Delays by patients in seeking treatment for acute chest pain: implications for achieving earlier thrombolysis

Pre-hospital delay in patients with acute chest pain

Introduction: Incidence of chest pain and discomfort varies in general population between 2 % and 5 %. Total prehospital delay involves two components: the time it takes for patients to recognise their symptoms as severe and seek medical attention, ie the decision-making time, and the time from seeking help to hospital admission, ie the transport time. Scope of the study was to analyse time loss in patients with chest pain hesitating to contact healthcare services, as well as distribution of acute myocardial infarction (AMI) and angina pectoris (AP) among them. Methods: Retrospective analysis of medical records of physicians working at the emergency medical services (EMS) Department of the City of Belgrade, Serbia, from 20 April 2006 to 22 July 2013 on a total of 5,310 completed field interventions. When placing a call to the EMS, 10.43 % of patients cited chest pain as a major symptom. After deducting all those ones who denied having the symptom on examination thereafter and those for whom there were no data, 349 patients remained, ie 6.57 % of the total number of calls available for analysis. Results: The average time between the onset of chest pain and the decision to call the EMS was 11.97 h, median 2 h and mode 1 h. Patient's minimum prehospital delay was 2 min and the maximum was 20 days. Most patients who experienced chest pain or discomfort waited less than an hour before calling the EMS. Most commonly diagnoses made for a symptom of chest pain were AMI and AP, ie AMI with 12.32 % of the total diagnoses, as well as the elevated arterial pressure. There were more female patients, with no difference found among the age groups. Conclusion: For the majority of patients with chest pain and discomfort presented in this paper the decision-making time was up to one hour, with cardiovascular causes being the at the top of the list.

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.

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.

High prevalence of lack of knowledge of symptoms of acute myocardial infarction in Pakistan and its contribution to delayed presentation to the hospital

Background

We conducted an observational study to determine the delay in presentation to hospital, and its associates among patients experiencing first Acute Myocardial Infarction (AMI) in Karachi, Pakistan.

Methods

A hospital based cross-sectional study was conducted at National Institute of Cardiovascular Disease (NICVD) in Karachi. A structured questionnaire was used to collect data. The primary outcome was delay in presentation, defined as a time interval of six or more hours from the onset of symptoms to presentation to hospital. Logistic regression analysis was performed to determine the factors associated with prehospital delay.

Results

A total of 720 subjects were interviewed; 22% were females. The mean age (SD) of the subjects was 54 (± 12) years. The mean (SE) and median (IQR) time to presentation was 12.3 (1.7) hours and 3.04 (6.0) hours respectively. About 34% of the subjects presented late. Lack of knowledge of any of the symptoms of heart attack (odds ratio (95% CI)) (1.82 (1.10, 2.99)), and mild chest pain (10.05 (6.50, 15.54)) were independently associated with prehospital delay.

Conclusion

Over one-third of patients with AMI in Pakistan present late to the hospital. Lack of knowledge of symptoms of heart attack, and low severity of chest pain were the main predictors of prehospital delay. Strategies to reduce delayed presentation in this population must focus on education about symptoms of heart attack.

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.

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.

Prehospital behaviour of patients admitted with acute coronary syndrome or witnessed cardiac arrest

OBJECTIVE

To study prehospital behaviour of patients admitted with acute coronary syndrome or witnessed cardiac arrest.

DESIGN

Structured interview of 250 consecutive patients with acute coronary syndrome and relatives of 48 patients with witnessed cardiac arrest. The following courses of action were studied: contact the emergency medical service (centre); contact the general practitioner from the emergency service or the general practitioner during working hours; self-transportation to the emergency department; or as the first action to call the emergency medical service.

RESULTS

Forty-four per cent of the patients admitted with cardiac arrest expressed no prior symptoms. Two-thirds of patients with typical symptoms interpreted it as cardiac-still only half took action within 20 min. Fifty per cent of patients who called a physician were delayed by wrong advice or misinterpretation. One hundred and thirteen patients (45%) knew of thrombolytic therapy. Twenty-seven of 75 patients with knowledge of the benefit of prompt treatment with thrombolysis, acted in accordance with this awareness.

CONCLUSION

Patients misinterpret symptoms of acute coronary syndrome and are misguided when calling for medical assistance. Perceiving jeopardy had positive influence on the behaviour. Awareness of therapeutic options influences the decision-making process.

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.

The symptom experience of angina in women

Angina is the symptom of myocardial ischemia and the most common presentation of women with coronary artery disease. Women have delayed responses to angina and postpone seeking care more than men. Myocardial ischemia is life threatening and timeliness of treatment is critical. Understanding the symptom experience is important to patients and health care providers alike to reduce morbidity and mortality rates. This article reviews current knowledge of the symptom experience to identify gaps in knowledge and provide a basis for future research and interventions. The symptom experience component of the Symptom Management Model is used as an organizing framework. In terms of chest pain perception, biopsychosocially oriented studies are inconsistent. Data suggest that women use different pain descriptors than men and that diabetes, somatic awareness, and hormonal status probably play a role in attenuating or altering anginal pain. In evaluating symptoms, findings suggest that if anginal symptoms were experienced as expected and/or were evaluated as cardiac in origin, response was more appropriate. Even when it is known that the symptoms are related to cardiac disease, women's responses are still delayed because of a need to self-treat to maintain control. If a patient recognizes symptoms to be cardiac in origin, an appropriate evaluation of the urgency of the situation was made more often, and a rapid response was more likely. Therefore, the larger problem may be the accurate perception of the symptom and the recognition that the symptom is cardiac in origin. This article has implications for future research dealing with improved responses.