Patient delay and receipt of thrombolytic therapy among patients with acute myocardial infarction from a community-wide perspective

Perceived Heart Attack Likelihood in Adults with a High Diabetes Risk

BACKGROUND

Heart disease is the leading cause of death for women and men in the United States. Yet, little is known about the motivation for care-seeking behavior for heart attack and the perception of self-risk of a heart attack in individuals, especially those at high risk for developing type 2 diabetes.

OBJECTIVES

This study aimed to describe knowledge and awareness of heart attacks and perceived risk for future heart attacks and evaluate factors associated with a low perceived risk of a heart attack in adults with a high risk for type 2 diabetes.

METHODS

In this secondary data, cross-sectional study, the screening/baseline data of 80 adults participating in the mobile phone-based diabetes prevention program trial were analyzed. Validated measures assessed knowledge, self-efficacy, and heart attack risk perception were used. Logistic regressions were performed.

RESULTS

The mean (standard deviation) age of participants was 55.4 (9.0) years. 32.5% of the sample failed to identify any heart attack symptoms. Half of the sample did not perceive their risk of having a heart attack in their lifetime. Older age, lower body mass index, not having a family history of heart attack, and current smokers were significantly associated with a lower perceived risk of heart attack (P < .05).

CONCLUSIONS

Healthcare providers need to assess the discrepancies between the individual's risk perception and the presence of actual risk factors of a heart attack in adults with a high risk for type 2 diabetes.

Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival

BACKGROUND

Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors.

PURPOSE

The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy.

METHODS

About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32-74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics).

RESULTS

Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., OR_high-low = 3.84 [1.127, 11.65]).

CONCLUSIONS

Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

A review of interventions aimed at reducing pre-hospital delay time in acute coronary syndrome: what has worked and why?

BACKGROUND

Delay in seeking treatment for acute coronary syndrome (ACS) symptoms is a well recognised problem. While the factors that influence pre-hospital delay have been well researched, to date this information alone has been insufficient in altering delay behaviour.

AIM

This paper reports the results of a critical appraisal of previously tested interventions designed to reduce pre-hospital delay in seeking treatment for ACS symptoms.

METHODS

The search was confined to interventions published between 1986 and the present that were written in English and aimed at reducing pre-hospital delay time. The following databases were searched using keywords: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pubmed, Academic Search Premier, Ovid, Cochrane, British Nursing Index, and Google Scholar. A total of eight intervention studies were identified as relevant. This review was developed following a systematic comparative analysis of those eight studies.

RESULTS

Seven of the eight interventions were based on mass media campaigns. One campaign was targeted at individuals. All were aimed at raising ACS symptom awareness and/or increasing prompt action in the presence of symptoms. Only two studies reported a statistically significant reduction in pre-hospital delay time.

CONCLUSION

In response to concerns about prolonged pre-hospital delay time in ACS, interventions targeting the problem have been developed. The literature indicates that responses to symptoms depend on a variety of factors. In light of this, interventions should include the scope of factors that can potentially influence pre-hospital delay time and ideally target those who are at greatest risk of an ACS event.

Age and sex differences and 20-year trends (1986 to 2005) in prehospital delay in patients hospitalized with acute myocardial infarction

BACKGROUND

The prompt administration of coronary reperfusion therapy for patients with an evolving acute myocardial infarction (AMI) is crucial in reducing mortality and the risk of serious clinical complications in these patients. However, long-term trends in extent of prehospital delay and factors affecting patient's care-seeking behavior remain relatively unexplored, especially in men and women of different ages. The objectives of this study were to examine the overall magnitude and 20-year trends (1986 to 2005) in duration of prehospital delay in middle-aged and elderly men and women hospitalized with AMI.

METHODS AND RESULTS

The study sample consisted of 5967 residents of the Worcester, Mass, metropolitan area hospitalized at all greater Worcester medical centers for AMI between 1986 and 2005 who had information available about duration of prehospital delay. Compared with men <65 years, patients in other age-sex strata exhibited longer prehospital delays over the 20-year period under study. The multivariable-adjusted medians of prehospital delay were 1.96, 2.07, and 2.57 hours for men <65 years, men 65 to 74 years, and men ≥75 years and 2.08, 2.33, and 2.27 hours for women <65 years, women 65 to 74 years, and women ≥75 years, respectively. These age and sex differences have narrowed over time, which has been largely explained by changes in patient's comorbidity profile and AMI-associated characteristics.

CONCLUSIONS

Our results suggest that duration of prehospital delay in persons with symptoms of AMI has remained essentially unchanged during the 20-year period under study and elderly individuals are more likely to delay seeking timely medical care than younger persons.

Trends in prehospital delay in patients with acute myocardial infarction (from the Worcester Heart Attack Study)

Delay in seeking medical care after symptom onset in patients with an acute myocardial infarction (AMI) is related to increased morbidity and mortality. Duration of prehospital delay in patients hospitalized with AMI has not been well characterized over time, and potentially changing patient characteristics associated with prolonged delay are not well understood. The study sample consisted of 5,967 residents (mean age 76 years; 39% women) of the Worcester, Massachusetts, metropolitan area hospitalized with AMI in 11 annual periods from 1986 to 2005. Mean and median delay times have remained essentially unchanged during the past 2 decades. Mean and median prehospital delay times were 4.1 and 2.0 hours in 1986, 4.7 and 2.2 hours in 1995, and 4.6 and 2.0 hours in 2005, respectively. Approximately 45% of patients with AMI presented within 2 hours of acute symptom onset, whereas an additional one third presented from 2 to 6 hours after the onset of acute coronary symptoms. Advancing age and history of either diabetes or MI were associated with prolonged delay. Compared with patients arriving within 2 hours of symptom onset, those with prolonged prehospital delay were less likely to receive thrombolytic therapy and percutaneous coronary intervention within 90 minutes of hospital arrival. In conclusion, results of this population-based study suggest that a large proportion of patients with AMI continue to show prolonged prehospital delay.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

The effects of health beliefs on health care-seeking decisions of Jordanian patients with myocardial infarction symptoms

The main purpose of this study was to examine the significance of health beliefs, perceived seriousness of harmful consequences and perceived barriers in explaining health care-seeking decisions of patients experiencing myocardial infarction symptoms. A structured interview guide developed by the researchers that included health beliefs, patient delay, sociodemographics and clinical characteristics of the patients was introduced to 79 myocardial infarction patients on the third day of hospitalization. Thirty-eight per cent of the patients delayed the health care-seeking decision > 1 h. Gender, age and perceived seriousness of the consequences significantly distinguished between delayers and non-delayers, correctly classifying 77% of the cases. Delayers were more likely to be female and young adults, and those who perceived increased negative consequences to myocardial infarction. Educational and counselling programmes for individuals at increased risk for myocardial infarction should consider the negative influence of perceived seriousness of consequences on the decision-making process of the patients. Also, interventions to change women's perception of their vulnerability to this illness are needed.

Delay in seeking care for symptoms of acute myocardial infarction: Applying a theoretical model

Thirty percent of people who experience symptoms of acute myocardial infarction (AMI) do not seek care until more than 2-6 hours after onset of symptoms, increasing their risk for morbidity and mortality. Using a model based on two frameworks, the common sense model of illness representation (CSM) and goal expectancy, variables associated with delay were examined to identify the most salient predictors of delay in seeking care for AMI. Hierarchical regression analysis revealed that the set of illness representation components from the CSM was a significant predictor of time to seek care, but individually, only recognition of symptoms as being caused by the heart was significant. Providing accurate information on symptoms of AMI may lead to early recognition, reduced delay, and reduced morbidity and mortality.

Differences in care-seeking behavior for acute chest pain in the United States and Japan

BACKGROUND

Delay from onset of acute myocardial infarction symptoms to the delivery of medical care is a major determinant of prognosis. Although studies have explored patient factors for delay in seeking care, there are limited data on international differences in care-seeking behavior.

METHODS

We surveyed 1032 people in the United States and 1422 people in Japan in January 1997 on decision-making responses to a chest pain scenario representing acute MI. Participants were asked about how they would seek initial care and how promptly they would seek care.

RESULTS

The mean age was 43.6 years in the United States and 48.3 years in Japan. For the hypothetical scenario, US respondents were more likely to seek care at an emergency department (22.9% vs 16.2% in Japan) or through emergency medical services/911 (55.9% vs 32.9% in Japan, P =.001). American subjects were also more likely to seek care immediately (83.1% vs 56.4% in Japan, P =.001).

CONCLUSION

Respondents in the United States and Japan differed substantially in their responses to a hypothetical chest pain scenario. Whether these differences result from cultural or health care system factors and whether these apparent attitudes produce gaps in real responses to acute coronary syndromes must be explored in further studies.

Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction

BACKGROUND

Prior studies have yielded conflicting data on the advantage of primary angioplasty compared with thrombolysis in elderly patients with acute myocardial infarction (AMI). These studies, however, were performed before the contemporary widespread use of intracoronary stents and glycoprotien IIb/IIIa antagonists.

METHODS

We prospectively compared the outcome of 130 consecutive elderly patients (aged > or =70 years) with ST-elevation AMI who were admitted to 2 similar neighboring medical centers. Patients were assigned to receive either thrombolytic therapy with accelerated tissue-type plasminogen activator (center I) or primary angioplasty with routine stenting (center II).

RESULTS

Of the patients assigned to receive primary angioplasty, 91% underwent stenting. At 6 months, patients treated with primary angioplasty, compared with those treated with thrombolytic therapy, had a lower incidence of reinfarction (2% vs 14%, P =.053) and revascularization for recurrent ischemia (9% vs 61%, P <.001) and a significant reduction in the prespecified combined end point of death, reinfarction, or revascularization for recurrent ischemia (29% vs 93%, P <.01). Primary angioplasty remained an independent predictor of the triple combined end point after controlling for potential covariables (relative risk 0.63, 95% CI 0.38-0.84). Major bleeding complications were also significantly reduced in the primary angioplasty group (0% vs 17%, P =.03).

CONCLUSIONS

Compared with thrombolysis, primary angioplasty with routine stenting in elderly patients with AMI is associated with better clinical outcomes and a lower risk of bleeding complications.

Decision making processes in people with symptoms of acute myocardial infarction: qualitative study

OBJECTIVE

To identify the themes that influence decision making processes used by patients with symptoms of acute myocardial infarction.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Two district hospitals in North Yorkshire.

PARTICIPANTS

22 patients admitted to hospital with confirmed second, third, or fourth acute myocardial infarction.

MAIN OUTCOME MEASUREMENTS

Patients' perceptions of their experience between the onset of symptoms and the decision to seek medical help.

RESULTS

Six main themes that influence the decision making process were identified: appraisal of symptoms, perceived risk, previous experience, psychological and emotional factors, use of the NHS, and context of the event.

CONCLUSIONS

Knowledge of symptoms may not be enough to promote prompt action in the event of an acute myocardial infarction. Cognitive and emotional processes, individual beliefs and values, and the influence of the context of the event should also be considered in individual interventions designed to reduce delay in the event of symptoms of acute myocardial infarction.

Acute ischemic syndromes. Early response

The optimal treatment of patients with AIS depends on a well-run, integrated system of care involving patients and teams of health care professionals. It begins with patient education and extends to a method for accessing an efficient and effective EMS system. Medics must be well equipped and well trained to evaluate and begin initial treatment during prompt transport to an appropriate hospital. The role of out-of-hospital 12-lead ECGs and thrombolysis is reviewed and may be appropriate for some EMS systems. The initial evaluation and treatment in the ED goes on simultaneously and is a dynamic process. Prompt treatment with oxygen, nitroglycerin, morphine, and aspirin is indicated. Initial risk stratification is based on the first ECG, cardiac biomarkers, and the clinical history and physical exam. Disposition and further evaluation is individualized according to the initial work-up and risk assessment.

Underutilization of reperfusion therapy in eligible African Americans with acute myocardial infarction: Role of presentation and evaluation characteristics

BACKGROUND

Immediate reperfusion therapy to restore coronary blood flow is recommended for all eligible patients with acute myocardial infarction. However, reperfusion therapy is reportedly underutilized among African Americans, even when they are eligible. Reasons for the lack of use have not been fully explored.

METHODS

We examined the demographic, clinical, and treatment data of 10,469 African Americans with acute myocardial infarction who were eligible for reperfusion therapy, enrolled in the National Registry of Myocardial Infarction-2 from June 1994 through March 1998.

RESULTS

The mean age was 62.58 (+/-14.4) years, and 44.7% were female. Although eligible, 47% of the African Americans in this study did not receive reperfusion therapy. In a multivariate analysis, the absence of chest pain at presentation (odds ratio [OR] 0.31, 95% CI 0.26-0.37) and initial admission diagnoses other than definite myocardial infarction (OR for receipt of reperfusion <0.12) were the strongest predictors of lack of early reperfusion therapy. Progressive delays in hospital arrival and hospital evaluation predicted a lower likelihood of early reperfusion. Prior stroke (OR 0.63, 95% CI 0.50-0.78), myocardial infarction (OR 0.75, 95% CI 0.65-0.86), and congestive heart failure (OR 0.49, 95% CI 0.40-0.60) were all associated with lack of reperfusion therapy.

CONCLUSION

Almost half of eligible African American patients with myocardial infarction did not receive reperfusion therapy. Potential reasons may include atypical presentation, patient and institutional delay, and underappreciation of myocardial infarction by care providers. Strategies to address these factors may improve the rate of use of reperfusion therapy.

Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective

OBJECTIVES

The goal of this study was to examine long-term trends in the incidence, in-hospital and long-term mortality patterns in patients with an initial non-Q-wave myocardial infarction (NQWMI) as compared with those with an initial Q-wave myocardial infarction (QWMI).

BACKGROUND

Limited data are available describing trends in the incidence and mortality from an initial QWMI and NQWMI from a multi-hospital community-wide perspective.

METHODS

Our study was an observational study of 5,832 metropolitan Worcester, Massachusetts residents (1990 census = 437,000) hospitalized with validated initial acute MI in all greater Worcester hospitals during 11 annual periods between 1975 and 1997.

RESULTS

The incidence of QWMI progressively decreased between 1975/78 (incidence rate = 171/100,000 population) and 1997 (101/100,000 population). In contrast, the incidence of NQWMI progressively increased between 1975/78 (62/100,000 population) and 1997 (131/100,000 population). Hospital death rates were 19.5% for patients with QWMI and 12.5% for those with NQWMI. After controlling for various covariates, patients with QWMI remained at significantly increased risk for hospital mortality (adjusted odds ratio = 1.63; 95% confidence interval: 1.35, 1.97). While the hospital mortality of QWMI has progressively declined over time (1975/78 = 24%; 1997 = 14%), the in-hospital mortality for NQWMI has remained the same (1975/78 = 12%; 1997 = 12%). These trends remained after adjusting for potentially confounding prognostic factors. The multivariable adjusted two-year mortality after hospital discharge declined over time for patients with QWMI and NQWMI.

CONCLUSIONS

Despite impressive declines in the incidence, in-hospital and long-term mortality associated with QWMI, NQWMI is increasing in frequency and has the same in-hospital mortality now as it did 22 years ago.

Women's risk of decision delay in acute myocardial infarction: implications for research and practice

Cardiovascular disease is the leading cause of death for women in the United States. Despite recent advances in treatment options for acute myocardial infarction (AMI), there has not been similar progress in decreasing the time between symptom onset and the decision to seek medical help (labeled "decision delay") and therefore availability of such treatments. Women delay longer than men before seeking help for symptoms of AMI, yet few studies have analyzed decision delay by gender. Factors studied to date do not adequately explain the differences in decision delay among women or between women and men with AMI. Additional research is needed to guide interventions to limit decision delay in women at risk for AMI. Until then, clinicians should use existing general guidelines to assist women at risk of AMI to avoid decision delay.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions

BACKGROUND

Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS

Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS

Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS

Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Treatment-seeking behavior for acute myocardial infarction symptoms in North America and Australia

OBJECTIVE

The goal of this study was to compare North American and Australian patients' sociodemographic, clinical, cognitive, emotional, and social factors associated with behavior in seeking treatment for symptoms of acute myocardial infarction.

PATIENTS

Subjects included 277 North Americans (mean age, 58 +/- 12 years; 72% men) and 147 Australians (mean age, 62 +/- 13 years; 66% men) with acute myocardial infarction.

METHODS

Data were obtained with the Response to Symptoms Questionnaire and from the patients' hospital records.

RESULTS

In both groups, patients who delayed longer (P </=.05) had lower incomes, known diabetes mellitus, and symptom onset while at home; in addition, they appraised their symptoms as not serious, waited for symptoms to go away, and worried about troubling others. Additional factors associated with longer delay in North Americans (P </=.05) were older age, intermittent symptoms, and attribution of symptoms to a noncardiac cause; other contributing factors include not recognizing the symptoms as cardiac and fearing the consequences of seeking help. In Australians (P </=. 05), contributing factors were fewer years of education, a history of hypertension, and embarrassment about seeking help.

CONCLUSION

Programs to reduce delay in response to acute myocardial infarction symptoms must take account of cognitive and emotional processes and differences in response in the particular cultures of patients.

Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment

BACKGROUND

There are few data on possible age and sex differences in presentation of symptoms for patients with acute coronary disease.

OBJECTIVE

To investigate demographic differences in presentation of symptoms at the time of hospital presentation for acute myocardial infarction (AMI) and unstable angina.

METHODS

The medical records of patients who presented with chest pain and who also had diagnoses of AMI (n = 889) or unstable angina (n = 893) on discharge from 43 hospitals were reviewed as part of data collection activities of the Rapid Early Action for Coronary Treatment trial based in 10 pair-matched communities throughout the USA.

RESULTS

Dyspnea (49%), arm pain (46%), sweating (35%), and nausea (33%) were commonly reported by men and women of all ages in addition to the presenting complaint of chest pain. After we had controlled for various characteristics through regression modeling, older persons with AMI were significantly less likely than were younger persons to complain of arm pain and sweating, and men were significantly less likely to report vomiting than were women. Among persons with unstable angina, arm pain and sweating were reported significantly less often by elderly patients. Nausea and back, neck, and jaw pain were more common complaints of women.

CONCLUSIONS

Results of this study suggest that there are differences between symptoms at presentation of men and women, and those in various age groups, hospitalized with acute coronary disease. Clinicians should be aware of these differences when diagnosing and managing patients suspected to have coronary heart disease.

Missed opportunities to impact fast response to AMI symptoms

The potential for reducing cardiovascular disease mortality rates lies both in prevention and treatment. The earlier treatment is administered, the greater the benefit. Thus, duration of time from onset of symptoms of acute myocardial infarction to administration of treatment is important. One major factor contributing to failure to receive efficacious therapy is the delay time from acute myocardial infarction (AMI) symptom onset to hospital arrival. This paper examines the relationship of several factors with regard to intentions to seek care promptly for symptoms of AMI. A random-digit dialed telephone survey (n = 1294) was conducted in 20 communities located in 10 states. People who said they would wait until they were very sure that symptoms were a heart attack were older, reported their insurance did not pay for ambulance services, and reported less confidence in knowing signs and symptoms in themselves. When acknowledging symptoms of a heart attack, African-Americans and people with more than a high school education reported intention to act quickly. No measures of personal health history, nor interaction with primary care physicians or cardiologists were significantly related to intention to act fast. The study confirms the importance of attribution and perceived self-confidence in symptom recognition in care seeking. The lack of significant role of health history (i.e. those with chronic conditions or risk factors) and clinician contact highlights missed opportunities for health care providers to educate and encourage patients about their risk and appropriate action.

Prehospital delay in patients hospitalized with heart attack symptoms in the United States: the REACT trial. Rapid Early Action for Coronary Treatment (REACT) Study Group

BACKGROUND

The use of thrombolytic therapy for patients with myocardial infarction has been limited by patient delay in seeking care. We sought to characterize prehospital delay in patients hospitalized for evaluation of heart attack symptoms.

METHODS AND RESULTS

The Rapid Early Action for Coronary Treatment (REACT) is a multicenter, randomized community trial designed to reduce patient delay. At baseline, data were abstracted from the medical records of 3783 patients hospitalized for evaluation of heart attack symptoms in 20 communities. The median prehospital delay was 2.0 hours; 25% of patients delayed longer than 5.2 hours. In a multivariable analysis, delay time was longer among non-Hispanic blacks than among non-Hispanic whites, longer at older ages, longer among Medicaid-only recipients and shorter among Medicare recipients than among privately insured patients, and shorter among patients who used an ambulance.

CONCLUSIONS

The observed pattern of differences is consistent with the contention that demographic, cultural, and/or socioeconomic barriers exist that impede rapid care seeking.

A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective

OBJECTIVES

The purpose of the present study is to describe changes over two decades (1975 to 1995) in the incidence, in-hospital and long-term case-fatality rates associated with acute myocardial infarction (AMI) from a multihospital community-wide perspective.

BACKGROUND

Despite the magnitude of, and mortality associated with acute myocardial infarction (AMI), relatively limited population-based data are available to describe recent and temporal trends in the attack and case-fatality rates associated with AMI from a representative population-based perspective.

METHODS

The community-based study included 5,270 residents of the Worcester, Massachusetts, metropolitan area hospitalized with confirmed initial AMI in all metropolitan Worcester, Massachusetts, hospitals (1990 census population = 437,000) in 10 one-year periods between 1975 and 1995.

RESULTS

The age-adjusted incidence rates of initial AMI increased between 1975 (244 per 100,000) and 1981 (272 per 100,000), after which time these rates declined through 1995 (184 per 100,000). The crude and multivariable-adjusted in-hospital case-fatality rates exhibited a consistent decline between 1975/1978 (17.8%), 1986/1988 (17.0%) and 1993/1995 (11.7%). Although there were no statistically significant differences in the unadjusted long-term case-fatality rates of discharged hospital survivors over the periods under study, declines in the multivariable-adjusted risk of dying within the first year after hospital discharge were observed between the earliest and most recently discharged patients with AMI.

CONCLUSIONS

The results of this population-based study of patients with validated initial AMI provide encouragement for efforts directed at the primary and secondary prevention of AMI given declining incidence and case-fatality rates.

Patient delay in seeking treatment for acute myocardial infarction symptoms

Patient delay before seeking treatment for the symptoms of acute myocardial infarction has a significantly negative effect on morbidity and mortality. Most patients delay 2 or more hours before accessing the emergency medical system, which limits the ability to use reperfusion strategies. This article reviews variables that have been implicated in delay and explores possible explanations for why certain characteristics may be associated with longer delays. The outcomes of educational campaigns that have targeted delay behavior will be examined and directions for future research are identified.

Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (The second National Registry of Myocardial Infarction)

This study examines the association between time to treatment with thrombolytic therapy and hospital outcomes in patients with acute myocardial infarction (AMI) enrolled in a national registry. A total of 71,253 patients hospitalized with AMI from June 1994 to July 1996 who received tissue plasminogen activator (t-PA) therapy in 1,474 United States hospitals were studied. In this study sample, approximately 39% of patients presented to participating hospitals within 2 hours of acute symptom onset and received t-PA; 36% were treated within 2.1 to 4 hours, 12% between 4.1 to 6 hours, and the remaining 13% thereafter. After controlling for potentially confounding factors, in-hospital death rates increased progressively with increasing delays in time of administration of t-PA. The lowest risk for dying during acute hospitalization was seen for those treated with t-PA within 2 hours of acute symptoms. No significant association was seen between time of administration of t-PA and in-hospital risk of recurrent AMI, myocardial ischemia, cardiogenic shock, major bleeding episodes, or stroke and/or intracranial bleeding. The incidence of sustained ventricular arrhythmias declined with progressively longer time to administration of t-PA. The results of this multihospital observational study suggest that patients with AMI treated earlier with t-PA are significantly more likely to survive the acute hospitalization than patients treated later. These data reinforce the benefits to be gained by treatment with t-PA as soon as possible following the onset of acute ischemic symptoms, and for community-wide efforts to reduce the duration of prehospital delay in patients with acute coronary disease.

Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective

OBJECTIVES

To describe sex differences in symptom presentation after acute myocardial infarction (AMI) while controlling for differences in age and other potentially confounding factors.

BACKGROUND

Although several studies have examined sex differences in diagnosis, management, and survival after AMI, limited data exist about possible sex differences in symptom presentation in the setting of AMI.

METHODS

Community-based study of patients hospitalized with confirmed AMI in all 16 metropolitan Worcester, Mass., hospitals (1990 census population = 437,000). Men (n = 810) and women (n = 550) hospitalized with validated AMI in 1986 and 1988 comprised the study sample.

RESULTS

After simultaneously controlling for age, medical history, and AMI characteristics through regression modeling, men were significantly less likely to complain of neck pain (adjusted odds ratio (OR) = 0.52; 95% CI: 0.35, 0.78), back pain (OR = 0.38; 95% CI: 0.26, 0.56), jaw pain (OR = 0.50; 95% CI: 0.31, 0.81), and nausea (O.R. = 0.58; 95% CI: 0.45, 0.75) than women. Conversely, men were significantly more likely to report diaphoresis (OR = 1.27; 95% CI: 1.00, 1.61) than women. There were no statistically significant sex differences in complaints of chest pain though men were more likely to complain of this symptom.

CONCLUSIONS

The results of this population-based observational study suggest differences in symptom presentation in men and women hospitalized with AMI. These findings have implications for public and health care provider education concerning recognition of sex differences in AMI-related symptoms and health care seeking behaviors.

Rapid early action for coronary treatment: rationale, design, and baseline characteristics. REACT Research Group

OBJECTIVE

Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay.

METHODS

Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed.

RESULTS

Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86).

CONCLUSIONS

REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction: A Report by the National Heart Attack Alert Program

An estimated 13 million people in the United States have coronary heart disease (CHD), peripheral vascular disease, or cerebrovascular disease. The risk for subsequent myocardial infarction (MI) and death in these patients is fivefold to sevenfold higher than for the general population. Many effective therapies are now available for patients with unstable angina, acute myocardial infarction (AMI), potentially fatal arrhythmias, and cardiogenic shock if they seek and receive care expeditiously. However, delays in accessing and receiving care are a continuing problem, threatening the effectiveness of available treatments. Patients with previously diagnosed CHD, including a previous MI, have the same or greater delay times as those without prior MI or CHD. Because of the high-risk status of these patients, combined with the problem of delay in seeking care, this Working Group of the National Heart Attack Alert Program Coordinating Committee advises physicians and other healthcare providers of their important role in reducing treatment delay in these patients. The Working Group recommends that primary care clinicians in the office and in inpatient settings provide these patients and their family members or significant others with contingency counseling about actions to take in response to symptoms of an AMI. The counseling should address the emotional aspects (e.g., fear and denial) that patients and those around them may experience, as well as barriers that may be associated with the healthcare delivery system. Assistance from other healthcare providers (e.g., nurses) should be solicited to initiate, reinforce, and supplement the counseling. A Patient Advisory Form is offered as an aid to providers in counseling their high-risk patients about these issues. Other materials and aids should be considered as well. Physicians' offices and clinics should devise a system to triage patients rapidly when they call or walk in seeking advice for possible AMI symptoms. Further research is needed to learn more about effective counseling strategies; symptom manifestation in high-risk groups, including the elderly, women, and minorities; and healthcare delivery systems that enhance access to timely care for patients with prior CHD or other clinical atherosclerotic disease.

Symptoms of acute myocardial infarction: expectations of a community sample

OBJECTIVE

To identify the lay public's expectations of the symptoms of acute myocardial infarction (AMI).

DESIGN

Street-intercept survey method.

SETTING

Four neighborhoods in a large metropolitan area.

SAMPLE

One hundred ninety-seven women and 217 men.

INSTRUMENT

The Representation of Heart Attack Symptoms questionnaire (RHAS), a 48-item instrument that identifies subjects' expectations concerning the associated symptoms of AMI and the location, quality, and intensity of the discomfort of AMI.

RESULTS

The symptoms most individuals expected during AMI included: chest pain, irregular heart beats, inability to move, and shortness of breath. The locations selected as most likely included: middle, left, and right side of the chest, upper and lower back. The most common descriptors of the expected discomfort were "tight," "pressure," and "heaviness." More than 88% of subjects expected the intensity of a heart attack to be at least a 9 on a scale of 0 (No discomfort) to 10 (The most discomfort imagined).

CONCLUSIONS

The lay public have both accurate and inaccurate expectations about the symptoms of AMI.

Factors associated with pre-hospital and in-hospital delay time in acute myocardial infarction: a 6-year experience

OBJECTIVES

To explore factors associated with delay time prior to hospital admission and in hospital amongst acute myocardial infarction (AMI) patients with particular emphasis on the delay time to the administration of thrombolytic therapy.

METHODS

During a 6-year period we prospectively computerized pre-hospital and in-hospital time intervals for AMI patients admitted to the coronary care unit (CCU) direct from the emergency department (ED) or via paramedics, at Sahlgrenska Hospital, Göteborg, Sweden.

RESULTS

Pre-hospital delay: independent predictors of a prolonged delay were increased age (P = 0.0007), female sex (P = 0.02) and a history of hypertension (P = 0.03). For AMI patients who received thrombolytic treatment and the only independent predictor of a prolonged delay was increased age (P = 0.005). In-hospital delay: for all AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P < 0.0001), increased age (P = 0.03) and a history of angina (P = 0.002), hypertension (P = 0.01) and diabetes (P = 0.01). For thrombolytic treated AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P < 0.0001), female sex (P = 0.02) and a history of diabetes (P = 0.02).

CONCLUSION

Risk factors for both pre-hospital and hospital delay time could in AMI be defined although slightly different. Two factors appeared for both, i.e. increasing age and a history of hypertension.

Prehospital delay in patients with acute coronary heart disease: concordance between patient interviews and medical records

Patient-associated delay in seeking medical care in the setting of acute coronary disease is assuming increasing importance as the benefits of reperfusion therapies become more time dependent. Given the importance of accurate information concerning prehospital delay, we examined the extent of concordance between information reported by patients in structured interviews by hospital staff nurses compared with information about time of acute symptom onset as recorded in the medical record. Data were obtained from 1137 patients with a discharge diagnosis of coronary heart disease who were admitted to six coronary care units in the Minneapolis-St. Paul metropolitan area. The average and median durations of prehospital delay were similar as reported in the structured personal interviews and through the review of medical records for the respective disease groups. The extent of individual level of agreement of delay time was considerably poorer, however. The Pearson correlation coefficients on the logarithmically transformed data were 0.48, 0.50, and 0.59 for persons with acute myocardial infarction, unstable angina, and chronic coronary disease, respectively, in comparing data noted in the medical record with that obtained in the personal interviews concerning prehospital delay time. These results suggest good agreement between personal interviews and medical record accounts in characterizing the average length of prehospital delay at the aggregate level but considerably less agreement at the individual patient level.

[The thrombolytic treatment of acute myocardial infarct in an emergency department]

INTRODUCTION AND OBJECTIVES

Although the importance of the early use of thrombolytic therapy in acute myocardial infarction has been demonstrated, it is usual to detect an unacceptable delay in its administration. We measured the in-hospital delay and, when it was determined we designed a protocol to reduce it.

METHOD

From January-92 to December-94 we performed a prospective analysis of the measured delay for patients with a diagnosis on admission of acute myocardial infarction or unstable angina within 24 hours of the onset of symptoms. To ensure a homogeneous population, we established a triage system: priority I, delay of the therapy not admissible and so immediate administration of thrombolytic agent (performed in the emergency department); priority II, need for a careful evaluation of the risk/benefit ratio for thrombolytic therapy and administration, when indicated, after admission to the coronary care unit, and priority III, thrombolytic therapy whether indicated or contraindicated. All data were evaluated periodically in order to detect possible failures and to correct them.

RESULTS

A total of 1,462 patients with a diagnosis of acute myocardial infarction (n = 1,006) or unstable angina (n = 456) were included. The administration of lytic therapy in the emergency department reduced the In-Hospital delay for thrombolysis by 54% from a median of 65 minutes (45 and 110) to 30 minutes (15 and 60) (p < 0.001) in priority I patients (40% of the patients diagnosed with AMI). For all cases with thrombolytic therapy this time was reduced from 87.5 minutes (50 and 155) to 50 minutes (25 and 110) minutes (p < 0.001).

CONCLUSIONS

Awareness of our in-hospital delay, establishing a triage system in the emergency department and administering thrombolytic drugs in the this area has made it possible to provide this therapy to selected patients as early as possible.

Women's decision to seek care for symptoms of acute myocardial infarction

OBJECTIVE

To describe the psychosocial processes by which women make the decision to seek care for the symptoms of Acute Myocardial Infarction (AMI).

DESIGN

The qualitative method of grounded theory was used to study the prehospital experience of women with symptoms of AMI.

PARTICIPANTS

Sixteen women between the ages of 42 and 82 years who were hospitalized in a coronary care unit after AMI.

RESULTS

The women delayed a median of 5.4 hours (range 1.5 to 144 hours). The psychosocial processes by which they made the decision to seek treatment after symptom onset were dynamic and multidimensional. The fundamental structure involved two core categories: (1) maintaining control, and (2) relinquishing control. Within these two core categories there were five subcategories: symptom awareness, perceived insignificance, self-treatment, perceived threat, and lay consultation.

CONCLUSION

Although these women immediately recognized their symptoms as abnormal, they did not acknowledge their seriousness until after the use of a variety of coping mechanisms and self-treatment behaviors to reduce threat and maintain control over the situation. Interventions to reduce delay should focus on the issue of perceived loss of control during symptom onset and attempt to reduce the sense of threat by describing the benefits of seeking treatment early.

Causes of delay in seeking treatment for heart attack symptoms

With the advent of thrombolytic therapy and other coronary reperfusion strategies, rapid identification and treatment of acute myocardial infarction greatly reduces mortality. Unfortunately, many patients delay seeking medical care and miss the benefits afforded by recent advances in treatment. Studies have shown that the median time from onset of symptoms to seeking care ranges from 2 to 61/2 hours, while optimal benefit is derived during the first hour from symptom onset. The phenomenon of delay by AMI patients and those around them needs to be understood prior to the design of education and counseling strategies to reduce delay. In this article the literature is reviewed and variables that increase patient delay are identified. A theoretical model based on the health belief model, a self regulation model of illness cognition, and interactionist role theory is proposed to explain the response of an individual to the signs and symptoms of acute myocardial infarction. Finally, recommendations are made for future research.

Temporal trends and factors associated with extent of delay to hospital arrival in patients with acute myocardial infarction: the Worcester Heart Attack Study

Factors associated with delay to hospital arrival after the onset of symptoms suggestive of acute myocardial infarction (AMI) were examined in the late 1960s and 1970s, but recent data concerning these characteristics are limited. The purpose of the present study was to examine overall and temporal distributions of the extent of patients' delay from the time of onset of AMI symptoms to hospital arrival and factors associated with delay in seeking medical care from a multihospital, population-based perspective. Review of medical records was undertaken of patients hospitalized with a discharge diagnosis of AMI in 16 teaching and community hospitals in Worcester, Mass. in 1986, 1988, and 1990. The study sample comprised 1279 patients hospitalized with validated AMI in whom data concerning extent of patient delay from onset of symptoms suggestive of AMI to hospital arrival were available. The average delay between onset of symptoms suggestive of AMI and arrival at local emergency departments did not change significantly with time (average of 4.1 hours in 1986, 4.0 hours in 1988, and 4.6 hours in 1990). The median delay was 2.0 hours during each of these years. Fifty percent of patients with AMI went to area-wide emergency departments within 2 hours of the onset of acute symptoms, 22% between 2 and 4 hours, and 28% delayed > 4 hours. Results of a multivariable regression analysis showed that older age, history of diabetes, type of medical insurance coverage and previous AMI were significantly associated with delays in hospital arrival of > 2 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency of inclusion of patients with cardiogenic shock in trials of thrombolytic therapy

The purpose of this study was to determine the extent to which patients with cardiogenic shock have participated in trials of thrombolytic therapy, to examine factors associated with their exclusion from these trials, and to summarize data on the efficacy of thrombolysis in these patients. Previous publications were searched for all randomized, controlled studies involving the use of thrombolytic medications used in the treatment of acute myocardial infarction. Data were abstracted for year of trial publication, performance location, sample size, maximal allowable delay between symptom onset and treatment, and exclusion criteria. Of the 94 trials included in the analysis, 22% included patients with cardiogenic shock, 37% excluded them, and the remainder contained no information on their inclusion or exclusion. Only 2 trials provided data on the efficacy of thrombolytic therapy in patients with cardiogenic shock. Multivariate analysis revealed that studies conducted exclusively in the U.S. were significantly more likely to exclude patients in cardiogenic shock than those conducted outside of the U.S., as were studies that excluded patients with a previous myocardial infarction, studies published more recently, and smaller trials. Patients with cardiogenic shock have frequently been excluded from clinical trials of thrombolytic agents. As a result, data on the efficacy of thrombolytic agents in these patients is extremely limited.