A comparative study of differences in the referral behaviour patterns of men and women who have experienced cardiac-related chest pain

An Exploration of the help-seeking experiences of patients in an allied professions-led rapid access chest pain pathway: a qualitative study

OBJECTIVE

A number of studies have explored delayed help-seeking practices for acute coronary syndrome (ACS) and have indentified multiple intersecting factors which may play a role, for example, attributing symptoms, age, gender, ethnicity and contextual influences. However, the pathway to diagnosis for suspected coronary heart disease (CHD) symptoms in a rapid access chest pain clinic (RACPC) context is underexplored. The objective of this study was to examine patients' help-seeking experiences of accessing RACPC services, from the point at which they notice and interpret symptoms, to their decision to seek help from their general practitioner.

DESIGN

Qualitative study.

SETTING

Interviews were conducted in the RACPC at Queen Mary's Roehampton Hospital, London, UK.

PARTICIPANTS

Maximum variation sampling was used to recruit 30 participants (15 men and 15 women) referred to a RACPC, using sampling dimensions of age, ethnicity and occupation.

METHODS

Semi-structured interviews focussed on the patient experience of their pathway to the RACPC. Thematic analysis was used to analyse the interview data.

RESULTS

Participant interpretation of symptoms was shaped by multiple influences; reluctance to seek help contributed to delay; various factors acted as drivers as well as barriers to help-seeking; and GP referrals to RACPC were based on symptoms as well as patients' need for reassurance.

CONCLUSION

We found complex issues shaped the patient's decision-making when accessing the RACPC, including making sense of symptoms and help-seeking practices. These findings can be used to develop health promotion literature to encourage early help-seeking and improve RACPC services.

Contesting lifestyle risk and gendering coronary candidacy: lay epidemiology of heart disease in Finland in the 1970s

This study addresses two issues currently under critical discussion in the epidemiology of cardiovascular diseases (CVD), the relative neglect of women and the individualised nature of key risk factors. It focuses on the North Karelia project (NKP), a community programme aimed at coronary heart disease (CHD) prevention in a predominantly rural Finnish region in the early 1970s, that is, during a period when the epidemiological understanding of CVD still was relatively new and actively promoted. Adopting the notions of lay epidemiology and coronary candidacy, culturally mediated explanatory models lay people use to assess who is likely to develop heart disease and why, the study shows that locals targeted by the project critically engaged with both of these bias. Based on the rich materials resulting from project activities the study shows, first, how many locals subsumed the individualised and lifestyle-based approach to CHD prevention promoted by NKP under a more general framework emphasising the health effects of ongoing structural changes in the area, and second, how women constructed themselves as viable coronary candidates. The case supports the position in the current discussions on lay expertise that wants to integrate lay experiences more firmly into epidemiological studies and public health.

Gender comparisons in non-acute cardiac symptom recognition and subsequent help-seeking decisions: a mixed methods study protocol

INTRODUCTION

Coronary heart disease (CHD) is one of the leading causes of death in both men and women worldwide. Despite the common misconception that CHD is a 'man's disease', it is now well accepted that women endure worse clinical outcomes than men following CHD-related events. A number of studies have explored whether or not gender differences exist in patients presenting with CHD, and specifically whether women delay seeking help for cardiac conditions. UK and overseas studies on help-seeking for emergency cardiac events are contradictory, yet suggest that women often delay help-seeking. In addition, no studies have looked at presumed cardiac symptoms outside an emergency situation. Given the lack of understanding in this area, an explorative qualitative study on the gender differences in help-seeking for a non-emergency cardiac events is needed.

METHODS AND ANALYSIS

A purposive sample of 20-30 participants of different ethnic backgrounds and ages attending a rapid access chest pain clinic will be recruited to achieve saturation. Semistructured interviews focusing on help-seeking decision-making for apparent cardiac symptoms will be undertaken. Interview data will be analysed thematically using qualitative software (NVivo) to understand any similarities and differences between the way men and women construct help-seeking. Findings will also be used to inform the preliminary development of a cardiac help-seeking intentions questionnaire.

ETHICS AND DISSEMINATION

Ethical approvals were sought and granted. Namely, the University of Westminster (sponsor) and St Georges NHS Trust REC, and the Trust Research and Development Office granted approval to host the study on the Queen Mary's Roehampton site. The study is low risk, with interviews being conducted on hospital premises during working hours. Investigators will disseminate findings via presentations and publications. Participants will receive a written summary of the key findings.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature

BACKGROUND

Patients' treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research.

METHODS AND RESULTS

We reviewed the English-language literature from 1998-2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing.

CONCLUSION

We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.

Thoughts and behaviors of women with symptoms of acute coronary syndrome

OBJECTIVE

Women delay seeking care for symptoms of acute coronary syndrome (ACS) because of atypical symptoms, perceptions of invulnerability, or keeping symptoms to themselves. The purpose of this study was to explore how women recognized and interpreted their symptoms and subsequently decided whether to seek treatment within the context of their lives.

METHOD

Grounded theory was used to provide the methodological basis for data generation and analysis. Data were collected using in-depth interviews with 9 women with ACS.

RESULTS

All participants went through a basic social process of searching for the meaning of their symptoms which informed their decisions about seeking care. Stages in the process included noticing symptoms, forming a symptom pattern, using a frame of reference, finding relief, and assigning causality. The evolving MI group (n = 5) experienced uncertainty about bodily cues, continued life as usual, until others moved them toward care. The immediately recognizable MI group (n = 4) labeled their condition quickly, yet delayed, as they prepared themselves and others for their departure.

CONCLUSIONS

All women delayed, regardless of their ability to correctly label their symptoms. Education aimed at symptom recognition/interpretation addresses only part of the problem. Women should also be educated about the potential danger of overestimating the time they have to seek medical attention.

Pain to hospital times after myocardial infarction in patients from Dalmatian mainland and islands, southern Croatia

AIM

To analyze pre-hospital delay in patients with myocardial infarction from mainland and islands of Split-Dalmatian County, southern Croatia.

METHODS

The study included all patients with myocardial infarction transported by ambulance to the University Hospital Split in 1999, 2003, and 2005. Pre-hospital delay was analyzed in the following intervals: pain-to-call, call-to-ambulance, ambulance-to-door, and door-to-coronary care unit interval. Patients were categorized according to the location from which they were transported: Split, mainland >15 km from Split, and islands.

RESULTS

There were 1314 patients (62.9% men) transported and hospitalized for myocardial infarction. Total pre-hospital delay (pain-to-hospital) was significantly reduced from 1999 to 2005 (5.2 hours vs 4.3 hours, P=0.011). Seventy-five patients (5.7%) were admitted to the coronary care unit within the recommended time-frame of less than 90 minutes, none of which was from the islands, while 248 patients (18.9%) were admitted more than 12 hours from the onset of pain.

CONCLUSION

Pre-hospital delay in patients with myocardial infarction in southern Croatia is still too long, especially in patients coming from outside of Split. Prognosis and survival of such patients may be improved by introducing changes to the health care system in remote areas, such as out-of-hospital thrombolysis, greater use of telemedicine, training of lay persons and paramedics in defibrillation, introduction of quality assessment mechanisms, and improved patient transport.

Women's help-seeking behaviour at the onset of myocardial infarction

Few studies have explored the factors affecting women's decisions to seek medical assistance at the onset of cardiac symptoms. Although some studies have shown that there are gender differences between men and women in terms of how they cope with having a myocardial infarction (MI) and heart disease, few have explored how women actually experience MI and what influences their help-seeking behaviour. Those studies that have, suggest that women often fail to recognize the signs of MI and delay seeking treatment for symptoms of MI longer than men do. This qualitative study explores the female experience of MI, focusing on some of the thought processes and coping strategies used by women when having an MI. Using a grounded theory research approach, 25 post-MI female patients were interviewed about their experiences during acute MI. Through analysing and coding data, a number of categories emerged that provide insight into the health seeking behaviour of women at the onset of MI. Emergent categories were: a delay in seeking help (main category); an engendered perception of heart disease (sub-category); not recognizing symptoms (sub-category); maintaining control through self-medication (sub-category). Analysis of the data suggests that when experiencing an MI, women delay seeking help for a number of reasons, including not recognizing symptoms, perceiving heart disease as a 'male' problem and preferring to self-medicate.

Stress in women's daily life before and after a myocardial infarction: a qualitative analysis

BACKGROUND

Little is known about women's perceptions of their daily life before and after a myocardial infarction (MI), especially with regard to stress, which is a risk factor for coronary heart disease (CHD).

AIM

To describe and explore women's perceptions of stress before and after an MI.

METHOD

Two interviews with women who suffered an MI, the first at the hospital (n = 20) and the second 4-10 months after the MI (n = 14), were analysed using a phenomenographic approach.

FINDINGS

The stress emanated either from within themselves (personal traits) or as an effect of their immediate surroundings. The period before the MI was stressful due to the different roles they had to maintain in their private and professional lives. They lost control over their daily life. After hospital discharge they both wanted and needed support, as they were terrified when they returned home. They did not know how much they could do and neither did their relatives, while little or no support was provided by the healthcare professionals.

CONCLUSIONS

To prevent CHD in daily life and avoid reinforcing stress, it is important to place greater emphasis on stress as an important risk factor. An understanding of this phenomenon can assist primary healthcare, coronary care unit (CCU) and rehabilitation nurses in supporting these women as well as their partners to adapt their daily lives both before and after an MI. It is essential to formulate and implement individualised treatment plans and to provide support groups for women.

Gender differences in rural and urban practice location among mid-level health care providers

CONTEXT

Mid-level providers comprise an increasing proportion of the health care workforce and play a key role in providing health services in rural and underserved areas. Although women comprise the majority of mid-level providers, they are less likely to work in a rural area than men. Maldistribution of health providers between urban and rural practices is an important issue influencing health care.

PURPOSE

To gain further insight into this issue, this study examined how mid-level practice location varied by gender.

METHODS

Semistructured interviews were conducted with a purposive sample of 55 nurse practitioners, physician assistants, and nurse anesthetists in New York State and Pennsylvania.

FINDINGS

Results suggest that family and community ties played a key role in influencing practice location. Men were particularly drawn to the broad scope of practice and autonomous nature of rural practice. Women in rural areas enjoyed the more personable environment and greater respect from colleagues and patients. Both male and female rural providers preferred their location because there were fewer turf issues, while some women were concerned about being professionally isolated. Meanwhile, both men and women enjoyed the fast pace, specialization, and greater opportunities urban areas had to offer.

CONCLUSIONS

Recruitment efforts should focus on candidates from rural areas and not underestimate the impact of family in decisions about work location.

Prehospital care pathway delays: gender and myocardial infarction

AIM

This paper reports the findings of a study that identified gender specific prehospital care pathway delays amongst Irish women and men with myocardial infarction.

BACKGROUND

Women are more likely to experience a poorer prognosis than their male counterparts following hospitalization for myocardial infarction, yet research shows that women continue to experience prehospital care pathway delays.

METHODS

A 1-year prospective census was carried in six major academic teaching hospitals in Dublin, Ireland in 2001-2002. A total of 277 (31%) female and 613 (69%) male patients with confirmed myocardial infarction were included in the study.

RESULTS

Women were more likely to experience prolonged 'initial symptom-onset to A&E delays' (14 hours vs. 2.8 hours P < 0.0001), and 'intense symptom-onset to A&E delays' (3.1 hours vs. 1.8 hours , P < 0.0001), i.e. arrival at a hospital accident and emergency department. Advancing age was associated with greater prehospital delays (P < 0.0001), whilst patients with private health insurance had shorter delays than public patients (without private health insurance) or those with medical cards (entitling them to means-tested medical benefits) (P = 0.001). Patients who drove themselves by car to hospital had shorter median prehospital times than those arriving by any other admission mode (P < 0.0001), whilst those referred by their general practitioner had longer delays than those who were self-referred (5 hours vs. 1.7 hours, P < 0.0001).

CONCLUSIONS

Female gender, advancing age, referral source, insurance status and mode of transport to hospital are independent factors contributing to prehospital patient delays. Nurses who care for patients with coronary artery disease have a unique opportunity to educate people about the most appropriate action to be taken in the event of experiencing symptoms.

In-hospital care pathway delays: gender and myocardial infarction

AIM

This paper reports the in-hospital findings of a study identifying gender specific care pathway delays or treatment opportunities amongst Irish women and men hospitalized with myocardial infarction.

BACKGROUND

Reperfusion therapy is of optimum benefit when administered early, yet research shows that women continue to experience greater in-hospital delays to treatment than men.

METHOD

A 1-year prospective census was carried out from December 2001 to November 2002 with 277 (31%) female and 613 (69%) male patients with myocardial infarction who were consecutively admitted to the six major teaching hospitals in Dublin, Ireland.

RESULTS

Women experienced greater 'Triage to first medical assessment' delays than men (P=0.001), and waited a median of 30 minutes for their first medical contact, compared with 20 minutes for men (P<0.0001). The median 'door to needle' time for women was 70 minutes in comparison with 52 minutes for men (P=0.02). Women waited longer than men for aspirin (P=0.02), whilst men received a bed in the coronary care unit almost 1 hour sooner than women (P<0.0001). Despite these delays to treatment, women and men experienced similar rates of reperfusion treatment.

CONCLUSIONS

In-hospital treatment delays experienced by women may limit their potential to achieve the maximum benefits from reperfusion therapies. Triage nursing provides the first entry point to hospital care for the majority of female patients with myocardial infarction, and therefore Accident and Emergency Department nurses are in an optimum position to influence positively the pathway of care for this group.

Coping, social support and quality of life over time after myocardial infarction

AIM

This paper describes gender differences in perceived coping, social support and quality of life 1, 4 and 12 months after myocardial infarction.

BACKGROUND

There is a shortage of studies with a longitudinal research design investigating coping, social support and quality of life in women and men after myocardial infarction.

METHODS

A longitudinal, descriptive and comparative design was used for the study, which included 74 women and 97 men. At 12 months, 60 women and 88 men remained. Data were collected using the Jalowiec Coping Scale, a social support questionnaire, the SF-36 Health Survey (health-related quality of life) and the Quality of Life Index-Cardiac version (quality of life). The data were collected during the period 1999-2001.

RESULTS

No statistically significant changes over time in coping assessments emerged in the study group, except for fatalistic coping, which diminished over time in men. Women used more evasive coping than men at 4 and 12 months. The perceived efficiency in coping with physical aspects of the heart disease increased. More women than men perceived available support from grandchildren and staff of the church. Health-related quality of life increased in women and men in physical functioning, role-physical, vitality, social functioning, and role-emotional scales. Moreover, an improvement in the mental health scale was evident in women and a reduction in pain in men. No statistically significant gender differences were found for quality of life at any point in time.

CONCLUSIONS

The findings can be used to inform caregivers that optimistic, self-reliant and confrontational coping were the most frequently used by both women and men over the first year after myocardial infarction, and that confrontational coping has been shown to have positive outcomes in the longer term. Nurses should tell women about the importance of seeking prompt treatment and discuss health problems with caregivers and significant others. Care planning should include family members and significant others so that they can support and encourage patients to cope with problems in daily life.

Women, men and coronary heart disease: a review of the qualitative literature

AIM

This paper presents a review of the qualitative literature which examines the experiences of patients with coronary heart disease. The paper also assesses whether the experiences of both female and male patients are reflected in the literature and summarizes key themes.

BACKGROUND

Understanding patients' experiences of their illness is important for coronary heart disease prevention and education. Qualitative methods are particularly suited to eliciting patients' detailed understandings and perceptions of illness. As much previous research has been 'gender neutral', this review pays particular attention to gender.

METHODS

Published papers from 60 qualitative studies were identified for the review through searches in MEDLINE, EMBASE, CINAHL, PREMEDLINE, PsychINFO, Social Sciences Citation Index and Web of Science using keywords related to coronary heart disease.

FINDINGS

Early qualitative studies of patients with coronary heart disease were conducted almost exclusively with men, and tended to generalize from 'male' experience to 'human' experience. By the late 1990s this pattern had changed, with the majority of studies including women and many being conducted with solely female samples. However, many studies that include both male and female coronary heart disease patients still do not have a specific gender focus. Key themes in the literature include interpreting symptoms and seeking help, belief about coronary 'candidates' and relationships with health professionals. The influence of social roles is important: many female patients have difficulties reconciling family responsibilities and medical advice, while male patients worry about being absent from work.

CONCLUSIONS

There is a need for studies that compare the experiences of men and women. There is also an urgent need for work that takes masculinity and gender roles into account when exploring the experiences of men with coronary heart disease.

What's wrong with me? Women's coronary heart disease diagnostic experiences

Most women are unaware that that they may experience atypical coronary heart disease (CHD) symptoms. Women's atypical presentation often results in women having difficulty being diagnosed with CHD or myocardial infarction. Investigating women's CHD diagnostic experiences may reveal vital areas amenable to intervention. This secondary analysis explored women's CHD diagnostic experiences. Forty women completed in-depth interviews in their homes that were audiotaped and lasted 2-3 hours. Using content analysis and constant comparison, five themes emerged: awareness, seeking treatment, frustration, treatment decisions, and anger. Despite numerous symptoms and visits with clinicians, most women were not diagnosed with CHD before myocardial infarction. During the infarction, women with typical symptoms were easily diagnosed while those with atypical symptoms received a delayed diagnosis. Those who repeatedly sought treatment were angry about not being diagnosed earlier. Further research is needed to promote early symptom recognition, timely diagnosis, and efficacious treatment-keys to improving women's CHD outcomes and to preventing similar negative diagnostic experiences.

Perceived coping, social support, and quality of life 1 month after myocardial infarction: a comparison between Swedish women and men

OBJECTIVE

The study objective was to compare coping, social support, and quality of life in Swedish women and men 1 month after myocardial infarction.

DESIGN

The study design was cross-sectional and descriptive-comparative.

SETTING

The study took place in 1 hospital service area in the middle of Sweden.

SUBJECTS

The sample consisted of 74 women and 97 men.

INSTRUMENTS

The Jalowiec Coping Scale, the Social Network and Social Support Questionnaire, the Short Form-36 Health Survey, and the Quality of Life Index-Cardiac Version were used.

RESULTS

Compared with men, women used more evasive and supportive coping and rated psychologic aspects of the heart disease as more problematic to manage. More women perceived available support from friends and grandchildren, and more men perceived available support from their partner. Women rated lower levels in physical and psychologic dimensions of quality of life.

CONCLUSION

The first month after myocardial infarction is a susceptible period especially for women. They used more evasive and supportive coping and experienced a lower quality of life compared with men.

Women's interpretation of their coronary heart disease symptoms

BACKGROUND

Men and women are known to delay in seeking medical attention when experiencing acute cardiac symptoms. However, women are more likely to have had chronic undifferentiated symptoms prior to an acute episode and then when experiencing an acute episode delay longer than do men. Studies have shown once women do present they tend to be further along the disease trajectory than men.

AIMS

The aim of this study was to explore women's own interpretation of the presenting symptoms they experienced.

METHODS

Twenty-nine women consented to take part in semi-structured interviews that focussed on their experience of coronary heart disease (CHD). The women's narrative around the initial disruption of their illness was analysed focusing on routine and reconstructed forms of narration.

RESULTS

The results showed that many failed to recognise and act on their symptoms. Most only sought medical attention after family or friends intervened. None of the women had seen themselves at risk of developing coronary heart disease despite many have a strong family history.

CONCLUSION

The women's early symptoms of coronary heart disease were often undifferentiated and difficult to interpret by the women themselves. There is a need for further research to understand and recognise early symptoms of coronary heart disease in women. This will allow women and health professionals to assess risk and identify women with coronary heart disease early on in their disease trajectory so therapy to prevent the morbidity associated with coronary heart disease and acute life threatening episodes will be reduced.

'Add women & stir'--the biomedical approach to cardiac research!

In conditions shared by women and men, the biomedical model of disease assumes that illness-symptoms and outcomes are biologically and socially 'neutral'. Consequently, up until a decade ago, white middle-aged men were the model subjects in most funded cardiac trials, with the assumption that whatever the findings, the results would also hold true for women. This 'add women and stir' approach has resulted in imbalances in cardiac care and an image of coronary artery disease, which portrays a middle-aged male as its victim. Moreover, cardiac health care has been designed with the male anatomy and male experience of illness in mind, and health promotional measures have been targeted towards men. Women have received these health promotional messages to protect the hearts of men, and have been less likely to modify their own lifestyles in a cardio-protective manner. However, the biological and social differences that exist between women and men, must surely invalidate such biased biomedical assertions, and signify a need to delve beyond the realm of biomedical reductionism for greater insights and understanding. This review examines how scientific reductionism has failed to explore the impact of coronary artery disease on the lives of women and how the gendered image of this disease has privileged the normative frame.

Prehospital delay in acute coronary syndrome—an analysis of the components of delay

BACKGROUND

Prompt hospital admission is essential when treating acute coronary syndrome. Delay prior to admission is unnecessarily long. Therefore, a thorough scrutiny of the influence of characteristics, circumstantial and subjective variables on elements of prehospital delay among patients admitted with acute coronary syndrome is warranted.

METHODS

A structured interview was conducted on 250 consecutive patients admitted alive with acute coronary syndrome.

RESULTS

Median prehospital, decision, physician and transportation delays were 107, 74, 25 and 22 min, respectively. Women (n=77) had more frequently atypical symptoms and increased prehospital delay caused by prolonged physician and transportation delay. Physician delay among women and men were 69 and 16 min, respectively. Patients with prior myocardial infarction had reduced prehospital delay, which was caused by shorter decision and physician delay; whereas patients with prior mechanical revascularisation or typical symptoms had prolonged prehospital delay due to long decision delay. When symptoms were interpreted as cardiac the decision and prehospital delay were reduced.

CONCLUSION

The medical profession underestimates the risk of acute coronary syndrome among women, and thereby contributes to unnecessary long delay to treatment. The patient's prior experience and interpretation has a significant influence on behaviour.

Womenʼs Delay in Seeking Treatment With Myocardial Infarction

Women, especially those older than 65 years, delay longer than do men before seeking medical treatment for symptoms of an acute myocardial infarction (AMI). The majority of delay time results from the patient's lengthy decision-making processes after symptoms begin and before seeking medical treatment. Effective treatment is time dependent as mortality and morbidity rise with each hour of delay. Therefore, the purpose of this research was 2-fold: (1) to synthesize reported research findings concerning women's reasons for delay in seeking treatment for symptoms of an AMI and (2) to identify areas for further research. Using Cooper's (Synthesizing Research. 3rd ed. London: Sage; 1998) framework for integrative review, this manuscript synthesized the literature from 48 reports published from 1995 to 2003 to describe the primary reason(s) for women's prehospital delay. Three categories emerged to explain why women delay in seeking treatment: (1) clinical, (2) sociodemographic, and (3) psychosocial factors. These factors are found to be multifaceted and complex. The most significant reasons for delay in seeking treatment for symptoms of AMI are the following: atypical presentation of symptoms, severity of presenting symptoms, presence of other chronic illnesses that confused acute symptoms, correct attribution or labeling of symptoms to the heart, perceived seriousness of the symptoms, beliefs of low self-perceived vulnerability to heart attack, and engagement in various other coping mechanisms. This synthesis identified and clarified the current state of science regarding women's prehospital delay in seeking treatment for symptoms of an AMI. Areas for future research are also discussed.

Myocardial infarction: gender differences in coping and social support

AIM

The aim of this review is to summarize current knowledge about gender differences in perceptions of coping and social support among patients who have experienced myocardial infarction.

RATIONALE

Women with coronary heart disease have physical, social and medical disadvantages compared with their male counterparts, which can influence their perception of recovery after cardiac events. No review has been found which focuses on gender differences in coping and social support in myocardial infarction patients.

METHOD

A computerized search was conducted using the keywords 'myocardial infarction', 'coping', 'gender differences' and 'social support'. Forty-one articles, published between 1990 and October 2002, were scrutinized.

FINDINGS

Two studies report that women used more coping strategies than men. Several qualitative studies found that women used a variety of coping strategies. Women minimized the impact of the disease, tended to delay in seeking treatment and did not want to bother others with their health problems. Household activities were important to them and aided their recovery. Men were more likely to involve their spouses in their recovery, and resuming work and keeping physically fit were important to them. Women tended to report that they had less social support up to 1 year after a myocardial infarction compared with men. They received less information about the disease and rehabilitation and experienced lack of belief in their heart problems from caregivers. Further, they received less assistance with household duties from informal caregivers. Men tended to report more support from their spouses than did women.

CONCLUSIONS

Traditional gender-role patterns may influence the recovery of patients who have experienced myocardial infarction. Caregivers may need to be more sensitive to gender-specific needs with regard to risk profiles, social roles, and the patient's own role identity. For many women, especially older ones, household duties and family responsibilities may be an opportunity and a base for cardiac rehabilitation.

Observational study of prehospital delays in patients with chest pain

OBJECTIVE

To define and measure patient reported prehospital delay in presentation to the emergency department with chest pain and identify simple strategies that may reduce this delay. The authors investigated the null hypothesis that the patients choice of service to call for acute medical help has no effect on the timing of thrombolysis.

METHOD

A prospective observational study of prehospital times and events was undertaken on a target population of patients presenting with acute chest pain attributable to an acute coronary syndrome over a three month period.

RESULTS

Patients who decided to call the ambulance service were compared with patients who contacted any other service. Most patients who contact non-ambulance services are seen by general practitioners. The prehospital system time for 121 patients who chose to call the ambulance service first was significantly shorter than for 96 patients who chose to call another service (median 57 min v 107 min; p<0.001). Of the 42 patients thrombolysed in the emergency department, those who chose to call the ambulance service had significantly shorter prehospital system times (number 21 v 21; median 44 v 69 min; p<0.001). Overall time from pain onset to initiation of thrombolysis was significantly longer in the group of patients who called a non-ambulance service first (median 130 min v 248 min; p=0.005).

CONCLUSIONS

Patient with acute ischaemic chest pain who call their general practice instead of the ambulance service are likely to have delayed thrombolysis. This is likely to result in increased mortality. The most beneficial current approach is for general practices to divert all patients with possible ischaemic chest pain onset within 12 hours direct to the ambulance service.

Managing thrombolysis in the accident and emergency department

The optimal management of acute myocardial infarction (AMI) today is founded upon the 'open artery' theory and driven by the need for early reperfusion strategies. Numerous randomised controlled trials demonstrate the unequivocal benefit of thrombolytic therapy in reducing mortality and improving long-term prognosis. These benefits are most striking when the thrombolytic therapy is given early. The National Service Framework for Coronary Heart Disease introduced national standards to reduce both 'call to needle' and 'door to needle' times to further augment early treatment. Subsequently many hospitals established 'fast track', 'nurse-led' or 'nurse initiated' thrombolysis within both the Accident and Emergency and Coronary Care Departments. This paper reviews these strategies and considers the benefits and limitations associated with the role of the 'thrombolysis nurse'. Thrombolysis nurses work to agreed protocols and play a fundamental role in the assessment and appropriate management of patients with acute MI. The evidence suggests that thrombolysis nurses are safe and effective in their practice and make a significant contribution to patient outcomes and enhance interprofessional education and practice.

The advanced practice nurse's role regarding women's delay in seeking treatment with myocardial infarction

PURPOSE

To synthesize nursing literature on reasons women delay in seeking treatment for signs and symptoms of an acute myocardial infarction (AMI), to hypothesize upon the primary reason(s) for this delay, and to propose advanced practice nurse (APN) interventions to reduce this delay.

DATA SOURCES

Utilizing Stetler's Model of Research Utilization, all reports published in nursing journals within the last 10 years specifically examining prehospital delay related to gender factors were analyzed.

CONCLUSIONS

Women, especially those in advanced age, delay longer before seeking treatment for signs and symptoms of AMI. Effective treatment is time dependent; mortality and morbidity rise with increased prehospital delay. The reasons identified in the literature for this delay included severity, specificity, atypical presentation of symptoms, differences in event perception according to gender roles, and the interpretation and attribution of symptoms.

IMPLICATIONS FOR PRACTICE

Identifying and teaching women at highest risk for delay, dispelling internal and external gender bias, increasing one's perception of patient vulnerability to AMI, and developing one's awareness of atypical presentations are the major factors that are likely to impact APN practice and consequently reduce prehospital delays for women at risk.

Is the radiation of chest pain a useful indicator of myocardial infarction? A prospective study of 541 patients

In recent years it has been claimed that in those presenting with chest pain, the extent of pain radiation may be predictive of MI and that women's and men's pattern of pain radiation differs. This prospective study therefore investigated whether there were differences in pain radiation between those with and without MI and according to gender. Patients (n = 541) presenting to a CCU with an episode of chest pain were asked to indicate on a body map the region of pain radiation they experienced at the time of symptom onset. As expected, radiation to the left and/or to right shoulder/arm was significantly higher in the MI group. Women with MI experienced more chest pain radiating to the right arm/shoulder (P = 0.0005), upper right region (P = 0.0006) and arm/shoulder than those without MI. Additionally, women with MI also described more pain radiation in the front neck (P = 0.015) area, and the right shoulder/arm (P = 0.02) than their male counterparts. A third of these women also experienced more pain radiating to the back (P = 0.005). The premise of greater chest pain distribution amongst those with an MI could not be confirmed. Nevertheless, the study identified significant differences amongst women with MI, the discussion analyses the implications for practice.

Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.

Challenging the rules: women's prodromal and acute symptoms of myocardial infarction

In this qualitative study the researcher identified symptoms women experienced prior to and during an acute myocardial infarction (AMI). The purposive nonprobability sample for this descriptive naturalistic study consisted of 40 women. Using content analysis and constant comparison, the researcher identified specific symptoms and grouped them according to time of occurrence, prodromal and acute. Thirty-seven women experienced prodromal symptoms, beginning from a few weeks to 2 years prior to their AMI and ranging from 0 to 11 symptoms per woman. The most frequent prodromal symptoms were unusual fatigue (n = 27), discomfort in the shoulder blade area (n = 21), and chest sensations (n = 20), whereas the most frequent acute symptoms were chest sensations (n = 26), shortness of breath (n = 22), feeling hot and flushed (n = 21), and unusual fatigue (n = 18). Only 11 women experienced severe pain during their AMI. Conclusions of this study are threefold: (a) women identified classic and unique symptoms of AMI, which challenge the content of current educational literature; (b) women experienced a gradual progression of number and severity of AMI symptoms; and (c) women need sufficient time to recognize their prodromal symptoms of their AMI.

Are manual gestures, verbal descriptors and pain radiation as reported by patients reliable indicators of myocardial infarction? Preliminary findings and implications

Patients experiencing an episode of acute chest pain need to be assessed promptly and effectively to ensure optimal management. The aim of this study was to investigate whether there were specific aspects of patients' symptom reports which could be viewed as additional indicators of myocardial infarction (MI) and contribute to the assessment process. The sample consisted of 267 patients who presented with an episode of acute chest pain. Methods of data collection were based on, or modified from, previous studies which had investigated the use of manual gestures, choice of verbal descriptors and extent of pain radiation in patients with and without MI. To determine whether these variables were of significance in the diagnosis, the responses of those with (n = 118) and without MI (n = 149) were compared. The results suggest that it is currently impossible to draw any conclusions as to whether the variables studied can be judged as reliable indicators of MI. The findings indicate that there are some differences between the groups particularly in the language used. Moreover, women with MI characterized their symptoms through stronger emotive words such as 'worrying' (P = 0.014) 'frightening' and 'intolerable' and also differed from their male counterparts in their reports regarding pain radiation. Implications for practice and for research are discussed.