Women's decision to seek care for symptoms of acute myocardial infarction

The patients' perception of recovery after coronary angioplasty

Coronary angioplasty and stent placement is associated with short hospital stays. Patients are expected to recover at home, alone, following limited care time with nurses. The purpose of the study was to describe participants' perceptions of recovery after angioplasty. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Data analysis revealed three major categories: awareness of the problem, coping response and appraisal of the situation. These were linked via a problem solving process. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. These categories were further defined by four phases identified as: pre-admission, admission, during the angioplasty and recovery. This paper describes the recovery phase. Awareness of the problem in the recovery phase was associated with 'relief from chest pain' for most participants. In contrast, anxiety continued and was associated with 'uncertainty over future health'. Participants described coping responses of "taking control of their life again" by undertaking both physical and psychological strategies. Finally, the situation was appraised to be either a 'good' or a 'bad' recovery. This appraisal was based on such considerations as the absence of chest pain, improvement in well-being and energy levels. The results of this study highlight patients' concerns and support the need for greater emphasis on their psychosocial needs. This care must be provided within the time constraints of short hospital stays. Nurses must also consider providing support to patients in the pre-admission and recovery phases.

The experiences of women with heart disease: what are their needs?

PURPOSE

To identify experiences and needs of women with coronary artery disease.

METHODS

Qualitative research utilizing focus groups and grounded theory. Women were recruited from the University of Ottawa Heart Institute Alumni, a group of former Heart Institute patients, and from the Heart Institute cardiac rehabilitation program.

FINDINGS

All women had difficulties recognizing their symptoms as heart disease and 35% reported they were initially misdiagnosed. In the post-diagnosis period, the experiences of older and younger women differed. For women over 60, maintaining their functional capacity, memory problems and a focus on resiliency were the main issues. For women under 60, emotionally focussed concerns were predominant. Both groups had to contend with over-protective family members.

CONCLUSIONS

These findings could contribute to the development of more effective public education campaigns. They also highlight the need for programs and research in the area of women's heart health and rehabilitation that address emotional aspects of the illness.

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.

Intubation and mechanical ventilation for COPD: development of an instrument to elicit patient preferences

BACKGROUND

Whether to simply provide palliative care or to intubate and use mechanical ventilation (MV) in a patient with severe COPD in acute respiratory failure is a difficult decision. The outcome of MV cannot be accurately predicted. Some patients cannot be weaned from the ventilator; those who are weaned often return to chronic severe respiratory disability. It is important that patients participate in this decision, but assistance is required. To address these issues, we developed and pilot-tested an aid to assist patients with MV decisions.

METHODS

A scenario-based decision aid was developed consisting of an audiocassette and a booklet describing intubation and MV and its possible outcomes. We used a probability tradeoff technique to elicit the patients' preferences and a decisional conflict scale to evaluate satisfaction.

RESULTS

With the assistance of the decision aid, all patients (10 men and 10 women) reached a decision. Two men and all 10 women declined MV. Mean decisional conflict was low (2.2 of a possible 5; SD, 0.9). At 1 year, only two patients (11%) had changed their decision. The agreement between physicians and patients was 65%; between next-of-kin and patients, there was uniform disagreement.

CONCLUSION

With the decision aid, stable decisions were made with satisfaction and confidence. Proxy decisions were incongruent, especially when made by family members. The strong gender effect should be further investigated. We suggest that the COPD decision aid be further tested in a community clinical setting.

Perceptions of women living with coronary heart disease: a pilot investigation

This qualitative study describes how forty-one perimenopausal and postmenopausal women with coronary heart disease (CHD) perceive their illness experience. Five focus groups were conducted by a professional facilitator at two community hospitals in New Jersey. All data were collected and analyzed based on the grounded theory approach. Findings indicate that participants often failed to recognize the significance of risk factors and symptoms, and even denied the presence of disease following diagnosis and treatment. Consequences of illness centered on women's efforts to maintain control over their health and their lives. Findings also indicate that there is a gap between the desire for knowledge and the ability to access and assimilate information in key areas regarding CHD and personal health behaviors. The insights provided by these women have several implications for future research and contribute valuable information related to the needs of this population.

Patient delay in seeking treatment for acute myocardial infarction symptoms

Patient delay before seeking treatment for the symptoms of acute myocardial infarction has a significantly negative effect on morbidity and mortality. Most patients delay 2 or more hours before accessing the emergency medical system, which limits the ability to use reperfusion strategies. This article reviews variables that have been implicated in delay and explores possible explanations for why certain characteristics may be associated with longer delays. The outcomes of educational campaigns that have targeted delay behavior will be examined and directions for future research are identified.

Gender differences in fears related to coronary arteriography

OBJECTIVE

To compare levels of fear and the intensity of specific fears in women and men related to coronary arteriography (CA).

DESIGN

Prospective survey.

SETTING

A 1360-bed university hospital. Data were collected before, during, and after CA, and again 6 months later.

SUBJECTS

The sample consisted of 54 women and 166 men undergoing scheduled CA.

METHODS

To compare fear levels at different points of evaluation; two analyses of covariance for repeated measures were performed.

RESULTS

On average, women had significantly higher mean scores of fear across the points of evaluation on the Visual Analogue Scale than men (P <.001). During the hospital stay, the most intense fear for both women and men was the fear of coronary artery bypass grafting and the uncertainty about the illness, whereas at home it was the fear of myocardial infarction. On average, women reported significantly intense fears more frequently than men across time. On average, men experienced more intensive fear of problems in their sex life than women (P =. 032). The changes in intensity of fears over time were not significantly different by gender, except in fear of pain (P =.013), health care staff not having enough time to care for the patient (P =.039), and health care staff discussing the patient's condition without the patient being present (P =.048). Age and prior CA were found to be significantly related to most of the fears at different points of evaluation, and to the changes of fears over time.

CONCLUSION

There existed differences in the tendency to report intensity of fears by gender; however, the intensity of fears changed in a similar way over time. The results suggest that the few gender differences in fears that existed may be explained by the treatment chosen for the patients and the patients' acceptance of it. Therefore, it is important to adapt information and support according to the treatment chosen for the patient.

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

Survival and long-term prognosis after a myocardial infarction are directly related to the individuals's decision to seek medical help. Early medical intervention is imperative if thrombolytic therapy is to be effective. Emerging research has indicated that women frequently have longer pre-hospital delays than men. Incorporating a comparative descriptive design, this research compared the pre-hospital admission behaviour patterns of women and men, following the onset of acute chest pain. A convenience sample of 12 women and 12 men were selected following admission to a local coronary care unit. Structured interviews and the examination of medical notes/relevant documentation provided the data. Findings were examined and compared through the use of content analysis and descriptive statistics. Severity of symptoms proved to be the strongest influence in shortening pre-hospital delay. Despite this, overall, men were admitted to hospital more quickly than women. Men were more ready than women to believe that they might be having a heart attack and this belief led them to seek treatment promptly. In order to improve female mortality and morbidity following a myocardial infarction, it is recommended that there is an urgent need to target women, through health promotion and media interventions.

[Differential characteristics and survival of women with acute myocardial infarction. Registry of Acute Myocardial Infarctions of the City of Valencia (RICVAL). Researchers of the RICVAL]

INTRODUCTION AND OBJECTIVES

The prevalence of women who are admitted to the hospital after acute myocardial infarction is lower to that of men and their prognosis is worse. The reason for these differences is unclear. We studied the demographic and historical variables, the evolution, treatment and early survival in 269 women included in the Register of Acute Myocardial Infarctions of the City of Valencia (RICVAL) and compared them with the 855 men included in the same Register.

PATIENTS AND METHODS

Register of patients admitted into a Coronary Care Unit in the City of Valencia since December, 1st, 1993 until November 30th, 1994.

RESULTS

23.9% of the patients were women with a mean age of 71.9 +/- 9 years; 46.8% of them were diabetics, 55.4% hypertensives, and 6.7% smokers. The women arrived for treatment later than men and 34.9% of them were thrombolised. The incidence in women of severe heart failure (Killip III and IV) was 40.1% and the mortality 29.7%. In women with thrombolytic treatment the mortality was 29.8%. In the logistic regression model performed, female sex predicted a higher mortality rate (odds ratio [OR] = 1.30; confidence interval [CI], 1.05-1.61).

CONCLUSIONS

Early mortality in women after acute myocardial infarction is higher than in men in the RICVAL Register. The longer delay in initiating medical care and thrombolysis might be the cause for the higher proportion of heart failure among women and explain their worse prognosis after an acute myocardial infarction compared to men.

A study of unplanned readmissions to a coronary care unit

OBJECTIVE

To determine the cause and frequency of unplanned readmissions to a coronary care unit (CCU) after initial transfer to a general cardiac unit, but before hospital discharge.

DESIGN

Analysis of 1776 admissions to a CCU during a 16-month period.

SETTING

The CCU of a major teaching hospital in South Australia.

PARTICIPANTS

All patients admitted to the CCU during the 16-month period.

OUTCOME MEASURES

CCU readmissions before hospital discharge were categorized as either "planned" or "unplanned." The latter were investigated for determination of casualty and variations in patient characteristics (including age, sex, initial diagnosis, pharmacotherapy, and duration of stay in the CCU).

RESULTS

Of the 1776 CCU admissions examined, 44 (2.5% of total) were unplanned readmissions before hospital discharge. Most of these (39 of 44) were related to "reactivation" of acute myocardial ischemia. Patients whose initial diagnosis was acute myocardial infarction or unstable angina pectoris were more likely to require a further unplanned CCU admission (p < 0.05); those with unstable angina pectoris had a second stay in CCU significantly longer than their first (p < 0.05). Six patients were readmitted within 6 hours of cessation of a heparin infusion (4 of the 6 without aspirin administration), and 11 patients had not received antiplatelet therapy after their initial CCU stay. Overall, a disproportionate number of men were readmitted to CCU (p < 0.05).

CONCLUSIONS

In the current study, unplanned readmissions to the CCU: (1) were relatively infrequent, (2) were more protracted than initial stays in CCU, (3) may have been prevented in 15 of the 44 cases with more appropriate pharmacotherapy, and (4) involved a disproportionate number of male patients.