) were <55 years and 384 (43.2%) were above 55 years. Of 107 females, 65 (7.3%) were <65 years and 42 (4.7%) were above 65 years.

Location of out-of-hospital cardiac arrest

Common locations of OHCA were residential areas followed by public buildings, other places, and street/highways.

Clinical details

Clinical details were reported in 32 media reports. Of these, 19 media reports contained details of prior heart disease and interventions such as previous heart ailments including heart attacks, angioplasty, and coronary artery bypass graft (CABG) procedures. There were very few reports which mentioned risk factors. There was a report of a heart attack as a cause of cardiac arrest in some (7).

Prior symptoms were reported in 58 subjects. Chest pain is the most common symptom reported (24), followed by collapse (20). Other symptoms reported were as follows: unconsciousness, fainting, and uneasiness.

Witnessed status

In 87 subjects, the OHCA was unwitnessed. In all others, the OHCA was witnessed. Time of the unwitnessed arrest: morning – 22, afternoon – 4, night – 13, and early hours of the morning – 5. In 43 subjects, the time of unwitnessed OHCA was unknown.

Cardiopulmonary resuscitation and survival

Fifteen reports indicated CPR: 11 survivals and 4 nonsurvivals. In those who have survived, there is a mention of undergoing percutaneous coronary intervention and CABG (two). Among those who received CPR, it was performed by an anesthesiologist (1), “doctor” (1), Central Reserve Police Force jawan (1), and Central Industrial Security Force person (1). The survival rate of OHCA in this study is 1.05%. One hundred seventeen subjects were reported to have been brought dead and six subjects were reported to have died in hospital. Follow-up data of those who have survived are not reported.

Details regarding EMS ambulance arrival were not mentioned in the majority of the reports. There are no reports of the use of an AED.

Terms used in the newspaper reports

Certain terms are often used in the media reports. The term “massive cardiac arrest” has been used in 47 reports and “severe cardiac arrest” in 1 report. Although these terms are not used clinically by the physicians, they probably convey the intensity of the event and generate interest to the lay reader.

The terms mentioning “brought dead or declared brought dead,” “died at the hospital,” and “died while undergoing treatment” which were commonly used in the media reports convey to the lay reader that the cardiac arrest has occurred in an out-of-hospital setting and attempts were made to revive at the hospital of arrival.


  Discussion Top


To the best of our knowledge, this is the first study covering reports of cardiac arrest, particularly OHCA in Indian print media. The study gives insight into OHCAs in India. The study also points to the role of newspapers in contributing to the health literacy of the lay reader about CVD, cardiac arrest, and CPR.

The study data based on Utstein reporting are also compared with international data from the USA, Europe, and Asian nations.[12],[13],[14]

Demographics

The study provides important data on demographics – gender and age. Male preponderance is similar to the reports in some international studies. The mean and median ages of OHCA are lower than those reported in these studies.

Location of out-of-hospital cardiac arrest

The common location of OHCA is residential. Predominance of OHCA in residential locations points to the need to train family members in CPR. Reducing EMS arrival times will improve survival outcomes of OHCA.[15] Individually, the predominant location of OHCA reported in this study is in residential areas. However, relatively, a majority of the OHCA reported by newspapers occurred in nonresidential locations. This might be because a OHCA in a nonresidential location attracts more media and public attention.

The various locations of OHCA in diverse situations (educational institutions, health-care facilities, places of recreation, transport centers, places of worship, polling stations, and other outdoor sites) across the country noted in this study help in identifying high-risk areas for OHCA and the need for public health measures.[16]

Time of out-of-hospital cardiac arrest

The study shows a significant number of OHCAs occurring during the day time. Previous studies have shown big temporal variability in the incidence and survival after OHCA.[17]

Data on clinical characteristics

Data on medical history are less reported in the media. Studies have demonstrated that classical risk factors for CAD such as previous heart attacks have increased risk for OHCA.[18] In our study, there is poor reporting of risk factors.

Symptoms

Studies have shown that chest pain and shortness of breath are the common symptoms preceding OHCA which usually point to CAD as the etiology.[19] Reporting of chest pain followed by sudden collapse as common symptoms will educate the lay reader about the possibility of OHCA. Those patients with prodromal symptoms before cardiac arrest are likely to receive early EMS help and may have better outcomes than those without symptoms.[20] Increasing awareness of warning symptoms of OHCA among the public may lead to seeking medical help sooner and may improve survivals.[21]

Resuscitation characteristics

Bystander CPR enhances the survival of OHCA victims. The 2017 Heart Disease and Stroke Statistics show that among the 356,000 OHCA that occurred, 45.7% received bystander CPR. Studies have also shown an increase in the number of victims receiving bystander CPR from 40.8% to 68.2% gradually.[22]

The poor bystander CPR response in this study (1.43%) may be probably due to relative lack of awareness of cardiac arrests and <1% of bystander hands-only CPR training among Indian population.[23]

The use of AEDs/defibrillators was not reported in this study. AEDs are not routinely available in major public locations. Public access defibrillators should be available to improve outcomes from OHCA. Barriers to the availability and use of AEDs should be overcome.[24]

Survival from out-of-hospital cardiac arrest

While the international data suggest a survival varying from 6% to 10%,[25] this study from India shows a survival of 1.05%.

Strategies to enhance bystander CPR, delivering early defibrillation with AED, and restoring the circulation soon (return of spontaneous circulation) before transporting to a hospital may improve aggregate rates of survival of OHCA.[26] Ninety-two percent with OHCA do not survive to hospital discharge. This can be improved with improving the links in the chain of survival.[27]

Role of media

Health literacy is important in health-related outcomes nationally. In general, sudden cardiac arrests are underreported in the media. A report of OHCA and its detailed portrayal will encourage the lay public to learn CPR.

Public education initiatives of the “chain of survival” are also possible through the use of digital tools and digital strategies such as mobile devices, social media, and crowdsourcing.[28]

Need for action

As majority of OHCA occurred in residential locations, there is a dire need to train family members in CPR. It is also important to conduct regular training programs in bystander CPR for staff at public buildings, places of worship, polling stations, workplaces, transport centers, recreation places, and educational institutions. Availability and access to AEDs at public places will improve outcomes significantly.

The reporting of chest pain, collapse, breathlessness, and other symptoms creates awareness among the lay readers about the prior symptoms of cardiac arrest. There is a need to educate the public about the circumstances of cardiac arrest. Reports of survivors of the OHCA encourage the lay public to learn CPR. The international evidence-based recommendations regarding the cardiac resuscitation systems of care will improve survival from OHCA.[29],[30]

Limitations of the study

The number of OHCA in the study is not the accurate total number as only limited information from select newspapers was available for review. There was no single agency with all needed data. Accessing the information from newspapers in different languages from different states was also a limiting factor. Considering these limitations, the study may not reflect the total burden of sudden cardiac arrests in general and OHCA in particular. The level of medical knowledge of the media personnel is another limiting factor in accurate reporting of data on OHCA which needs to be addressed.


  Conclusions Top


With an increasing number of newspaper readers, a detailed reporting of cardiac arrests is important. With 384 million Internet users which include 50% of rural population in India, there is a vast scope for the digital media to improve health literacy in enhancing cardiac arrest awareness and bystander CPR.

There needs to be an official source for capturing health-related information. Making OHCA a reportable event in India would increase the number of cardiac arrests reported. In the absence of National Data Bank, any reported study of cardiac arrests will be incomplete. There needs to be a consistent contribution from all media sources, print, audiovisual, and digital. All stakeholders involved in the delivery of health care such as the medical professionals and governmental agencies need to coordinate and combine their resources for pooling the data.

This pilot study recognizes the need to have systems in place at the local, regional, state, and national levels contributing to a comprehensive national cardiac arrest data pool (National OHCA Registry). All governmental and nongovernmental organizations involved with health care need to combine their resources. The authors recognize the challenges involved in initiating and maintaining such a system in India. However, these crucial data will help in developing and implementing a national program of OHCA awareness with bystander CPR and AED training to improve outcomes. The Government of India needs to address this major health-care issue soon to prevent lakhs of preventable sudden deaths every year.

Dataset

Ramaka, Srinivas; Murthy, Vemuri; Nanda, Navin; Sindgi, Vasudeva Murthy; Sarvar Mohammed, Adil (2020), “Data of “An Observational Study of Out-of-Hospital Cardiac Arrests Reported In Indian Print Media“”, Mendeley Data, V1, doi: 10.17632/ckjrch6bxg.1. http://dx.doi.org/10.17632/ckjrch6bxg.1.

Key messages

*What is already known about this subject?

There is paucity of data on OHCA in India.

*What this study adds?

In the absence of national representative data on OHCA, this study on newspaper reports of OHCA provides a glimpse of OHCA in India.

*What is the likely impact?

This study is likely to generate interest among various stakeholders in prevention of cardiac arrest and focus on measures to improve outcomes from OHCA, an important public health problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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