Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

A comprehensive review of prehospital and in-hospital delay times in acute stroke care

The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (P<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from emergency department arrival to emergency department evaluation (3.1%, P=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from emergency department arrival to neurology evaluation or notification (P=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from emergency department arrival to initiation of computed tomography (P=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community-based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care.

Emergency medical services use by stroke patients: a population-based study

OBJECTIVES

Emergency medical services (EMS) use by stroke patients varies from 38% to 65%. In an epidemiological study, we determined the proportion of stroke patients who used EMS, hypothesizing that demographics, stroke severity, stroke type, and location at stroke onset would be associated with EMS use.

METHODS

Stroke and transient ischemic attack patients were identified in a population of 1.3 million in the Cincinnati area in 1999. Patient charts and EMS records were abstracted by research nurses and reviewed by study physicians. The proportion of EMS users was computed. Logistic regression was used to test for associations with EMS use.

RESULTS

Of 3949 strokes, we excluded strokes/transient ischemic attacks that occurred in the hospital (n = 283), out of town (n = 10), during EMS transport (n = 2), and at unknown locations (n = 73). Patients with unknown EMS use (n = 301); those with missing estimated stroke severity (n = 174), prestroke disability (n = 78), race (n = 3), and stroke type (n = 3); and those younger than 18 years (n = 14) were also excluded. The remaining 3008 patients had a mean age of 74 years, 17% were black, and 45% were men. Emergency medical services was used by 1532 (50.9%) patients. Age, prestroke disability, stroke severity, hemorrhagic stroke, and stroke at work were associated with EMS use. Race, sex, and prior stroke were not associated with EMS use.

CONCLUSION

Half of stroke patients used EMS in our population-based study. Older patients; those with greater prestroke disability, more severe stroke, and hemorrhagic stroke; and those having stroke at work were more likely to use EMS.

Early ischemic stroke presentation in Pakistan

INTRODUCTION

There are no studies from Pakistan that describe stroke presentation rates or factors associated with early or delayed presentation. This is important to know because current clinical protocols limit the use of recombinant tissue plasminogen activator (rtPA), the only available therapy for acute ischemic stroke, to a three-hour window from symptom onset.

METHODS

All patients aged 14 years or above with acute ischemic stroke of < or = 48 hours duration were prospectively identified from the Aga Khan University Stroke Data Bank over a 22-month period ending May 2001.

RESULTS

269 ischemic stroke patients presented within 48 hours of stroke onset. 55 out of 269 (21%) presented within first three hours and 110 out of 269 (41%) within first six hours. Unawareness of treatment options (p < 0.001) and inappropriate diagnosis and field triage (p = 0.005) were associated with delayed presentation. Small vessel occlusion or lacunar stroke in the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) ischemic stroke subtype was associated with delayed presentation (p = 0.047) and cardioembolic stroke was associated with earlier presentation (p = 0.048). Stroke severity assessed with the National Institutes of Health Stroke Scale at a cut off score of > or = 15 was not associated with earlier time to presentation at three hours (p = 0.114) but there was some tendency at six hours (p = 0.097).

CONCLUSIONS

The rate of early stroke presentation in a Pakistani tertiary care facility is comparable to certain developed countries. To increase the proportion of patients who can benefit from thrombolytic therapy, programs need to be instituted to increase public awareness of treatment options for stroke and expedited referral by the primary care provider.

Gender differences in presenting and prodromal stroke symptoms

BACKGROUND AND PURPOSE

Prompt recognition of stroke symptoms is critical to timely treatment and women have increased delay to treatment. Women may be more likely to present with atypical symptoms, but this hypothesis has not been extensively evaluated.

METHODS

We examined gender differences in the prevalence of presenting and prodromal stroke symptoms among 1107 consecutive patients hospitalized with neurologist-confirmed acute ischemic stroke. Patient demographics, clinical variables, and stroke symptoms were abstracted from medical records by trained abstractors using standardized forms. Estimates were age-standardized to the age distribution of men and women combined. Presenting symptoms occurred within 24 hours of incident stroke admission; prodromal symptoms occurred >or=24 hours of admission.

RESULTS

Women were significantly older (P<0.001), more likely to have cardioembolic stroke (P<0.01), and less likely to receive aspirin (P=0.014) or statins (P<0.001). Thirty-five percent of the sample (n=389) reported prodromal symptoms. Women were more likely to have >or=1 somatic prodromal and presenting symptoms (P=0.03; P=0.008), but did not differ from men on specific somatic symptoms. Women did not differ from men in classic presenting stroke symptoms (P=0.89).

CONCLUSIONS

Women did not differ significantly in the prevalence of traditional stroke symptoms but were more likely to have somatic presenting and prodromal symptoms. We found no differences in specific prodromal symptoms, making it difficult to craft a public health message about gender differences in early warning signs of stroke. These results suggest that the focus of stroke prevention education for women should continue to emphasize traditional stroke risk factors.

Acute stroke and heart attack management within a four-hour time window

BACKGROUND AND PURPOSE

Although brain embolism is a uncommon complication of myocardial infarction, sequential treatment of cerebral and coronary artery occlusion within a 4-hour time window is unusual.

SUMMARY

of case A 60 year-old man experienced successful intravenous recombinant thrombolysis (tPA) for acute middle cerebral artery (MCA) occlusion followed by efficient angioplasty stenting of a troponin-negative coronary occlusion which, while painless, involved clear electrocardiographic abnormalities. Both pathologies were treated within a 4-hour time window.

CONCLUSION

Acute brain and heart ischemia may be successfully treated within a 4-hour time window, thanks to an efficient multidisciplinary approach.

Lay public's knowledge and decisions in response to symptoms of acute myocardial infarction

Despite public health initiatives targeting rapid action in response to symptoms of myocardial infarction (MI), people continue to delay in going to a hospital when experiencing these symptoms due to lack of recognition as cardiac-related. The objective of this research was to characterize lay individuals' knowledge of symptoms of acute myocardial infarction (AMI) and associated decision processes for timely action. Thirty participants were interviewed about their knowledge of AMI, then presented with unrelated, unfamiliar and familiar scenarios of AMI symptoms and instructed to "think aloud" as they made decisions in response to the scenarios in order to capture the decision process directly. Data were analyzed using qualitative and quantitative methods to identify the semantic relationships between knowledge and decisions. Results showed that most participants (80%) identified three symptoms or less (e.g., chest pain: 93%; dyspnea: 53%). All participants identified urgent actions (calling 911, going to ED) as the appropriate response to AMI symptoms. Urgent action decisions increased with familiarity of symptoms (57% for unrelated symptoms to 83% for most familiar symptoms), and was highest for the cardiac group. Lay knowledge of AMI is necessary, but not sufficient for people to develop required heuristics for timely action. This ineffective decision increases as a function of ambiguous and unfamiliar situations. Health education interventions should focus on teaching clusters of problems with varying levels of familiarity and complexity to increase flexibility in making decisions.

The effect of a short one-on-one nursing intervention on knowledge, attitudes and beliefs related to response to acute coronary syndrome in people with coronary heart disease: a randomized controlled trial

BACKGROUND

Coronary heart disease (CHD) and acute coronary syndrome (ACS) remain significant public health problems. The effect of ACS on mortality and morbidity is largely dependent on the time from symptom onset to the time of reperfusion, but patient delay in presenting for treatment is the main reason timely reperfusion is not received.

OBJECTIVES

We tested the effect of an education and counseling intervention on knowledge, attitudes and beliefs about ACS symptoms and the appropriate response to symptoms, and identified patient characteristics associated with changes in knowledge, attitudes and beliefs over time.

METHODS

We conducted a two-group randomized controlled trial in 3522 people with CHD. The intervention group received a 40 min, one-on-one education and counseling session. The control group received usual care. Knowledge, attitudes and beliefs were measured at baseline, 3 and 12 months using the ACS Response Index and analyzed with repeated measures analysis of variance.

RESULTS

Knowledge, attitudes and beliefs scores increased significantly from baseline in the intervention group compared to the control group at 3 months, and these differences were sustained at 12 months (p=.0005 for all). Higher perceived control over cardiac illness was associated with more positive attitudes (p<.0005) and higher state anxiety was associated with lower levels of knowledge (p<.05), attitudes (p<.05) and beliefs (p<.0005).

CONCLUSION

A relatively short education and counseling intervention increased knowledge, attitudes and beliefs about ACS and response to ACS symptoms in individuals with CHD. Higher perceived control over cardiac illness was associated with more positive attitudes and higher state anxiety was associated with lower levels of knowledge, attitudes and beliefs about responding to the health threat of possible ACS.

Ethnic disparities in stroke recognition in individuals with prior stroke

OBJECTIVE

Studies of stroke awareness suggest that knowledge of early warning signs of stroke is low in high-risk groups. However, little is known about stroke knowledge among individuals with a history of prior stroke who are at significant risk for recurrent stroke.

METHODS

Data from 2,970 adults with a history of prior stroke from the 2003 Behavioral Risk Factor Surveillance System were examined. Recognition of the five warning signs of stroke and appropriate action to call 911 was compared across three racial/ethnic groups: non-Hispanic white, non-Hispanic black, and Hispanic/other. Multiple logistic regression analyses were used to: (1) determine the association between race/ethnicity and recognition of multiple stroke signs and appropriate first action and (2) identify independent correlates of recognition of multiple stroke signs and taking appropriate action to seek treatment among individuals with prior stroke.

RESULTS

Recognition of all five signs of stroke and taking appropriate action to call 911 was lowest among the non-Hispanic black group (22.3%) and Hispanic/other group (16.7%). In multivariate models, Hispanic/other (odds ratio [OR] 0.42 [0.25, 0.71]), age 50-64 (OR 0.64 [0.43, 0.97]), age > or =65 (OR 0.36 [0.23, 0.55]), and >high school education (OR 1.79 [1.22, 2.63]) emerged as independent correlates of recognition of all five signs of stroke and first action to call 911.

CONCLUSIONS

Less than 35% of people with prior stroke can distinguish the complex symptom profile of a stroke and take appropriate action to call 911. Targeted educational activities that are sensitive to differences in race/ethnicity age, and education levels are needed for individuals with prior stroke.

Stroke awareness among low literacy Latinos living in the South Carolina low country

BACKGROUND

Little is known about stroke awareness in Latinos with low literacy and living in regions with high stroke rates.

METHODS

We surveyed a convenience sample of 60 adult Latinos living in Charleston South Carolina to examine recognition of 4 common warning signs of stroke and appropriate first action to call 9-1-1.

RESULTS

Forty-six percent of the participants recognized sudden facial, arm, or leg weakness; 39% recognized sudden vision loss; 43% recognized sudden trouble walking; 45% recognized sudden headache; 17% recognized all four warning signs. Twenty-seven percent of the participants incorrectly identified chest pain as a warning sign of stroke. Participants at the lowest literacy levels recognized three of the four warning signs more frequently than the participants at higher literacy levels.

DISCUSSION

Overall, awareness of stroke warning signs was considerably low in this high-risk population. The relationship between low-literacy and stroke awareness was unclear in this sample.

Help-seeking at the time of stroke: stroke survivors' perspectives on their decisions

Stroke is a major cause of death and disability in many countries. Early access to the most appropriate medical treatment can improve health outcomes. Despite this, only 30-60% of people who experience a stroke seek medical help within the recommended 3-hour timeframe. This study used open-ended interviews to explore patients' views on factors that influenced their decision to seek help at the time of stroke. Twenty participants were recruited from five centres: three hospitals, a community-based stroke support service and a primary healthcare service focused on providing health care for Maori. A qualitative methodology drawing on Grounded Theory informed data collection and analysis. Four main themes influenced the decision to seek help: making sense of symptoms, maintaining a sense of normality, presence and influence of another person and perception of medical services. Participants appeared to go through a process of recognition, interpretation and negotiation during their decision-making. Each of the four themes seemed to influence this process, either assisting or delaying help-seeking behaviour. The more time spent going through this process (or repeating each step), the longer the delay appeared to be. Our key findings which add to current help-seeking literature, include: (1) people tended to prioritise everyday commitments and responsibilities over their own health; (2) at times the presence and influence of another person contributed to delays in seeking help; and (3) people had different personal thresholds for when they perceived themselves to be 'sick enough' to seek medical help.

Utilizing video on myocardial infarction as a health educational intervention in patient waiting areas of the developing world: A study at the emergency department of a major tertiary care hospital in India

Objective

To study the effect of health educational video instruction on increasing patients' knowledge in a hospital waiting area of a developing country.

Methods

An educational video on signs, symptoms, and risk factors of myocardial infarction (MI) was played in an Emergency Department (ED) patient waiting area of an urban tertiary care hospital in India. Participants (n = 217) were randomly assigned to two groups: an intervention group that viewed the MI video (n = 111) and a control group that did not view the video (n = 106). Each group took a standard survey of thirty-seven questions to assess baseline knowledge pertaining to MI (pretest). The intervention group then viewed the video and the initial survey was re-administered to each group (posttest).

Results

At baseline (pretest) there was no statistically significant difference between the intervention and control group in the mean number of correct (18.1 vs. 19.0, p = 0.19), incorrect (9.4 vs. 8.6, p = 0.27) and unsure (9.6 vs. 9.3, p = 0.78) responses per participant. After viewing the video on MI, the intervention group had a statistically significant improvement in the mean number of correct responses (27.0 vs. 20.0, p < 0.001), and a significant decline in the mean number of unsure responses (1.8 vs. 9.4, p < 0.001) compared to the posttest responses of the control group. There was no significant change in the number of incorrect responses on the posttest between the intervention and control groups, (8.3 vs. 7.7, p = 0.35), respectively.

Conclusion

A health educational video can serve as an effective tool for increasing patients' short-term knowledge and awareness of health conditions in a hospital waiting area of a developing country.

Practice Implications

Health educational videos serve as a public health low cost intervention that demonstrates clear short term benefits. Health care workers in developing countries can help educate individuals presenting to hospitals by displaying these videos in hospital waiting areas.

Pre-hospital delay in patients with acute coronary syndrome: factors associated with patient decision time and home-to-hospital delay

Background

Pre-hospital delays in patients experiencing acute coronary syndromes (ACS) remain unacceptably long.

Aims

To examine simultaneously a wide range of clinical, sociodemographic and situational factors associated with total pre-hospital delay and its two components.

Methods

Pre-hospital delay data were collected from 228 patients with ACS using patient's medical notes and semi-structured interviews. Total pre-hospital delay (symptom onset to hospital admission) was divided into 2 components: decision time (symptom onset to call for medical help), and home-to-hospital delay (call for help to hospital admission).

Results

Shorter total pre-hospital delays and decision times were associated with ST segment myocardial infarction (STEMI), recognizing symptoms as cardiac in origin, being married, symptom onset outside the home and the presence of a bystander. Shorter home-to-hospital delays were more likely among younger patients, those experiencing an STEMI, and patients reporting a greater number of symptoms. Initial contact with emergency medical services was related to shorter total delays and decision times.

Conclusions

Different factors were associated with shorter times in the 2 component phases. Greater understanding of the factors impacting on the component phases may help target interventions more effectively and reduce pre-hospital delays.

Acute coronary syndrome: what do patients know?

BACKGROUND

The effectiveness of therapy for an acute coronary syndrome (ACS) is dependent on patients' quick decision to seek treatment. We surveyed patients' level of knowledge about heart disease and self-perceived risk for a future acute myocardial infarction (AMI) in patients with documented ischemic heart disease.

METHODS

Patients (N = 3522) had a mean age of 67 years, 68% were male, and all had a history of AMI or invasive cardiac procedure for ischemic heart disease. Data were gathered using a 26-item instrument focusing on ACS symptoms and appropriate steps to seeking treatment. Patients were asked to identify their level of perceived risk for a future AMI.

RESULTS

Forty-six percent of patients had low knowledge levels (ie, <70% of answers were correct). The mean score was 71%. Higher knowledge scores were significantly related to female sex (P = .001), younger age (P = .001), higher education (P = .001), participation in cardiac rehabilitation (P = .001), and receiving care by a cardiologist rather than an internist or general practitioner (P = .005). Clinical history (eg, AMI [P = .24] and cardiac surgery [P = .38]) were not significant predictors of knowledge. Most (57%) identified themselves as being at higher risk for a future AMI compared with an age-matched individual without heart disease with 1 exception. Namely, patients who had undergone coronary artery bypass surgery felt significantly less vulnerable for a future AMI than other individuals of the same age.

CONCLUSIONS

Even following diagnosis of ACS and numerous interactions with physicians and other health care professionals, knowledge about ACS symptoms and treatment on the part of patients with cardiac disease remains poor. Patients require continued reinforcement about the nature of cardiac symptoms, the benefits of early treatment, and their risk status.

Awareness of warning signs among suburban Nigerians at high risk for stroke is poor: a cross-sectional study

Background

Although stroke is a leading cause of morbidity and mortality in Nigeria, there is no information on awareness of its warning signs. This study was designed to assess awareness of stroke warning signs in Nigerians at increased risk.

Methods

A hospital-based cross-sectional study conducted at Irrua Specialist Teaching Hospital, in southern Nigeria. Patients with a diagnosis of hypertension, diabetes or both were interviewed for the warning signs of stroke in the outpatient clinic by trained interviewers. The main outcome measure was ability to identify at least one stroke warning sign.

Results

There were 225 respondents with a mean age of 58.0 ± 11.7 years. Only 39.6% could identify at least one stroke warning sign while the commonest sign identified was sudden unilateral limb weakness (24.4%). On multivariate logistic regression analysis, male sex (β = 0.26, 95% CI = 0.14–0.39, p < 0.001) and 11 or more years of education (β = 0.16, 95% CI = 0.03–0.29, p = 0.02) emerged the independent predictors of ability to identify at least one warning sign.

Conclusion

Awareness of stroke warning signs is poor among Nigerians at increased risk for the disease. Efforts should be made to improve on the level of awareness through aggressive health education.

Multiple causes for delay in arrival at hospital in acute stroke patients in Aydin, Turkey

This descriptive, hospital-based study, performed in western Turkey, was designed to assess the level of pre-hospital delay and reasons for such delay in acute stroke patients, taking into consideration certain factors such as socioeconomic status, availability of transport options at onset of symptoms. Data were collected from hospital records, and a questionnaire was administered that included questions about socio-demographics, self-reported risk factors and questions related to hospital arrival. The rate of patients arriving at the hospital more than 3 hours after symptom onset was found to be 31.6% for this study. Approximately 1/3 of patients delayed going to the hospital because they were waiting for symptoms to go away while 1/3 of patients were not aware of the importance of seeking immediate medical help. There was a significant relationship between the use of ambulance transportation and length of time before arrival at the hospitals, though there was no statistically significantly relationship between the existence of stroke risk factors and hospital arrival delay. These results will likely be helpful to health care decision makers as they develop a model for stroke health care and community based training.

Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction

BACKGROUND

Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction.

METHODS

We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482,327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic.

RESULTS

The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P < .001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those < 70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P < .01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes).

CONCLUSIONS

Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

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.

Care seeking after stroke symptoms

OBJECTIVE

To assess risk factors associated with care for stroke symptoms.

METHODS

Using data from the population-based national cohort study (REasons for Geographic And Racial Differences in Stroke) conducted January 25, 2003-February 28, 2007 (N = 23,664), we assessed care-seeking behavior among 3,668 participants who reported a physician diagnosis of stroke/transient ischemic attack (n = 647) or stroke symptoms (n = 3,021) during follow-up. Care seeking was defined as seeking medical attention after stroke symptoms or a physician diagnosis.

RESULTS

Overall, 58.5% of participants (2,146/3,668) sought medical care. In multivariable models, higher income was associated with greater likelihood of seeking care (p = 0.02): participants with income of > or = $75,000 had odds 1.43 times (95% confidence interval [CI], 1.02-2.02) greater than those with income of less than $20,000. Diabetes and previous heart disease were associated with increased care seeking: odds ratio (OR) of 1.23 (95% CI, 1.04-1.47) and OR of 1.26 (95% CI, 1.06-1.49), respectively. Participants with previous stroke symptoms but no stroke history were less likely to seek care than those with stroke history or without previous symptoms (OR, 0.80; 95% CI, 0.67-0.96). Past smoking was associated with lower likelihood (OR, 0.71; 95% CI, 0.59-0.85; p = 0.0003) of seeking care relative to nonsmokers.

INTERPRETATION

Only approximately half of participants with stroke symptoms sought care. This is despite the encouragement of advocacy groups to seek prompt attention for stroke symptoms. Our results highlight the importance of identifying characteristics associated with care-seeking behavior. Recognizing factors that contribute to delays provides opportunities to enhance education on the importance of seeking care for stroke symptoms.

Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction

BACKGROUND

We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time.

METHODS

Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as < or =1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time.

RESULTS

In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting < or =1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively.

CONCLUSIONS

Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Patent foramen ovale and cryptogenic stroke

Strokes are the leading cause of long-term, serious disability. A variety of identifiable risk factors exists for the development of a stroke. Individuals who had no definite and clearly identifiable cause for a stroke experience a cryptogenic stroke. The presence of a patent foramen ovale, a flaplike opening of the atrial septum between the septum primum and secundum, contributes to a 40% to 56% incidence of a cryptogenic stroke. This article reviews the pathophysiology of a patent foramen ovale, the diagnostic tests, and nurse's awareness of the potential etiology of a stroke in a younger individual.

How people decide to seek health care: a qualitative study

BACKGROUND

There is considerable variation in service use, with overuse in conditions such as upper respiratory tract infections and high levels of unmet need in older patients with embarrassing conditions such as incontinence. The reasons for this situation are varied but to facilitate appropriate accessing of services the decision processes involved in help-seeking require greater understanding.

OBJECTIVES

This study aimed to describe the decision making process for help-seeking in middle and older aged people with urinary storage symptoms.

METHODS

In-depth qualitative interviews were carried out with 33 men and women who had sought medical care for urinary symptoms. Respondents were recruited from an epidemiological study of the prevalence of urinary symptoms in community dwelling adults aged 40 years and over. Questions were directed at help-seeking for urinary symptoms as well as help-seeking in general. Interviews were audio-taped and a thematic analysis carried out according to grounded theory methods.

RESULTS

The steps in the decision process to seek medical care were drawn from the data. These consisted of appraisals of the presence and cause of symptoms, treatment options and the severity of symptoms and their impact on quality of life. Once the level of threat of the symptom was established, the costs and benefits of treatments and services were balanced against the perceived impact of symptoms on quality of life. These results were considered in relation to available models of health behaviour.

CONCLUSIONS

Interventions that increase individuals' active involvement in their health care and which encourage greater knowledge of symptoms and outcomes will facilitate appropriate help-seeking and service use.

The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction

Background

Patients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction (AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation-wide longitudinal study we wanted to evaluate long-term survival after AMI in relation to socioeconomic position (SEP) and use of revascularization.

Methods

From the Swedish Myocardial Infarction Register we identified all 45 to 84-year-old patients (16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5-year survival after the AMI.

Results

Patients with the highest cumulative income (adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co-morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long-term mortality among patients who did not undergo revascularization.

Conclusion

This nationwide Swedish study showed that patients with high income had a better long-term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.

Cardiovascular health disparities: a systematic review of health care interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.

Population-based analysis of the impact of expanding the time window for acute stroke treatment

BACKGROUND AND PURPOSE

Currently, a major focus on expanding acute ischemic stroke treatment opportunities centers on the development of drugs and devices with longer time windows for use. We sought to determine the time intervals within which stroke patients present to establish whether time window expansion will translate into more treatment.

METHODS

Data were derived from the Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study in an urban, southeast Texas county. This community does not contain an academic medical center, thus providing a "real-world" setting to capture patient arrival times. Onset time was recorded from the chart according to a prespecified methodology.

RESULTS

From January 2000 to June 2005, 2347 patients with acute ischemic stroke were validated. The mean age was 71 years, and 53% were female. Thirty-one percent presented within 3 hours of symptom onset; 13% between 3 and 6 hours; and 15% between 6 and 12 hours. Forty-one percent presented beyond 12 hours from symptom onset. Nearly half of patients with moderate and severe strokes presented in the 0- to 3-hour time window, whereas only 28% of mildly affected patients presented early.

CONCLUSIONS

This population-based study provides estimates of time to presentation in a representative community without tertiary referral bias. These data are useful for planning acute stroke therapy interventions and suggest that in addition to developing therapies with expanded time windows, research resources should also be devoted to reducing hospital presentation delays.

Launching online education for 911 telecommunicators and EMS personnel: experiences from the North Carolina Rapid Response to Stroke Project

OBJECTIVE

We describe the development and implementation of the North Carolina Rapid Response to Stroke (NCRRS) project--a community-based online education project developed for 911 telecommunicators and EMS personnel.

METHODS

Two online courses, one for 911 telecommunicators and one for EMS personnel, were designed to provide timely and accessible continuing education on stroke assessment and care. Eight county-based emergency management systems, representing 15 agencies, were recruited for participation in a 4-month trial of the online courses in 2003. A total of 150 telecommunicators and 208 EMS personnel completed the courses.

RESULTS

Results showed high levels of participant satisfaction with the program and improvements in posttest scores; agency leaders also provided positive feedback on the project. Motivators to complete the education identified by participants included peers, agency support, and materials provided by the NCRRS project. Courses were revised on the basis of feedback and successfully sustained online through August 2006, providing free stroke education for almost 1,000 additional 911 telecommunicators and EMS personnel in North Carolina.

CONCLUSIONS

We describe the process of development and implementation that ensured project success. The results of this study show the need for and value of online stroke education for emergency services personnel and describe the challenges of developing and implementing online continuing education for this population. Similar education programs should be developed. Programs should incorporate comprehensive recruitment programs and community-based networks that sustain interest and promote full participation in educational offerings.

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.

Patient delay in responding to symptoms of possible heart attack: can we reduce time to care?

In Australia, many deaths and significant cardiac disability result from delayed response to symptoms of heart attack. Although delays due to transport and initiation of reperfusion therapy in hospital may contribute to late treatment, the major component of delay is the time patients take in deciding to seek help. A critical examination of campaigns to shorten patient delay concludes that they were based on a factual, short-term, non-targeted approach that included education and mass media strategies. They achieved equivocal results. One randomised controlled trial has been conducted. Although this showed an improved understanding of heart attack symptoms, it did not shorten pre-hospital delays. The implications of these findings are that future campaigns to shorten patient delay are likely to be more effective if they address the psychosocial and behavioural blocks to action, are ongoing rather than short term, and focus on people at highest risk, including those with known or high risk of coronary heart disease, those in rural locations, and Indigenous Australians. The National Heart Foundation of Australia proposes a comprehensive strategy to incorporate this approach into its future campaigns to reduce patient delay for suspected heart attack.