Circumstances around the Onset of a Myocardial Infarction

A Review of Atypical Clinical Manifestations of Acute Myocardial Infarction

This review describes pertinent demographic and ill ness characteristics of patients who are seen with atyp ical symptoms of acute myocardial infarction. The determination of psychosocial, behavioral, and envi ronmental patterns of patients complaining of chest discomfort adds important information to the clinical assessment of chest pain. Systematic information about the pain and other symptoms of acute myocardial infarc tion and about the variables that influence these symp toms can assist practitioners as well as sufferers of myo cardial pain to resolve the uncertainty surrounding it.

Prenalterol as long-term therapy for chronic congestive heart failure. A randomized cross-over trial

Ten patients with severe chronic congestive heart failure (CHF) due to ischaemic heart disease treated with digitalis and diuretics were randomly allocated to oral treatment with prenalterol (100-200 mg daily in addition to their basal treatment) or to intensified treatment with diuretics in a cross-over trial. A wash-out period of 1-4 weeks was allowed between the two modes of treatment. Most of the patients demonstrated subjective improvement during prenalterol therapy, but this improvement could not be verified objectively by exercise test, echocardiography, chest X-ray or weight measurements. No serious side-effects of either mode of treatment were observed. Heart rate was significantly lower during exercise when the patients were treated with prenalterol than during the control periods or during intensified conventional treatment, indicating that prenalterol acts as a beta-adrenergic receptor blocker during exercise in this patient group. The results indicate that prenalterol is a partial beta-receptor agonist without superior beneficial effects compared to those of intensified conventional treatment in patients with chronic, severe CHF.

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.

Impact of a national educational campaign to reduce patient delay in possible heart attack

In 1989 the National Heart Foundation (NHF) of Australia's Heart Week campaign was directed towards encouraging those with symptoms of possible myocardial infarction (MI) to seek help as promptly as possible. To evaluate its effect, three surveys were conducted of patients admitted to 22 coronary care units (CCUs). Two (335 and 221 patients) preceded and one (253 patients) followed the public education campaign. During the third survey a subset of patients were asked why they delayed, how long they thought one should wait before seeking help, whether they were aware of the media campaign and whether this had influenced their behaviour. Overall, only 42% of 809 patients sought help within one hour (median delay 1.2 hours). The median time of arrival and the proportion of patients arriving within one, two and four hours was not altered after this campaign. Those who admitted to having been aware of the campaign sought help no more promptly. The Heart Week campaign could not be shown to have produced any clinically important change in patient delay. Future campaigns will need to be modified in the light of this experience.

Components of delay time in suspected acute myocardial infarction with particular emphasis on patient delay

Two hundred and thirty-four patients admitted to a coronary care unit (CCU) were interviewed a few days after arrival in hospital to determine reasons for patient delay and the various components of total delay time from onset of symptoms to arrival in CCU. Of the three major components of delay, decision time (time from onset of symptoms to decision to go to hospital), and hospital procedure time (time from arrival in hospital to arrival in the CCU), were of the same magnitude, 1 h 15 min and 1 h 30 min (median), whereas the median time for preparation and transportation to hospital was somewhat shorter, being 45 min. Decision time appeared to be similar in patients with confirmed and non-confirmed acute myocardial infarction (AMI) and was not associated with intensity of pain or infarct size. Half of the patients hesitated to go to hospital, which resulted in a prolonged decision delay (3 h). It is concluded that patient indecision to seek medical help is the most important reason for delay in hospital arrival in patients with suspected AMI.

Factors influencing the time from onset of chest pain to arrival at hospital

One hundred patients who were admitted to a coronary-care unit were interviewed to determine the time interval from the onset of chest pain to their arrival at the Emergency Department of Royal Prince Alfred Hospital. Forty-nine per cent of patients took longer than two hours and 29% took longer than four hours to arrive at hospital; the patient who reported the longest time interval reached hospital 72 h after the onset of chest pain. Most of the delay between the onset of symptoms and arrival at hospital was a result of the time that the patients took to decide to seek medical attention. Once this decision was made, there was relatively-little delay before hospital presentation in patients who went directly to hospital. However, those patients who contacted a doctor rather than going directly to hospital took significantly longer to arrive at hospital, with a median total time to reach hospital of 212 min compared with 85 min for those who went directly to hospital (P = 0.002). Time delays of this magnitude compromise the efficacy of interventions such as thrombolytic therapy. There should be continuing public education to encourage patients with chest pain to seek early medical attention and, in metropolitan areas, patients with chest pain should be advised to proceed directly to hospital.

Postnatal emotional balance in women with and without antenatal fear of childbirth

Women in the later stages of pregnancy were identified as 'suffering' or 'not suffering' from fear of childbirth by means of a special questionnaire. The two samples were interviewed two months after delivery. Women with antenatal fear of childbirth were found to run an increased risk of sustaining severe emotional imbalance postnatally with possible implications on their relationship to the child.