Delay time in suspected acute myocardial infarction and the importance of its modification

Association of a telephone triage service for emergency patients with better outcome: a population-based study in Osaka City, Japan

OBJECTIVE

Telephone triage service in emergency care has been introduced in many countries, and it is important to determine the effect of telephone triage service on the outcome of emergency patients. The aim of this study was to evaluate the effect of telephone triage service on the outcome of emergency patients using propensity score.

METHODS DESIGN, SETTINGS, AND PARTICIPANTS

This was a retrospective study with a study period from January 2016 to December 2019. We included all patients transported by ambulances of the Osaka Municipal Fire Department during study period.

EXPOSURE

Telephone triage service.

OUTCOME MEASURES AND ANALYSIS

The main outcome of this study was unfavorable outcome following use of the telephone triage service. In this study, unfavorable outcome was defined as patients who were admitted, transferred, or died after care in the emergency department. Propensity scores were calculated using a logistic regression model with 12 variables that were present before the telephone triage service was used or were indicative of the patient's condition. Data analyses were not only propensity score matching but also a multivariable logistic regression model and regression model with propensity score as a covariate.

MAIN RESULTS

The number of patients eligible for analyses was 707 474. Of these patients, 8008 (1.0%) used the telephone triage services and 699 466 patients (99.0%) did not use it. The number of patients with an unfavorable outcome was 407 568 (57.6%) in the total cohort. Of them, 2305 patients (28.8%) used the telephone triage service and 297 601 patients (42.5%) did not use it. For propensity score matching, 8008 patients were matched from each group. Use of the telephone triage service was inversely associated with unfavorable outcome in a multivariate logistic regression model with propensity score as a covariate [adjusted odds ratio (OR) 0.874; 95% confidence interval (CI), 0.831-0.919] and propensity score matching (crude OR, 0.875; 95% CI, 0.818-0.936).

CONCLUSIONS

This study revealed that the use of the telephone triage service in Osaka city, Japan was associated with better outcomes of patients transported by ambulance.

Why People Experiencing Acute Myocardial Infarction Delay Seeking Medical Assistance

Background: Delay time from onset of symptoms of myocardial infarction to seeking medical assistance can have life-threatening consequences. A number of factors have been associated with delay, but there is little evidence regarding the predictive value of these indices. Aim: To explore potential predictors of patient delay from onset of symptoms to time medical assistance was sought in a consecutive sample of patients admitted to CCU with acute myocardial infarction. Methods: The Cardiac Denial of Impact Scale, Health Locus of Control Scale, Health Value Scale and Pennebaker Inventory of Limbic Languidness were administered to 62 patients between 3 and 6 days after admission. Results: Attribution of symptoms to heart disease and health locus of control had a significant predictive effect on patients seeking help within 60 min, while previous experience of heart disease did not. Conclusion: Assisting individuals to recognise the potential for symptoms to have a cardiac origin is an important objective. Interventions should take into account the variety of cognitive and behavioural factors involved in decision making.

Danshen (Chinese medicinal herb) preparations for acute myocardial infarction

BACKGROUND

Acute myocardial infarction (AMI) is the most important cause of morbidity from ischaemic heart disease, and is among the leading causes of death in the western world. Danshen, a Chinese herbal medicine, is widely used in China for treatment of several diseases, including AMI.

OBJECTIVES

To assess the effects (both benefits and harms) of danshen preparations for AMI.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (issue 4, 2006), MEDLINE (1966-2006), EMBASE (1980-2006), and the Chinese Biomedical Database (CBM) (1982-2006). We also handsearched 75 Chinese medical journals.

SELECTION CRITERIA

Randomised controlled trials (RCTs) lasting at least 7 days were sought. Since it seemed evident that few RCTs were available, we also considered other controlled studies.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by three reviewers.

MAIN RESULTS

Six studies comprised of 2368 participants were included. Only one trial was judged to be a genuine RCT and showed no statistically significant difference in reduction of total mortality (Peto OR 0.55, 95% CI 0.23 to 1.32), but a quasi-RCT reported a reduced total mortality (Peto OR 0.42, 95% CI 0.23 to 0.77). Pooling these trials yielded an approximate halving of mortality in those patients treated with danshen preparations plus usual care compared with usual care alone (Peto OR 0.46, 95% CI 0.28 to 0.75).

AUTHORS' CONCLUSIONS

The evidence to support use of danshen preparations is too weak to make any judgement about its effects. Evidence from RCTs is insufficient and of low quality. The safety of danshen preparations is unproven, although some adverse events have been reported. More evidence from high quality trials is needed to support the clinical use of danshen preparations.

Glycoprotein IIb/IIIa receptor inhibitor-thrombolytic combination therapy for acute myocardial infarction

Over the past two decades, we have witnessed a large decrease in the death and complication rate of patients experiencing acute myocardial infarction (MI), due to our ability to restore blood flow to infarct-related arteries. Therapies include strategies to inhibit platelet function and induce fibrinolysis, and mechanical reperfusion with percutaneous intervention. Despite decreases in morbidity and mortality with thrombolytic therapy, reperfusion rates remain less than optimal. With standard fibrinolytic therapy in combination with aspirin, it is thought that thrombolytic-induced platelet activation may be an important reason for failure to induce perfusion, or maintain reperfusion in the infarct-related artery. In the past 10 years we have moved from platelet inhibition with aspirin to newer, more potent platelet inhibitors such as glycoprotein (GP) IIb/IIIa antagonists. Recent trials have evaluated the efficacy and safety of combining thrombolytic drugs with GP IIb/IIIa receptor antagonists. Future trends may use combination therapy as a part of a mechanical strategy, using these medications to induce early reperfusion as the patient is prepared for percutaneous intervention. This review summarizes recently published trials using combination thrombolytic and GP IIb/IIIa receptor inhibitor therapy in the treatment of acute MI.

Use of emergency medical services for suspected acute cardiac ischemia among demographic and clinical patient subgroups: the REACT trial. Rapid Early Action for Coronary Treatment

OBJECTIVE

Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia.

METHODS

A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged > or = 30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9).

RESULTS

The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07-1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18-1.99, and adjusted OR 1.52, 95% CI 1.17-1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS ulse in those who were retired (adjusted OR 1.62, 95% CI 1.29-2.04) or had systolic blood pressure (SBP) at or below 160 mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26-1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88-2.97 for SBP <100 mm Hg).

CONCLUSIONS

The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.

ST-Segment Elevation Myocardial Infarction

ST-segment elevation myocardial infarction (MI) is an emergency medical condition. Expediting the steps leading to coronary reperfusion is of critical importance in improving survival after acute MI. After the diagnosis of acute MI is made, patients should be treated with oxygen, aspirin, nitroglycerin, beta-blockers, heparin, and analgesics, barring any contraindications. If an experienced cardiac catheterization laboratory is available within 60 to 90 minutes, then catheter-based reperfusion therapy is recommended; otherwise, thrombolysis should be considered as an alternate therapy. Therapy with a reduced-dose thrombolytic agent and a glycoprotein IIb/IIIa receptor inhibitor appears to be of an added benefit in establishing TIMI (Thrombolysis in Myocardial Infarction) 3 flow, but this approach awaits final approval prior to widespread use. The adjunctive use of glycoprotein IIb/IIIa receptor inhibitors with percutaneous transluminal coronary angioplasty, with or without stenting, appears to be beneficial and is being used more frequently in the acute setting. Coronary angiography should be performed in patients who fail to respond to thrombolytic therapy or who have evidence of recurrent ischemia. This procedure should not be routinely performed in patients who have responded to thrombolytic therapy. Four to 6 days after an acute MI event, assessment of left ventricular function is recommended. Submaximal exercise test (with or without nuclear or echocardiographic imaging) should be considered in patients prior to discharge from the hospital--an exception can be made in patients with one-vessel disease treated successfully with percutaneous transluminal coronary angioplasty. After discharge, a regular exercise test should be obtained 4 to 6 weeks after an uncomplicated acute MI event. Secondary prevention measures such as weight loss, cessation of smoking, aspirin, beta-blockers, lipid-lowering agents, and angiotensin-converting enzyme inhibitors should be considered in all patients, barring contraindications.

Tenecteplase: a review of its pharmacology and therapeutic efficacy in patients with acute myocardial infarction

Tenecteplase is a triple combination mutant variant of alteplase with high fibrin specificity and resistance to plasminogen activator inhibitor-1. The reduced rate of systemic clearance of the drug relative to alteplase allows tenecteplase to be given by rapid bolus injection to patients with acute myocardial infarction (AMI) with ST segment elevation. The efficacy of tenecteplase in AMI has been demonstrated in a phase I dose-ranging trial [Thrombolysis in Myocardial Infarction (TIMI) 10A], a nonblind phase II comparison with alteplase (TIMI 10B), and a randomized double-blind phase III comparison with alteplase in 16 949 patients [the second Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) trial]. Patients also received aspirin and intravenous heparin in all trials. In TIMI 10A and 10B, TIMI grade 3 coronary flow was achieved after 90 minutes in 54.3 to 65.8% of patients receiving tenecteplase 30, 40 or 50 mg; in TIMI 10B, grade 3 flow was reported in 62.7% patients receiving alteplase (</=100mg by front-loaded infusion over 90 minutes). Thirty-day mortality was similar with bodyweight-adjusted intravenous bolus doses of tenecteplase 30 to 50mg and front-loaded 90-minute infusion of alteplase in ASSENT-2 (approximately 6.2%). Rates of reinfarction and cardiogenic shock were also similar between groups, although mortality was reduced with tenecteplase in patients receiving treatment more than 4 hours after onset of symptoms (7 vs 9.2%; p = 0.018). Preliminary data show maintenance of the similarity between groups over 1 year (approximate 10.2% mortality in both groups), with loss of statistical significance between groups in patients treated late. ASSENT-2 showed the risks of intracranial hemorrhage (0.93%) and stroke (all causes) [1.78%] with tenecteplase to be similar to those with alteplase (0.94 and 1.66%, respectively). The rate of noncerebral bleeding was lower with tenecteplase than with alteplase (26.43 vs 28.95%; p = 0.0003). No causal link has been demonstrated between tenecteplase and allergic reactions in patients.

CONCLUSIONS

Bolus tenecteplase is an effective thrombolytic agent, suitable for first-line use in patients with AMI with ST segment elevation. Results to date show overall efficacy and tolerability profiles similar to those of alteplase, with comparable mortality after 1 year's follow-up. The apparent advantages of tenecteplase (reduced mortality in patients receiving late treatment and reduced incidence of noncerebral bleeding complications) in ASSENT-2 are of interest and merit further attention. The full implications of the availability of bolus administration and its potential clinical advantages over the currently widely used infusion regimens, together with the effect on outcomes of addition of tenecteplase to platelet glycoprotein IIb/IIIa inhibition, are currently under investigation.

Current concepts in secondary prevention after acute myocardial infarction

Acute myocardial infarction (MI) is the leading cause of death around the globe. Advances in the field of cardiology have identified several effective treatments that have lead to decrease in mortality from this cause over the past 3 decades. The purpose of this article is to review the existing literature in regards to secondary prevention after acute MI. A search of MEDLINE through August of 1999 was carried out to identify any available publications on secondary prevention after MI. Evidence on the use of both pharmacological and nonpharmacological interventions that was shown to be effective in improving morbidity and mortality was sought. Recommendations for the treatment of patients with acute MI are made based on existing evidence. Betablockers, aspirin and lipid-lowering agents for patients with low density lipoprotein-cholesterol > 130 mg% should be used for all patients following a MI. Angiotensin converting enzyme inhibitors are indicated for patients with congestive heart failure and/or reduced left ventricular ejection fraction and are likely protective in most patients. Calcium channel blockers (Verapamil and Diltiazem) are indicated as second-line therapy for patients who have contraindications or are intolerant to betablockers. The routine prophylactic use of antiarrhythmic drugs to suppress ventricular ectopic beats should be avoided. Recommendations regarding diet, smoking cessation and achievement of ideal body weight should be an integral part of patient management. Referral for outpatient rehabilitation should also be strongly encouraged. Finally, adequate control of blood pressure and diabetes cannot be overemphasized. Adherence to these goals in patients with acute MI will lead to better long-term outcomes and reduction in cardiac death, recurrent MI, stroke, and need for coronary revascularization.

Envisioning a network of care for at-risk patients after myocardial infarction

Myocardial infarction (MI) continues to be a significant health care issue because of its prevalence. As treatment options improve the survival rate, an increasing number of individuals have to learn how to adjust to this major life event and prevent recurrence. Recovery can be difficult. Many patients experience emotional distress, fear of dying, and family turmoil, fail to return to work when physiologically capable of doing so, are unable to return to their previous levels of sexual activity, and are not capable of making the necessary diet and exercise changes. Acute management strategies continue to be aimed at limiting the infarct size, whereas holistic approaches to the patient and family adjustment must target seeking prompt treatment when symptoms present, psychologic adjustment, stress reduction, and patient and family education for self-care and risk reduction. As hospital length of stay for acute MI decreases, health care professionals must provide an interdisciplinary, collaborative approach to ensure that the at-risk MI patient is provided all of the information and support needed to lead a satisfying, productive, healthy life. An excellent way for nurses to not only address this challenge, but to lead the effort, would be to develop a network of care for the at-risk MI patient.

Elderly patients at highest risk with acute myocardial infarction are more frequently transferred from community hospitals to tertiary centers: reality or myth?

BACKGROUND

The objective of this study was to assess the characteristics of patients with acute myocardial infarction transferred from community hospitals. The study was designed as a retrospective chart review, and the data source was the Cooperative Cardiovascular Project from Michigan.

METHODS AND RESULTS

Included in the study were consecutive Medicare patients with acute myocardial infarction discharged from acute-care hospitals in Michigan between April 1, 1994, and July 31, 1995 (n = 7041): 2866 patients treated at community hospitals, 1241 transferred from community hospitals, 2731 admitted directly to tertiary hospitals, and 203 transferred from an outside emergency room to tertiary hospitals. The outcomes measured were patient characteristics, quality indicators, resource use, and 30-day mortality rates. Compared with patients not transferred, those transferred from community hospitals were younger, more frequently of the male sex, smokers, and were seen earlier after symptom onset. They had fewer cases of diabetes and lower Acute Physiology And Chronic Health Evaluation (APACHE II) scores and Medicare Mortality Prediction System (MMPS) values. Aspirin during hospitalization and at discharge, thrombolytic therapy, and reperfusion therapy were all used more frequently in transferred patients, whereas the other key discharge quality indicators were no different. Mortality rate at 30 days was lower for transferred patients (9.4% vs 25%, P <.0001) when compared with those not transferred.

CONCLUSIONS

Patients who are less ill, those who are seen early, and those who received thrombolytic therapy are more often transferred from community hospitals. On average, patients with greater comorbidity rates are treated at community hospitals and not transferred. Predicted and observed mortality rates were lower for the transferred group. Higher comorbidity rate in patients treated at community hospitals appears to be the major determinant of the observed higher mortality rates in these patients.

Body-surface map models for early diagnosis of acute myocardial infarction

The standard 12-lead ECG is only 50% sensitive for the detection of acute myocardial infarction (AMI). The majority of leads for optimal classification of AMI probably lie outside the area covered by the 6 precordial leads. Thus, body-surface mapping (BSM) may be more helpful, as a larger thoracic area is sampled. We recorded 64-lead anterior BSMs in 635 patients with chest pain suggestive of AMI and abnormal electrocardiograms (ECGs), and 125 controls without chest pain. Of the 635 patients, 325 had AMI according to World Health Organization (WHO) criteria (203 presenting with ST segment elevation, and 122 with nondiagnostic ECG), and 310 had an "abnormal ECG but not AMI." QRS and ST-T isointegrals and variables describing map shape were derived. Subjects were randomly allocated to a training set (63 controls, 321 patients) and a validation set (62 controls, 314 patients). Multiple logistic regression was used in the training set to identify which variables gave best discrimination between groups. A model with these variables was then tested prospectively in the validation set. In stage 1 (all subjects), controls were compared with patients. In the training set, a model containing 21 variables classified 58/63 controls (specificity 92%) and 316/321 patients (sensitivity 98%). In the validation set, the model classified 48/62 controls (specificity 77.4%) and 302/314 patients (sensitivity 96%). In stage 2 (studying patients only), patients with AMI were compared with patients who had an abnormal ECG-not AMI. In the training set, a model containing 28 variables classified 132/165 patients (sensitivity 80%) with AMI and 134/156 patients (specificity 86%) with an abnormal ECG-not AMI. In the validation set, the model classified 123/160 patients (sensitivity 77%) with AMI and 131/154 patients (specificity 85%) with an abnormal ECG-not AMI. Combining results of both stages in a two-step algorithm gave an overall classification in the training set of controls 92%, abnormal ECG-not AMI 84%, AMI 80%, and in the validation set of controls 77%, abnormal ECG-not AMI 82%, AMI 74%. Thus, in conclusion, when compared with the 12-lead ECG, BSM models results in higher sensitivity and specificity for detection of AMI, particularly in patients presenting with chest pain and nondiagnostic ECG changes. The use of BSM models in such patients, may lead to the earlier detection of AMI and appropriate administration of fibrinolytic therapy and/or anti-platelet agents.

Acute stroke: delays to presentation and emergency department evaluation

STUDY OBJECTIVE

To document prehospital and inhospital time intervals from stroke onset to emergency department evaluation and to identify factors associated with presentation to the ED within 3 hours of symptom onset, the current time window for thrombolytic therapy.

METHODS

Patients admitted through the ED with a diagnosis of stroke were identified through admitting logs. Time intervals were obtained from EMS runsheets and ED records. Information regarding first medical contact, education, and income was obtained by patient interview. Baseline variables were analyzed to assess association with ED arrival within 3 hours of symptom onset; variables significant on univariate analysis were placed in a multivariable model.

RESULTS

There were 151 stroke patients (59% white and 41% black). Time of stroke onset and time to ED arrival were documented for 119 patients (79%). The median time from stroke onset to ED arrival was 5.7 hours; 46 patients (30%) presenting within 3 hours. Of those with times recorded, the median time from stroke onset to EMS arrival was 1.7 hours. Multivariable logistic regression identified use of EMS (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3 to 12.1) and white race (OR, 3.5; 95% CI, 1.3 to 10) as being independently associated with ED arrival within 3 hours of symptom onset. Median time from ED arrival to physician evaluation was 20 minutes. Median time from ED arrival to computed tomographic evaluation was 72 minutes. When patients were asked the main reason they sought medical attention, 40% (60/141) of those able to be interviewed said that they themselves did not decide to seek medical attention, but rather a friend or family member told them they should go to the hospital.

CONCLUSION

The median time from stroke onset to ED evaluation was 5.7 hours, with almost a third of patients presenting within 3 hours. Use of EMS and white race were independently associated with arrival within 3 hours.

Emergency management of acute myocardial infarction. Focus on pharmacologic therapy

Treatment of acute myocardial infarction has evolved significantly in the past two decades. Reperfusion therapies of thrombolysis and percutaneous angioplasty are major advances that can be employed to save infarcting myocardium and reduce mortality. When reperfusion therapy is combined with the use of aspirin, beta-blockade, heparin, and nitroglycerin, the emergency management of the patient with myocardial infarction can be completed. Outcomes in patients are determined by what happens in the first few minutes to hours after onset, and any delay in diagnosis or treatment may have significant consequences. This article reviews intervention and treatment strategies for acute myocardial infarction.

Assessment of chest pain onset and out-of-hospital delay using standardized interview questions: the REACT Pilot Study. Rapid Early Action for Coronary Treatment (REACT) Study Group

OBJECTIVE

To determine the consistency of responses to a standardized 2-part "key" question (Key-Q) about acute symptom onset in patients presenting with chest pain when measured using alternative questions (Qs) about symptom perception and decisions to seek treatment.

METHODS

A structured patient interview was performed at 3 university teaching hospitals and 1 community hospital. Convenience samples of adult patients presenting to these EDs with chest pain were asked specific questions related to their symptoms and recognition of illness. Information obtained included the 2-part Key-Q: "What are the symptoms that brought you here today?" and "When did those symptoms start?" The alternative Qs (in order of use) were as follows: Q1 = "When did your very first symptom or sensation begin?"; Q2 = "When did your symptoms lead you to think something was wrong or that you were ill?"; Q3 = "When did your symptoms become serious enough for you to seek medical care?"; and Q4 = "When did you actually call 9-1-1/emergency medical services (EMS) or go to the hospital?" The documented ED arrival time, demographic variables, and whether the patient arrived by ambulance were obtained from the medical record. Patients also were queried regarding potential barriers to seeking medical care and their cardiac risk factors.

RESULTS

Of the 135 patients surveyed, 9 were unsure of the date and time of symptom onset. For the 126 patients with analyzable data, the mean (+/- SD) patient age was 62 +/- 16 years, and 59% were male. The general sequence of events reported from acute symptom onset until hospital care was Q1/Key-Q-->Q2-->Q3-->Q4-->ED arrival. The median differences and interquartile ranges (IQRs) in minutes between Q times and the Key-Q response were: Q1 = 0 (0-0); Q2 = 30 (0-210); Q3 = 140 (30-720); Q4 = 265 (90-1,215); and ED arrival = 340 (120-1,230). The interval from the Key-Q response until calling 9-1-1/EMS or going to the hospital was shorter for those who used an ambulance and for those who did not consult a physician first. The interval from the Key-Q response until considering symptoms to be serious was shorter for those with a family history of heart disease, but longer for non-white patients.

CONCLUSION

The Key-Q elicited a response recalled near the time of first symptoms and generally before the patient had concluded something was "wrong or that he or she was ill." Measurement of the out-of-hospital delay in chest pain patients using the Key-Q appears promising.

Group psychotherapy for patients with coronary heart disease

Group therapy with cardiac patients is a relatively new specialty. The field is supported by a substantial epidemiological and experimental literature demonstrating links between heart and mind. There are several clinical trials that have demonstrated less morbidity, improved quality of life, and, to some extent, lower mortality for patients who have received psychosocial intervention, generally group therapy, compared to control patients. Different theoretical orientations and a small number of clinical techniques have been developed to help cardiac patients make an adjustment to heart-healthy living. This article provides a brief review of the literature in cardiac psychology, suggestions for developing a psychotherapy practice specialty with cardiac patients, techniques for treating these patients, and conclusions by a psychologist-cardiologist team that has been active in this area for more than a decade.

[Analysis of causes of excessive prehospital delay of patients with acute myocardial infarction in the province of Teruel]

BACKGROUND

To analyze the delay of patients who come to the hospital and are diagnosed with acute myocardial infarction, its causes and the variables with determine it.

PATIENTS, MATERIAL AND METHODS

Prospective study of 115 patients (79 male and 36 female). The pre-hospital delay time was measured as the time which passed from the moment when the patient feels the first symptoms "chest pain", until his arrival and registration at the Emergency Service. This time was divided into three subdivisions: decision time, medical time and transport time. We determined: place of origin, indications and means of transport used to reach the hospital, diagnosis and treatment given by the general practitioner before arrival at the hospital, the cardiovascular risk factors, location of patients pain, the time of day and the delay at the Emergency Service.

RESULTS

The mean pre-hospital delay was 364 +/- 534 min (median of 195 min). Most of the patients (73.7%) came to hospital during the first six hours. The major part of total delay corresponded to the decision delay (202 +/- 363 min with a median of 75), which occupied 50.1% of the whole (confidence interval 95% [CI 95%], 44.6-55.6%), while the transport time occupied 34.6% (CI 95%, of 30.1-39%) with a median of 50 min. Major pre-hospital delay corresponded to the patients coming from rural areas (p = 0.007), to those asked for medical assistance (p = 0.0029), to diabetics (p = 0.01) and to those who felt the pain during their night sleep (p = 0.0023). Transport time was negatively influenced by old age (p = 0.0012), rural origin (p = 0.0001), the appearance of the night sleep pain (p = 0.031) and calling the general practitioner for first aid (p = 0.0001), but it was not influenced by the form of transport used to get to the hospital. The intra-hospital delay time had an median of 60 min, being longer for older people (p = 0.007), for patients with hypertension (p = 0.014) and those who were admitted from the Intensive Care Unit (p = 0.0001).

CONCLUSIONS

The pre-hospital delay detected in our environment is longer than other studies and confirms that half of it is not due to the intrinsic functioning of our health system, even through it should get involved as much as possible to diminish the delay time.

Responding to symptoms and signs of acute myocardial infarction--how do you educate the public?: a social-psychologic approach to intervention

In an era of highly time-dependent therapies for acute myocardial infarction-namely thrombolytic therapy and cardiopulmonary resuscitation-it is imperative that public education programs facilitate expeditious care-seeking. However, community intervention studies to reduce the interval of time-from the onset of an acute myocardial infarction to arrival at a hospital emergency department-have shown ambiguous results. To understand and reduce this time interval, a theoretic model is proposed that draws from self-regulation theory. The combined model focuses on three issues: first, information for systematic sign-and-symptom recognition and labeling; second, behavioral information as to what to do in the event of an acute myocardial infarction; and third, information on how to control affective and emotional responses that may interfere with effective coping. Seven recommendations are made for guiding community intervention with use of the proposed model.

An evaluation of the results of media and educational campaigns designed to shorten the time taken by patients with acute myocardial infarction to decide to go to hospital

OBJECTIVE

To describe the benefits and pitfalls of educational campaigns designed to reduce the delay between the onset of acute myocardial infarction (AMI) and its treatment.

METHODS

All seven educational campaigns reported between 1982 and 1994 were evaluated.

RESULTS

The impact on delay time ranged from a reduction of patient decision time by 35% to no reduction. One study reported a sustained reduction that resulted in the delay time being halved during the three years after the campaign. The use of ambulances did not increase. Only one study reported that survival was unaffected. There was a temporary increase in the numbers of patients admitted to the emergency department with non-cardiac chest pain in the initial phase of educational campaigns.

CONCLUSION

The challenge of shortening the delay between the onset of infarction and the start of treatment remains. The campaigns so far have not been proved to be worthwhile and it is not certain that further campaigns will do better. New media campaigns should be run to establish whether a different type of message is more likely to change the behaviour of people in this life-threatening situation.

Causes of delay in seeking treatment for heart attack symptoms

With the advent of thrombolytic therapy and other coronary reperfusion strategies, rapid identification and treatment of acute myocardial infarction greatly reduces mortality. Unfortunately, many patients delay seeking medical care and miss the benefits afforded by recent advances in treatment. Studies have shown that the median time from onset of symptoms to seeking care ranges from 2 to 61/2 hours, while optimal benefit is derived during the first hour from symptom onset. The phenomenon of delay by AMI patients and those around them needs to be understood prior to the design of education and counseling strategies to reduce delay. In this article the literature is reviewed and variables that increase patient delay are identified. A theoretical model based on the health belief model, a self regulation model of illness cognition, and interactionist role theory is proposed to explain the response of an individual to the signs and symptoms of acute myocardial infarction. Finally, recommendations are made for future research.

"Brain attack": the rationale for treating stroke as a medical emergency

Stroke is the third leading cause of death in the United States, behind only heart disease and cancer. With an estimated three million survivors of stroke in the United States, the cost to society, both directly in health care and indirectly in lost income, is staggering. Despite recent advances in basic and clinical neurosciences, which have the potential to improve the treatment of acute stroke, the general approach to the acute stroke patient remains one of therapeutic nihilism. Most basic science studies show that to be effective, acute intervention to reperfuse ischemic tissue must take place within the first several hours, as is the case with ischemic myocardium. In addition, most neuroprotective agents must also be administered within a short time frame to be effective at salvaging at-risk tissue. Recent studies have suggested that the outcome after intracerebral and subarachnoid hemorrhage is improved with early intervention. However, most stroke patients fail to present to medical attention within this short "window of opportunity." The public's knowledge about stroke is woefully inadequate. However, clinicians who deal with stroke can use the dramatic changes in the treatment of acute myocardial infarction over the last 2 decades as a guide for shaping changes in the management of acute stroke. Comprehensive educational efforts aimed at clinicians and the public at large have dramatically reduced the time from symptom onset to presentation and treatment for acute myocardial infarction, enabling treatment methods such as thrombolysis to be effective. The Decade of the Brain offers a unique opportunity to all concerned with the treatment of the patient with acute stroke to engage in a concerted effort to bring patients with a "brain attack" to specialized neurological attention within the same timeframe that the "heart attack" patient is handled. Such an effort is justified because, although at the present time there are few therapeutic interventions of "proven" value in the treatment of acute stroke, there is more than sufficient suggestive evidence that a number of approaches may be beneficial within the first few hours after the onset of the stroke.

Comparison of delay times to hospital presentation for physicians and nonphysicians with acute myocardial infarction

To evaluate whether patients who recognize the symptoms of myocardial ischemia and have easy access to medical care have shortened time delays between onset of symptoms and hospital presentation, the total time interval between symptom onset and hospital arrival for 258 U.S. male physicians experiencing a first acute myocardial infarction (AMI) in the Physicians' Health Study (PHS) was compared with that of a comparable group of 240 men enrolled in the U.S. component of the Second International Study of Infarct Survival (ISIS-2), as well as with those of previously published series of patients with AMI. For patients presenting for medical care within 24 hours of symptom onset, the median time delay from onset of symptoms to presentation for medical care was 1.8 hours in the PHS, and 4.9 hours in the U.S. component of ISIS-2 (p less than 0.001). Furthermore, 56% of participants in the PHS presented for medical care within 2 hours and 72% within 4 hours of symptom onset compared with 20% (p less than 0.001) and 44% (p less than 0.001), respectively, for ISIS-2 participants. In previously published series, the average time to presentation was comparable to that in the ISIS-2 trial, with variation depending on country of origin and on local population density. The median time to medical presentation in any previous series was not shorter than that in the PHS. Thus, physicians in the PHS had significantly shorter time delays between onset of symptoms and presentation for medical care. This difference may help explain the far lower than expected cardiovascular mortality rates among physician participants in the PHS.(ABSTRACT TRUNCATED AT 250 WORDS)

The cardiac denial of impact scale: a brief, self-report research measure

Denial is an important aspect of recovery from cardiac trauma. It has been associated with reduced anxiety, better initial physical and psychological outcomes, decreased retention of information about the illness, and decreased treatment compliance. Although interview methods for assessing denial have been available for some time, they present both psychometric and methodological difficulties that a self-report measure could alleviate. This study provides the initial psychometric evaluation of the self-report Cardiac Denial of Impact Scale. It demonstrated adequate internal consistency as well as good criterion and discriminant validity. The availability of a self-report measure of denial can simplify its assessment in both research and treatment applications.

Eligibility for intravenous thrombolysis in suspected acute myocardial infarction

Based on the registration of all the 7,157 patients admitted during a 21-month period to the emergency ward of a single hospital in an urban area with chest pain or other symptoms suggestive of acute myocardial infarction, we studied eligibility for intravenous thrombolysis in suspected acute myocardial infarction. We have limited the present analysis to those 1,715 patients with a strong suspicion of myocardial infarction, and for these patients, we have calculated the percentages eligible for thrombolysis when various electrocardiographic and delay time criteria are applied, but we have not considered contraindications to thrombolysis. We have also calculated the proportions of all infarctions in this group that would thereby receive the treatment, and the proportions of patients treated that would develop a confirmed infarction. Using the criteria ST elevation on the initial electrocardiogram and arrival in hospital within 6 hours from onset of symptoms, 18% of patients would have been given early intravenous thrombolysis, 37% of confirmed infarctions would have been treated, and 91% of all treated patients would have developed a confirmed infarction; with a delay time criterion of 12 hours, these percentages would have been 20%, 41%, and 91%, respectively; with a criterion of 24 hours, they would have been 22%, 45%, and 90%, respectively. By not considering the initial electrocardiogram and applying only the criterion of delay time, these percentages would have been 70%, 72%, and 45%, respectively, for a delay time of 6 hours; 83%, 84%, and 45%, respectively, for a delay time of 12 hours; and 91%, 92%, and 44%, respectively, for a delay time of 24 hours.(ABSTRACT TRUNCATED AT 250 WORDS)