Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time

Delays to Hospital Presentation in Women and Men with ST-Segment Elevation Myocardial Infarction: A Multi-Center Analysis of Patients Hospitalized in New York City

Purpose

Previous studies have shown longer delays from symptom onset to hospital presentation (S2P time) in women than men with acute myocardial infarction. The aim of this study is to understand the reasons for delays in seeking care among women and men presenting with an ST-Segment Elevation Myocardial Infarction (STEMI) through a detailed assessment of the thoughts, perceptions and patterns of behavior.

Patients/Methods and Results

A total of 218 patients with STEMI treated with primary angioplasty at four New York City Hospitals were interviewed (24% female; Women: 68.7 ± 13.1 years and men: 60.7 ± 13.8 years) between January 2009 and August 2012. A significantly larger percentage of women than men had no chest pain (62% vs 36%, p<0.01). Compared to men, a smaller proportion of women thought they were having a myocardial infarction (15% vs 34%, p=0.01). A larger proportion of women than men had S2P time >90 minutes (72% of women vs 54% of men, p= 0.03). Women were more likely than men to hesitate before seeking help, and more women than men hesitated because they did not think they were having an AMI (91% vs 83%, p=0.04). Multivariate regression analysis showed that female sex (Odds Ratio: 2.46, 95% CI 1.10–5.60 P=0.03), subjective opinion it was not an AMI (Odds Ratio 2.44, 95% CI 1.20–5.0, P=0.01) and level of education less than high school (Odds ratio 7.21 95% CI 1.59–32.75 P=0.01) were independent predictors for S2P >90 minutes.

Conclusion

Women with STEMI have longer pre-hospital delays than men, which are associated with a higher prevalence of atypical symptoms and a lack of belief in women that they are having an AMI. Greater focus should be made on educating women (and men) regarding the symptoms of STEMI, and the importance of a timely response to these symptoms.

Lay Consultations in Heart Failure Symptom Evaluation

PURPOSE

Lay consultations can facilitate or impede healthcare. However, little is known about how lay consultations for symptom evaluation affect treatment decision-making. The purpose of this study was to explore the role of lay consultations in symptom evaluation prior to hospitalization among patients with heart failure.

METHODS

Semi-structured interviews were conducted with 60 patients hospitalized for acute decompensated heart failure. Chi-square and Fisher's exact tests, along with logistic regression were used to characterize lay consultations in this sample.

RESULTS

A large proportion of patients engaged in lay consultations for symptom evaluation and decision-making before hospitalization. Lay consultants provided attributions and advice and helped make the decision to seek medical care. Men consulted more often with their spouse than women, while women more often consulted with adult children.

CONCLUSIONS

Findings have implications for optimizing heart failure self-management interventions, improving outcomes, and reducing hospital readmissions.

Effect of the number of request calls on the time from call to hospital arrival: a cross-sectional study of an ambulance record database in Nara prefecture, Japan

OBJECTIVES

In Japan, ambulance staff sometimes must make request calls to find hospitals that can accept patients because of an inadequate information sharing system. This study aimed to quantify effects of the number of request calls on the time interval between an emergency call and hospital arrival.

DESIGN AND SETTING

A cross-sectional study of an ambulance records database in Nara prefecture, Japan.

CASES

A total of 43 663 patients (50% women; 31.2% aged 80 years and over): (1) transported by ambulance from April 2013 to March 2014, (2) aged 15 years and over, and (3) with suspected major illness.

PRIMARY OUTCOME MEASURES

The time from call to hospital arrival, defined as the time interval from receipt of an emergency call to ambulance arrival at a hospital.

RESULTS

The mean time interval from emergency call to hospital arrival was 44.5 min, and the mean number of requests was 1.8. Multilevel linear regression analysis showed that ∼43.8% of variations in transportation times were explained by patient age, sex, season, day of the week, time, category of suspected illness, person calling for the ambulance, emergency status at request call, area and number of request calls. A higher number of request calls was associated with longer time intervals to hospital arrival (addition of 6.3 min per request call; p<0.001). In an analysis dividing areas into three groups, there were differences in transportation time for diseases needing cardiologists, neurologists, neurosurgeons and orthopaedists.

CONCLUSIONS

The study revealed 6.3 additional minutes needed in transportation time for every refusal of a request call, and also revealed disease-specific delays among specific areas. An effective system should be collaboratively established by policymakers and physicians to ensure the rapid identification of an available hospital for patient transportation in order to reduce the time from the initial emergency call to hospital arrival.

To Be Stricken with Acute Myocardial Infarction: A Grounded Theory Study of Symptom Perception and Care-seeking Behaviour

The process of perceiving symptoms of illness is complex, and many patients delay seeking care when symptoms of acute myocardial infarction occur. However delayed treatment can have great consequences for the prognosis. This article reports on a grounded theory study, the aim of which was to increase our understanding of the individual’s thoughts, feelings and actions at the onset of an acute heart attack. Qualitative analysis of semi-structured interviews revealed four different ways of perceiving the onset of symptoms: understanding, misinterpretation, amazement and disregard. The symptom perception categories were related to two core categories labelled health beliefs and acute reactions. Some persons were aware of risks for coronary heart disease and were ready to seek care immediately. Several others had illusions of invulnerability. Such illusions caused people to delay seeking care at the onset of symptoms of myocardial infarction.

Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Background

In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥ 2 h.

Methods

A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

Results

The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

Conclusions

Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0271-x) contains supplementary material, which is available to authorized users.

A pathway care model allowing low-risk patients to gain direct admission to a hospital medical ward--a pilot study on ambulance nurses and Emergency Department physicians

A pathway care model allowing low-risk patients to gain rapid admission to a hospital medical ward - a pilot study on ambulance nurses and Emergency Department physicians.

BACKGROUND

Patients with non-urgent medical symptoms who nonetheless require inpatient hospital treatment often have to wait for an unacceptably long time at the Emergency Department (ED). The purpose of this study is to evaluate the feasibility and effect on length of delay of a pathway care model for low-risk patients who have undergone prehospital assessment by an ambulance nurse and ED assessment by a physician within 10 minutes of arrival at the ED.

METHODS

The pilot study comparing two low-risk groups took place in western Sweden from October 2011 until January 2012. The pathway model for low-risk patients was used prospectively in the rapid admission group (N = 51), who were admitted rapidly after being assessed by the nurse on scene and then assessed by the ED physician on ED admission. A retrospectively assembled control group (N = 51) received traditional care at the ED. All p-values are age-adjusted.

RESULTS

Patients in the rapid admission group were older (mean age 80 years old) than patients in the control group (mean age 73 years old) (p = 0.02). The median delay from arrival at the patient's side until arrival in a hospital medical ward was 57 minutes for the rapid admission group versus 4 hours 13 minutes for the control group (p < 0.0001). However, the median delay time from the ambulance's arrival at the patient's side until the nurse was free for a new assignment was 77 minutes for the rapid admission group versus 49 minutes for the control group (p < 0.0001). The 30-day mortality rate was 20% for the rapid admission group and only 4% for the control group (p = 0.16).

CONCLUSION

The pathway care model for low-risk patients gaining rapid admission to a hospital medical ward shortened length of delay from the first assessment until arrival at the ward. However, the result was achieved at the cost of an increased workload for the ambulance nurse. Furthermore patients who were rapidly admitted to a hospital ward had a high age level and a high early mortality rate. Patient safety in this new model of fast-track assessment needs to be further evaluated.

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.

Emergency care of acute myocardial infarction and the great East Japan earthquake disaster

BACKGROUND

Although emergency care of acute myocardial infarction (AMI) could theoretically be improved through improved patient delay, this notion remains to be confirmed. Additionally, the influence of large earthquakes on the emergency care of AMI cases remains to be elucidated. The Great East Japan Earthquake (March 11, 2011) has enabled us to address these issues.

METHODS AND RESULTS

 We analyzed the data from 2008 to 2011 (n=3,937) in the Miyagi AMI Registry Study. In-hospital mortality was significantly lower in 2011 as compared with the previous 3 years (7.3% vs. 10.5%, P<0.05). This improvement was noted especially during the first 2 months after the Earthquake, associated with shorter elapsing time from onset to admission (120 vs. 240min, P<0.001) and higher performance rate of primary percutaneous coronary intervention (PCI) (86.8% vs. 76.2%, P<0.01). Importantly, after the Earthquake, patients with early admission (≤3h from onset) was significantly increased (59.1% vs. 47.0%, P<0.05) and their prognosis became better (7.9% vs. 11.4%, P=0.02), associated with a lower prevalence of heart failure on admission (6.9% vs. 16.2%, P=0.02) and higher performance rate of primary PCI (89.1% vs. 76.4%, P<0.01).

CONCLUSIONS

 Emergency care of AMI improved soon after the Great East Japan Earthquake compared with ordinary times by the contribution of earlier admission from onset and higher performance rate of primary PCI.  (Circ J 2014; 78: 634-643).

The effect of symptoms on prehospital delay time in patients with acute myocardial infarction

Objective

To improve time to treatment, the effects of acute myocardial infarction (AMI) symptoms on prehospital delay time (PDT) were investigated.

Methods

Patients with AMI completed a questionnaire on their AMI symptoms and their general knowledge of AMI symptoms.

Results

In total, 116 patients completed questionnaires. The mean PDT was 7.3 ± 2.4  h; the median PDT was 2.2 h. Each patient experienced a mean of 3.6 symptoms during their AMI. PDT was significantly shorter in the following groups: patients with chest compression pain/chest discomfort, profuse sweating or dyspnoea than in patients with other symptoms; patients presenting with typical rather than atypical symptoms; patients with pain scores >6 compared with scores ≤6; patients who were aware rather than unaware of AMI symptoms. Patients actually having AMI symptoms and patients being aware of AMI symptoms were inversely correlated with PDT. There was a linear relationship between pain scores and PDT.

Conclusion

Public awareness of AMI symptoms should be enhanced, in order to shorten PDT and improve AMI survival rates.

Social network types and acute stroke preparedness behavior

Objectives

Presence of informal social networks has been associated with favorable health and behaviors, but whether different types of social networks impact on different health outcomes remains largely unknown. We examined the associations of different social network types (marital dyad, household, friendship, and informal community networks) with acute stroke preparedness behavior. We hypothesized that marital dyad best matched the required tasks and is the most effective network type for this behavior.

Methods

We collected in-person interview and medical record data for 1,077 adults diagnosed with stroke and transient ischemic attack. We used logistic regression analyses to examine the association of each social network with arrival at the emergency department (ED) within 3 h of stroke symptoms.

Results

Adjusting for age, race-ethnicity, education, gender, transportation type to ED and vascular diagnosis, being married or living with a partner was significantly associated with early arrival at the ED (odds ratio = 2.0, 95% confidence interval: 1.2–3.1), but no significant univariate or multivariate associations were observed for household, friendship, and community networks.

Conclusions

The marital/partnership dyad is the most influential type of social network for stroke preparedness behavior.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Sex and age specific time patterns and long term time trends of pre-hospital delay of patients presenting with acute ST-segment elevation myocardial infarction

BACKGROUND

Prompt initiation of treatment after symptom onset of ST-elevation myocardial infarction (STEMI) is a central goal in limiting myocardial damage because of the time-dependent nature of reperfusion therapies. We examined time patterns and long term time trends of pre-hospital delay time (PHDT) of STEMI patients.

METHODS

PHDT from 3093 STEMI patients derived from the Augsburg Myocardial Infarction Registry (1985-2004) surviving >24h after admission was obtained by a standardized bedside interview. Patients with in-hospital MI (n=140) and resuscitation (n=157) were excluded. Linear regression models were used to examine monthly median PHDT and individual PHDT over time.

RESULTS

Female sex was associated with longer PHDT (189 (98-542quartiles) min vs. 154 (85-497) min; p<0.0003). Median PHDT in the youngest male subgroup (25-54 years) was 128 (73-458) min and mounted to 205 (107-600) min in the oldest female subgroup (65-74 years). A minority of 12.4% of patients reached hospital within 1h of delay ranging from 8.7% (in oldest women) to 15.9% (in youngest men). The age-adjusted linear regression model for monthly PHDT revealed no significant change over 20-year time in both sexes. The corresponding average annual percentage change estimates were -0.45 (95% CI: -1.40 to 0.54) for men and -0.08 (95% CI: -1.80 to 1.67) for women. Emergency ambulance use increased over time, however transportation time remained stable.

CONCLUSIONS

PHDT in STEMI patients is constantly high over a 20-year observation period. Room for improvement especially in older women was evidenced. Preventive strategies with focused efforts on this subgroup are warranted.

Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review

BACKGROUND

Coronary heart disease is the leading cause of morbidity and mortality in American men and women. Although there have been dramatic changes in the management of patients hospitalized with acute myocardial infarction (AMI) over the past several decades, a considerable proportion of patients with AMI continue to delay seeking medical care in a timely manner. This review provides an overview of the published literature that has examined age and sex differences in extent of prehospital delay in patients hospitalized with AMI.

METHODS AND RESULTS

A systematic review of the literature from 1960 to 2008, including publications that provided data on duration of prehospital delay in patients hospitalized with AMI, was conducted. A total of 44 articles (42 studies) were included in the present analysis. The majority of studies showed that in patients hospitalized with AMI, women and older persons were more likely to arrive at the hospital later than men and younger persons. Several factors associated with duration of prehospital delay, including sociodemographic, medical history, clinical, and contextual characteristics differed according to sex.

CONCLUSIONS

The elderly and women were more likely to exhibit longer delays in seeking medical care after the development of symptoms suggestive of AMI compared with other groups. Further research is needed to more fully understand the reasons for delay in these vulnerable groups.

Information search and information distortion in the diagnosis of an ambiguous presentation

Physicians often encounter diagnostic problems with ambiguous and conflicting features. What are they likely to do in such situations? We presented a diagnostic scenario to 84 family physicians and traced their information gathering, diagnoses and management. The scenario contained an ambiguous feature, while the other features supported either a cardiac or a musculoskeletal diagnosis. Due to the risk of death, the cardiac diagnosis should be considered and managed appropriately. Forty-seven participants (56%) gave only a musculoskeletal diagnosis and 45 of them managed the patient inappropriately (sent him home with painkillers). They elicited less information and spent less time on the scenario than those who diagnosed a cardiac cause. No feedback was provided to participants. Stimulated recall with 52 of the physicians revealed differences in the way that the same information was interpreted as a function of the final diagnosis. The musculoskeletal group denigrated important cues, making them coherent with their representation of a pulled muscle, whilst the cardiac group saw them as evidence for a cardiac problem. Most physicians indicated that they were fairly or very certain about their diagnosis. The observed behaviours can be described as coherence-based reasoning, whereby an emerging judgment influences the evaluation of incoming information, so that confident judgments can be achieved even with ambiguous, uncertain and conflicting information. The role of coherence-based reasoning in medical diagnosis and diagnostic error needs to be systematically examined.

Diagnostic difficulty and error in primary care--a systematic review

BACKGROUND

Diagnostic error in primary care can have serious implications for the patient, the clinician and the health-care system, possibly more so than other types of error.

OBJECTIVE

To identify common characteristics of diseases that GPs may misdiagnose.

METHODS

Systematic search of the MEDLINE and EMBASE databases for primary research on diagnostic error/delay in primary care. Papers on system errors, patient delay, case reports, reviews, opinion pieces, studies not based on actual cases and studies not using a systematic sample were excluded from the review. Twenty-one papers were included. All papers were assessed for quality using the GRADE system. Common features were identified across diseases and presentations that made diagnosis difficult and led to error/delay.

RESULTS

Most studies were retrospective cohorts of patients recruited in hospital and collected data from patient interviews and/or hospital records, resulting in incomplete and potentially biased information. It was usually not possible to determine preventability of the delay. Some conditions were extremely rare, suggesting a specialist research interest rather than an increased rate of misdiagnosis. Conditions investigated were malignancies, myocardial infarction, meningitis, dementia, iron deficiency anaemia, asthma, tremor in the elderly and HIV. Common features of difficulty were atypical presentations, non-specific presentations, very low prevalence, the presence of co-morbidity and perceptual features and could be missed.

CONCLUSIONS

Misdiagnosis in primary care covers a wide range of conditions that may be related in the manner in which they present. The challenge is to identify ways of supporting the diagnostic process in potentially difficult presentations.

Predictors of diagnostic accuracy and safe management in difficult diagnostic problems in family medicine

OBJECTIVE

To investigate the role of information gathering and clinical experience on the diagnosis and management of difficult diagnostic problems in family medicine.

METHOD

Seven diagnostic scenarios including 1 to 4 predetermined features of difficulty were constructed and presented on a computer to 84 physicians: 21 residents in family medicine, 21 family physicians with 1 to 3 y in practice, and 42 family physicians with >or=10 y in practice. Following the Active Information Search process tracing approach, participants were initially presented with a patient description and presenting complaint and were subsequently able to request further information to diagnose and manage the patient. Evidence-based scoring criteria for information gathering, diagnosis, and management were derived from the literature and a separate study of expert opinion.

RESULTS

Rates of misdiagnosis were in accordance with the number of features of difficulty. Seventy-eight percent of incorrect diagnoses were followed by inappropriate management and 92% of correct diagnoses by appropriate management. Number of critical cues requested (cues diagnostic of any relevant differential diagnoses in a scenario) was a significant predictor of accuracy in 6 scenarios: 1 additional critical cue increased the odds of obtaining the correct diagnosis by between 1.3 (95% confidence interval [CI], 1.0-1.8) and 7.5 (95% CI, 3.2- 17.7), depending on the scenario. No effect of experience was detected on either diagnostic accuracy or management. Residents requested significantly more cues than experienced family physicians did.

CONCLUSIONS

Supporting the gathering of critical information has the potential to improve the diagnosis and management of difficult problems in family medicine.

The causes of prehospital delay in myocardial infarction

INTRODUCTION

The elapsed time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with myocardial infarction. The patients' own decision time is the most important component of prehospital delay.

METHODS

Selective literature review based on the references in a meta-analysis, complemented by a PubMed search on the expression "prehospital delay" in combination with "myocardial infarction," "acute coronary syndrome," "psychological factors," "gender," and "public campaign." A total of 73 papers addressing factors that influence prehospital delay were selected.

RESULTS

The reasons for delays of more than 120 minutes in a patient with symptoms of myocardial infarction reaching the hospital are still not sufficiently elucidated. Patients' uncertainty about their symptoms, advanced age, and female sex are three factors that appear to be associated with longer delays.

DISCUSSION

Factors influencing prehospital delay operate at the following levels: the perception of acute symptoms, the recognition of the importance of these symptoms, and the decision to call for help. Intervention trials should consider these levels in meeting the needs of clinically relevant subpopulations.

Response to Signs and Symptoms of Acute Coronary Syndrome: Differences Between Lebanese Men and Women

Background Signs and symptoms of acute coronary syndromes differ between men and women, but whether men and women respond differently to these indications is not well understood. Such responses influence health outcomes because success of treatment depends on how quickly healthcare is sought.

Objective To explore differences between Lebanese men and women in cognitive, emotional, and behavioral responses to signs and symptoms of acute coronary syndromes.

Methods A convenience sample of 149 men and 63 women with unstable angina or acute myocardial infarction were interviewed within 72 hours of admission to coronary care in a tertiary center by using the Response to Symptoms Questionnaire. Demographic and clinical data were obtained from medical records.

Results Women were older, less educated, and more often widowed than men. More women had hypertension but more men were current smokers. Women had shoulder pain, dyspnea, nausea and vomiting, and palpitations more often than men did. Women’s signs and symptoms were rated more severe by the women than men’s were by the men. Women were less likely to know signs and symptoms of myocardial infarction than were men and delayed coming to the hospital longer than men did. Delay correlated with the characteristics of the signs and symptoms and not realizing their importance in men and with dyspnea and taking the “wait and see” approach in women.

Conclusion Factors related to promptness in seeking care for acute coronary syndromes differ between Lebanese men and women.

The effect of health care provider consultation on acute coronary syndrome care-seeking delay

PROBLEM

The time required for health care provider (HCP) consultation during acute coronary syndrome (ACS) has not been systematically studied. This study seeks to understand who calls an HCP and the duration of HCP evaluation during ACS.

METHODS

Interviews were conducted with 1102 hospitalized patients with ACS in Columbus, Ohio. At discharge, diagnoses were acute myocardial infarction (560), unstable angina (214), cardiac disease (122), and noncardiac emergencies (206).

RESULTS

Among the 1102 patients studied, 40.9% (451) contacted an HCP. Situational factors were more important than demographic factors in accounting for medical evaluation phase incidence and duration. Advice from HCPs to call the emergency medical services or travel to the emergency department reduced medical evaluation phase duration. The median total time duration was 6 hours for HCP consulters and 1 hour 30 minutes for nonconsulters (P < .001). Patients foregoing HCP consultation experienced significantly greater hemodynamic instability than patients contacting an HCP. Calling an HCP significantly (P < .001) reduced emergency medical services use.

CONCLUSIONS

Consulting an HCP during ACS extended total time duration from symptom onset to emergency department arrival. In general, patients calling an HCP experienced a less severe ACS event than patients not contacting an HCP. There is a need for an epidemiologic study of calls to HCPs to develop a protocol for ACS call management.

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.

Gender-specific risk factors for mortality associated with incident coronary heart disease--a prospective community-based study

BACKGROUND

Risk factors for mortality in community-residing persons developing congestive heart failure (CHF) and acute myocardial infarction (AMI) may differ for males and females.

METHOD

Persons from the Groningen Longitudinal Aging Study with incident CHF (N=274) or AMI (N=198) were identified between 1993 and 1998 and their survival status was collected in 2001. Risk factors are assessed prior to the cardiac diagnosis.

RESULTS

The 1-, 5-, 7-year survival rates were 65, 53, 50% for AMI and 74, 45, 32% for CHF. Multivariate analyses showed that male gender, high age, smoking, diabetes and low physical function were risk factors for mortality among persons with CHF. For AMI, 1 month mortality was related to high age and baseline low body mass index, while longer term mortality was related to male gender and high age. In addition, diabetes increased longer term mortality among females but not among males with AMI. Depression was not a risk factor for mortality for either condition in either gender.

CONCLUSION

Males with CHF or AMI have worse survival rates compared to females. Risk factors for mortality are predominantly similar for males and females, except for diabetes which is a risk factor among females, but not males with AMI.

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.

Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987-2000

BACKGROUND

Prolonged delay in seeking care for acute myocardial infarction (AMI) is associated with decreased use of time-dependent treatments and increased mortality and morbidity.

METHODS

Time from symptom onset to arrival at hospital and emergency medical service use were abstracted from medical records of 18,928 patients hospitalized for AMI and captured in the community surveillance component of the ARIC study from 1987 to 2000. A cut point of 4 hours was used to assess clinically relevant delay time recommendations for treatment with current therapies.

RESULTS

In 2000, the overall proportion of persons with delays from symptom onset to hospital arrival of > or = 4 hours was 49.5%. Blacks and women consistently delayed longer than whites and men. Between 1987 and 2000, there was no statistically significant change in the proportion of patients delaying > or = 4 hours (relative change +0.6% in men, -7.4% in women, -2.3% in whites, -8.9% in blacks, -7.9% in persons with diabetes, and -0.8% in persons without diabetes); however, there is a noticeable narrowing of gaps between sex, race, and diabetes status over the study period. The percentage of those who used emergency medical services increased significantly over the study period (1987 37.1%, 2000 44.5%, P < or = .0001).

CONCLUSIONS

Many patients continue to experience prolonged delays from onset of symptoms to hospital arrival. Delay time for hospitalized AMI changed little in the ARIC communities from 1987 to 2000. New public health strategies should be developed to facilitate rapid access to acute care for AMI.

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.

Self-rated ill-health strengthens the effect of biomedical risk factors in predicting stroke, especially for men -- an incident case referent study

OBJECTIVES

To examine how self-rated ill-health interacts with biomedical stroke risk factors in predicting stroke and to explore differences between men and women and educational groups.

DESIGN

An incident case-referent study where the study subjects had participated in a prior health survey.

SETTING

Nested within the Västerbotten Intervention Program (VIP) and the Northern Sweden MONICA cohorts.

SUBJECTS

The 473 stroke cases had two referents per case, matched for age, sex and residence, from the same study cohorts.

RESULTS

Self-rated ill-health independently increased the risk of stroke, specifically for men. The interaction effect between self-rated health and biomedical risk factor load was greater for men than for women. The attributable proportion due to interaction between having a risk factor load of 2+ and self-rated ill-health was 42% for men and 15% for women. Better-educated individuals with self-rated ill-health and two or more of the biomedical risk factors had a higher risk of stroke than the less educated. Calculations of the respective contribution to the stroke cases of self-rated health, hypertension and smoking showed that self-rated ill-health had a role in 20% of the cases and could alone explain more than one-third of the cases among those who rated their health as bad, more so for men than for women.

CONCLUSIONS

The results underscore the importance of including both a gender and a social perspective in discussing the role of self-rated health as a predictor of disease outcome. Physicians must be more gender sensitive when discussing their patient's own evaluation of health in relation to biomedical risk factors.

Exploring sex differences in case fatality in acute myocardial infarction or coronary death events in the northern Sweden MONICA Project

OBJECTIVES

To investigate sex differences in reaching diagnosis, medical management and case fatality (CF) in acute myocardial infarction (AMI) in the population aged 35-64 years in northern Sweden.

METHODS

Within the framework of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) Project, definite AMI was monitored in people aged 35-64 years from 1989 through 1995 (target population 510 000 in 1991).

SETTING

In a population based coronary register, all coronary events were recorded in nine hospitals in 1989-95.

RESULTS

The number of events included in the definite coronary myocardial infarction register was 2483 men and 669 women. On admission, a higher proportion of men with definite AMI had chest pain or ECG changes typical for AMI (P < 0.0001). Disagreement between clinical diagnosis and classification by MONICA criteria occurred more often in women (P=0.008). A significantly higher proportion of men was admitted in the coronary care unit and they were significantly more often treated with thrombolytics, nitroglycerine, beta-blockers, or antiplatelet agents. Women received significantly more diuretics, inotropics or calcium antagonists. Diabetes, conferring a worse prognosis, was more common in women (20 vs. 15%; P=0.003). Prehospital CF was significantly higher in men (24.1 vs. 18.3%; P=0.005), but in patients treated in hospital, the CF was significantly lower in men (12.7 vs. 21.2%; P < 0.001). Total CF was equal in men and women.

CONCLUSIONS

Several factors contributing to the excess in-hospital CF in women were identified, including greater problems in diagnosis of AMI in women which may be one of the reasons for less intensive treatment in women. Differences in co-morbidity, most notably diabetes and medical treatment between men and women with acute AMI may also have played a part.