The Process of Care-seeking for Myocardial Infarction Among Patients With Diabetes

Awareness of cardiovascular risk among persons with type 2 diabetes: a qualitative study

PURPOSE

To describe the process of becoming aware of and acting on personal cardiovascular (CVD) risk in type 2 diabetes (T2D).

METHOD

A purposive sample of 14 persons living with T2D participated in semi-structured, open-ended, in-dept interviews. The interviews were analysed with grounded theory.

RESULT

The analysis identified the core category "Balancing emotions, integrating knowledge and understanding to achieve risk awareness and act on it." Five categories describe the movement from not being aware of the risk of cardiovascular disease (CVD) to becoming aware of this risk and taking action to reduce it. Persons with T2D need to transform their knowledge and experience of CVD risk and incorporate it in their individual situations. Emotional and existential experiences of CVD risk can lead to awareness about the severity of the condition and contribute to increased motivation for self-management. However, an overly high emotional response can be overwhelming and may result in insufficient self-management.

CONCLUSION

Persons with T2D seemed not to fully grasp their increased risk of CVD or recognize that self-management activities were aimed at reducing this risk. However, their awareness of CVD risk gradually increased as they came to understand the severity of T2D and became more emotionally and existentially engaged.

Predictors of acute coronary syndrome symptom knowledge, attitudes, and beliefs in adults without self-reported heart disease

BACKGROUND

The time of symptom onset to the time an individual decides to seek care is the most significant contributor to total treatment delay.

OBJECTIVES

To explore predictors of ACS symptom knowledge, attitudes, and beliefs in adults without diagnosed heart disease.

METHODS

We used a cross-sectional, descriptive, and correlational design, employing an online survey including the ACS Response Index and the avoidance subscale of the Coping Strategy Indicator. We leveraged social media platforms and a university email list-serv to enroll participants. Stepwise hierarchical linear regressions were used.

RESULTS

We analyzed responses from 981 participants, with a mean age of 35.2 years (SD 16.5) and 75% female. The regression analyses yielded models that explained 14%, 23%, and 25% of the variance for knowledge, beliefs, and attitudes, respectively. Ethnicity, race, exposure to ACS symptom information (in the media or by teaching), and perceived health were the predictors of ACS symptom knowledge, attitudes, and beliefs with the largest effect, though others were statistically significant.

CONCLUSIONS

The findings underscore the importance of community education to raise awareness of ACS symptoms while considering social determinants of health. Future research and clinician interventions for ACS symptom knowledge, attitudes and beliefs should be expanded with a focus on ethnicity and gender.

Symptoms of Acute Myocardial Infarction as Described in Calls to Tele-Nurses and in Questionnaires: A Mixed-Methods Study

BACKGROUND

Patient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed.

AIM

The aim of this study was to gain an understanding of patients' symptom description in more detail before and within 24 hours after a confirmed MI diagnosis.

METHODS

A convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation.

RESULTS

Thirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires ( P = .01 and P = .02), whereas "other" symptoms were more often mentioned in calls compared with answers given in the questionnaire ( P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets.

CONCLUSION

Patients' MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.

Women's Prodromal Myocardial Infarction Symptom Perception, Attribution, and Care Seeking: A Qualitative Multiple Case Study

BACKGROUND

Most women experience prodromal myocardial infarction (MI) symptoms, but more information is needed about the perception, attribution, and care-seeking behaviors related to these prodromal symptoms.

OBJECTIVES

We aimed to describe women's perceptions, attributions, and care-seeking behaviors related to prodromal MI symptoms.

METHOD

We used a qualitative, multiple case study approach, recruiting participants during summer 2019 from a large hospital in the Midwestern United States. Data were collected from interviews with the women who experienced MI and some of their family members, journals, and electronic health records. An inductive, comparative analysis procedure was applied.

RESULTS

Ten women, ages 42 to 84, participated in the study. The women experienced a mixture of certainty and uncertainty related to their symptoms and engaged in several cognitive processes to conceptualize and act upon their symptoms. Although all the women retrospectively reported at least 4 prodromal symptoms, they lacked knowledge of prodromal MI symptoms and often responded to prodromal sensations that they experienced using emotion- and avoidance-based strategies. It was difficult for the women to establish a symptom pattern that was attributable to heart disease.

DISCUSSION

The findings of this study may be used as evidence to support interventions that would facilitate women's care seeking for and health care providers' recognition of prodromal MI symptoms. Additional research is necessary to more fully characterize the cognitive processes at play for women of many different sociocultural backgrounds who experience prodromal MI symptoms.

Perceptions of delay when afflicted by an acute myocardial infarction during the first wave of the COVID-19 pandemic

AIMS

To describe the perceptions of delay in medical care-seeking, when afflicted by an acute myocardial infarction (AMI) during the first wave of the pandemic.

METHODS AND RESULTS

A qualitative descriptive study with an inductive approach. Fourteen semi-structured interviews were conducted, analysed by qualitative content analysis with a manifest approach. One category and six sub-categories emerged. The decision was reached when the health threat was perceived as critical, which made the earlier thoughts of the pandemic fade away. The risk of infection during medical visits caused fear of contracting the disease. This resulted in hesitation, neglect of symptoms, and avoidance of healthcare visits. Following recommendations from authorities and media about personal responsibility was motivated by fear, affecting the care-seeking.

CONCLUSION

It appears that the COVID-19 pandemic raised the threshold for deciding to seek medical care when presenting with an AMI. The pandemic led to increased patient delay due to several reasons among which fear of contracting the disease was prominent. The emotion of fear was related to the external threat to one's own health, due to COVID-19, and not fear of symptoms related to an AMI. The media reporting the healthcare system as overloaded increased insecurity and may have had an influence on delay.

Perceived personal risk and vulnerability in recognizing and responding to symptoms of acute coronary syndrome: an integrative review

BACKGROUND

Simply knowing the common symptoms of acute coronary syndrome (ACS) is not sufficient to ensure prompt care-seeking when these symptoms occur. Factors other than symptom knowledge contribute to prompt care-seeking behaviours and correct symptom attribution to the heart.

OBJECTIVES

To explore how perceived personal risk and perceived personal vulnerability towards ACS affect a person's ACS symptom recognition and attribution and also how this perception affects a person's response to ACS symptoms.

DESIGN

An integrative review, using Whittemore and Knafl's approach.

DATA SOURCES

PubMed, Academic Search Complete, CINAHL Complete, APA PsycINFO, and APA PsycARTICLES.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

We included studies that (i) were original human-subjects research or secondary analyses of human-subjects research, (ii) provided information about how perceptions of risk or perceptions of vulnerability towards ACS or heart disease affect symptom recognition, attribution, and/or response to symptoms, and (iii) were published in English.

RESULTS

Thirteen articles were included. Studies were conducted in nine different countries and were descriptive or exploratory in nature. The existing evidence suggests that perceived personal risk or vulnerability towards heart disease may promote earlier care-seeking for ACS symptoms and facilitates attribution of symptoms to the heart.

CONCLUSION

The designs of the included studies limit causal attribution, and additional prospective and intervention-based research is needed to determine how perceived risk/vulnerability may affect care-seeking and ACS symptom attribution. Increasing perceptions of vulnerability towards heart disease may reduce care seeking delay.

Differences in symptoms, first medical contact and pre-hospital delay times between patients with ST- and non-ST-elevation myocardial infarction

Aim:

In ST-elevation myocardial infarction, time to reperfusion is crucial for the prognosis. Symptom presentation in myocardial infarction influences pre-hospital delay times but studies about differences in symptoms between patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction are sparse and inconclusive. The aim was to compare symptoms, first medical contact and pre-hospital delay times in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction.

Methods and results:

This multicentre, observational study included 694 myocardial infarction patients from five hospitals. The patients filled in a questionnaire about their pre-hospital experiences within 24 h of hospital admittance. Chest pain was the most common symptom in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction (88.7 vs 87.0%, p=0.56). Patients with cold sweat (odds ratio 3.61, 95% confidence interval 2.29–5.70), jaw pain (odds ratio 2.41, 95% confidence interval 1.04–5.58), and nausea (odds ratio 1.70, 95% confidence interval 1.01–2.87) were more likely to present with ST-elevation myocardial infarction, whereas the opposite was true for symptoms that come and go (odds ratio 0.58, 95% confidence interval 0.38-0.90) or anxiety (odds ratio 0.52, 95% confidence interval 0.29–0.92). Use of emergency medical services was higher among patients admitted with ST-elevation myocardial infarction. The pre-hospital delay time from symptom onset to first medical contact was significantly longer in non-ST-elevation myocardial infarction (2:05 h vs 1:10 h, p=0.001).

Conclusion:

Patients with ST-elevation myocardial infarction differed from those with non-ST-elevation myocardial infarction regarding symptom presentation, ambulance utilisation and pre-hospital delay times. This knowledge is important to be aware of for all healthcare personnel and the general public especially in order to recognise symptoms suggestive of ST-elevation myocardial infarction and when to decide if there is a need for an ambulance.

'Just like a normal pain', what do people with diabetes mellitus experience when having a myocardial infarction: a qualitative study recruited from UK hospitals

OBJECTIVE

The objective of the study was to investigate the symptoms people with diabetes experience when having a myocardial infarction (MI), their illness narrative and how they present their symptoms to the health service.

SETTING

Three London (UK) hospitals (coronary care units and medical wards).

PARTICIPANTS

Patients were recruited with diabetes mellitus (DM) (types 1 and 2) with a clinical presentation of MI (ST elevated MI (STEMI), non-ST elevated MI (NSTEMI), acute MI unspecified and cardiac arrest). A total of 43 participants were recruited, and 39 interviews met the study criteria and were analysed. They were predominantly male (n=30), aged 40-90 years and white British (18/39), and just over a half were from other ethnic groups. The majority had type 2 DM (n=35), 24 had an NSTEMI, 10 had an STEMI and five had other cardiac events.

DEFINITIONS OF SELECTION/EXCLUSION CRITERIA

A diagnosis of MI and DM and the ability to communicate enough English to complete the interview. Ward staff made a clinical judgement that the participant was post-treatment, clinically stable and well enough to participate.

METHODS

A qualitative study using taped and transcribed interviews analysed using a thematic analysis.

RESULTS

While most participants did experience chest pain, it was often not their most striking symptom. As their chest pain did not match their expectations of what a 'heart attack' should be, participants developed narratives to explain these symptoms, including the symptoms being effects of their DM ('hypos'), side effects of medication (oral hypoglycaemics) or symptoms (such as breathlessness and indigestion) related to other comorbidities, often leading to delays in seeking care.

CONCLUSIONS

While truly absent chest pain during MI among people with DM was rare in this study, patients' attenuated symptoms often led to delay in seeking attention, and this may result in delays in receiving treatment.

Barriers to timely treatment-seeking in patients with acute myocardial infarction in Malaysia: a qualitative study

Background

Persisting delay in seeking treatment among Acute Myocardial Infarction (AMI) patients was reported in Malaysia despite intensified efforts in educating the public on symptoms of AMI and the importance of seeking prompt treatment. Studies outside Malaysia have shown that patients’ personal thoughts during symptom onset could contribute to the delay. The purpose of this study is to explore the barriers of AMI patients prior to the decision of seeking treatment in Malaysia.

Methods

A qualitative descriptive research approach was chosen. Individual in-depth interviews were conducted among 18 patients with AMI. Data were analysed using thematic analysis. Recordings were transcribed and coded, codes were subsequently organized into categories. The stages of coding and identifying categories were repeated before themes were identified.

Results

Three meaningful themes with nine sub-themes that may have influenced the delayed decision to seek treatment were identified. Some themes identified were culturally bound.

Conclusions

The findings of this study give insights on barriers prior to the decision of seeking treatment when patients were experiencing AMI. Findings indicates that interventions targeted at increasing knowledge about AMI symptoms and correct actions using an informative approach at the current practice may not be adequate to reduce patient delay. The findings of this study could provide basis for the development of interventions that are culturally relevant to the Malaysians setting to promote behavioural change in the population and reduce pre-hospital delay.

Symptoms and delay times during myocardial infarction in 694 patients with and without diabetes; an explorative cross-sectional study

BACKGROUND

In myocardial infarction (MI) a short pre-hospital delay, prompt diagnosis and timely reperfusion treatment can improve the prognosis. Despite the importance of timely care seeking, many patients with MI symptoms delay seeking medical care. Previous research is inconclusive about differences in symptom presentation and pre-hospital delay between patients with and without diabetes during MI. The aim of this study was to describe symptoms and patient delay during MI in patients with and without diabetes.

METHODS

Swedish cross-sectional multicentre survey study enrolling MI patients in 5 centres within 24 h from admittance.

RESULTS

Chest pain was common in patients both with and without diabetes and did not differ after adjustment for age and sex. Patients with diabetes had higher risk for shoulder pain/discomfort, shortness of breath, and tiredness, but lower risk for cold sweat. The three most common symptoms reported by patients with diabetes were chest pain, pain in arms/hands and tiredness. In patients without diabetes the most common symptoms were chest pain, cold sweat and pain in arms/hands. Median patient delay time was 2 h, 24 min for patients with diabetes and 1 h, 15 min for patients without diabetes (p = 0.024).

CONCLUSION

Chest pain was common both in patients with and without diabetes. There were more similarities than differences in MI symptoms between patients with and without diabetes but patients with diabetes had considerably longer delay. This knowledge is important not only for health care personnel meeting patients with suspected MI, but also for the education of people with diabetes.