Causal beliefs, cardiac denial and pre-hospital delays following the onset of acute coronary syndromes

Why do women with cardiac symptoms delay seeking medical help? Insights from a qualitative study among Jewish Israeli women

BACKGROUND

The delay time from onset of symptoms of a myocardial infarction to seeking medical assistance can have life-threatening consequences. Women delay significantly more often than men do in calling for medical help, once symptoms of a myocardial infarction occur.

OBJECTIVES

The current qualitative study's main aim was to explore psychosocial factors that contribute to Israeli women's delaying calls for medical assistance and, by contrast, the motivational factors that encourage them to do so.

DESIGN

A qualitative study.

METHOD

In total, 12 women were interviewed shortly after experiencing a myocardial infarction. Qualitative data were subjected to thematic analysis.

RESULTS

Two major themes emerged describing barriers to seeking help: (1) the use of denial as a defense mechanism and (2) the need for control. The motivational factor which enhanced help-seeking was "fear of death."

CONCLUSION

These findings may help in designing gender-sensitive interventions with the aim of minimizing the symptom onset to call time and thus preventing irreversible and life-threatening health damage.

Illness Denial in Medical Disorders: A Systematic Review

INTRODUCTION

Illness denial pertains to medical patients who do not acknowledge the presence or severity of their disease or the need of treatment.

OBJECTIVE

This systematic review was performed to clarify the clinical role and manifestations of illness denial, its impact on health attitudes and behavior, as well as on short- and long-term outcomes in patients with medical disorders.

METHODS

The systematic search according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines was conducted on PubMed, Scopus, and Web of Science.

RESULTS

The initial search yielded a total of 14,098 articles; 176 studies met the criteria for inclusion. Illness denial appeared to be a relatively common condition affecting a wide spectrum of health attitudes and behavior. In some cases, it may help a person cope with various stages of illness and treatment. In other situations, it may determine delay in seeking treatment, impaired adherence, and reduced self-management, leading to adverse outcomes. The Diagnostic Criteria for Psychosomatic Research (DCPR) were found to set a useful severity threshold for the condition. An important clinical distinction can also be made based on the DCPR for illness denial, which require the assessment of whether the patient has been provided with an adequate appraisal of the medical situation.

CONCLUSIONS

This systematic review indicates that patients with medical disorders experience and express illness denial in many forms and with varying degrees of severity. The findings suggest the need for a multidimensional assessment and provide challenging insights into the management of medical disorders.

Variation in Seeking Care for Cardiovascular Disease and Ambulance Utilization among Migrants in Australia: Time, Ethnicity, and Delay (TED) Study III

Insight into differences in seeking medical care for chest pain among migrant populations is limited. This study aimed to determine ethnic differences in seeking care behaviors and using ambulances among migrants compared to an Australian-born group. A total of 607 patients presenting with chest pain to a tertiary hospital between 1 July 2012 and 30 June 2014 were randomly selected. Data from the emergency department dataset and medical record reviews were collected and linked for analysis. The migrant group was stratified into nine ethnic groups for analysis based on the Australian Standard Classification of Cultural and Ethnic Groups. The overall median prehospital delay time was 3.7 (1.5, 10.7) h, which ranged from 2.5 (1.0, 10.7) (Southern and Eastern European group) to 6.0 (2.3, 20.6) (Sub-Saharan African group). The median decision time was 2.0 (0.8, 7.9) h, which ranged from 1.5 (Australian-born group) to 4.5 h (Sub-Saharan African group). Five ethnic groups had significantly longer decision times compared to the Australian-born group. Decision time accounted for 58.4% of pre-hospital delay time. Migrant patients were 60% less likely to seek care for chest pain within one hour (odds ratio 0.40, (0.23–0.68), p = 0.001). There was no significant difference in ambulance utilization between migrant and Australian-born groups. In conclusion, ethnic differences in seeking care for chest pain do exist, and ethnicity plays a vital role in a longer delay in seeking care. To reduce the delays and improve patient outcomes, appropriate health campaigns focusing on ethnic differences among migrant populations and normalizing cultural competency into practice are recommended.

Surviving to Acute Myocardial Infarction: The Role of Psychological Factors and Alexithymia in Delayed Time to Searching Care: A Systematic Review

The time from symptom onset to reperfusion is a critical determinant of myocardial salvage and clinical outcomes in patients with acute myocardial infarction (AMI). This time period could be delayed if people do not seek help promptly and/or if the health system is not efficient in responding quickly and attending to these individuals. The aim of this study was to identify psychological factors associated with pre-hospital delay (PHD) or patients’ decisional delay (PDD) in people with an ongoing AMI. A search in PubMed/Medline from 1990 to 2021 with the keywords “pre-hospital delay” OR “prehospital delay” OR “patient delay” OR “decisional delay” OR “care seeking behavior” AND “psychological factors” OR “alexithymia” AND “myocardial infarction” was performed. Thirty-six studies were included, involving 10.389 patients. Wrong appraisal, interpretation and causal beliefs about symptoms, denial of the severity of the symptoms and high levels of alexithymia were found related to longer PHD or PDD. Alexithymia may be an overarching construct that explains the disparate findings of the studies exploring the role of psychological factors in PHD or PDD. Further studies are needed in order to analyse the role of alexithymia in patients with risk factors for AMI to prevent delay.

Impact of 2020 SARS-CoV-2 outbreak on telemedicine management of cardiovascular disease in Italy

The Covid-19 pandemic affected large part of Italy since February 2020; we, therefore, aimed to assess the impact of 2020 SARS-CoV-2 outbreak on telemedicine management of cardiovascular disease (CVD) in Italy. We analyzed data from three telemedicine dispatch centers, one located in Genoa, serving private clients (pharmacies, general practitioners), one in Brescia, serving pharmacies, and one in Bari, serving regional public STEMI network and emergency medical service in Apulia (4 million inhabitants). Demographic data and principal electrocardiogram diagnosis were collected and analyzed. Records from the time interval March 1, 2020 and April 1, 2020 were compared with the corresponding period in 2019. The comparative analysis of data shows a 54% reduction of telemedicine electrocardiogram transmission in Genoa telemedicine center (from 364 to 166), 68% in Brescia (from 5.745 to 1.905), 24% in Bari (from 15.825 to 11.716); relative reduction according to electrocardiogram diagnosis was 38% for acute coronary syndrome, 40% for other acute CVD in Genoa center, 24% for acute coronary syndrome, and 38% for other acute CVD in Bari. Male/female ratio remained substantially unchanged. A dramatic reduction of telemedicine access for CVD was observed during Covid-19 outbreak in March 2020 in Italy. The reduction was substantially consistent for all electrocardiogram findings, ACS, other acute CVD and normal.

A Systematic Review of the Instruments Used for Evaluating Causal Beliefs and Perceived Heart Risk Factors

Background: The etiologies and causal beliefs of heart disease are considered one of the 5 dimensions of health self-regulatory model. Thus, the present study aimed to review the literature and screen the appropriate tools for evaluating the causal beliefs and perceived heart risk factors (PHRFs). Methods: The review samples encompassed all published articles from 1992 to March 2017. A systematic search was conducted across 6 databases: the Web of Science, Scopus, Medline, EBSCO, ProQuest, PsycINFO, and Google Scholar. The qualitative evaluation of the articles was examined using the checklists of the Critical Appraisal Skills Programme (CASP) by 2 independent investigators. After the application of the criteria for inclusion in the study, 22 studies were obtained according to the PRISMA guidelines. Results: A total of 10 504 (50.5% male) patients at an average age of 57.85±10.75 years participated in 22 studies under review. The results of the systematic review showed that 22 tools were available to measure PHRFs. The instruments were categorized into 4 groups of valid scales (6 studies), invalid questionnaires (6 studies), checklists (3 studies), and open-ended single items (7 studies). Only 23.2% of the measuring instruments were sufficiently valid. Conclusion: The results of this systematic review showed that a limited number of valid tools were available to measure PHRFs. Considering the importance of studying cardiac patients' perception of the etiology of disease and the paucity of standards and valid grading scales, it seems necessary to design and provide tools with broader content that can cover all aspects of patients' beliefs.

Implanted Monitor Alerting to Reduce Treatment Delay in Patients With Acute Coronary Syndrome Events

BACKGROUND

Increased pre-hospital delay during acute coronary syndrome (ACS) events contributes to worse outcome.

OBJECTIVES

The purpose of this study was to assess the effectiveness of an implanted cardiac monitor with real-time alarms for abnormal ST-segment shifts to reduce pre-hospital delay during ACS events.

METHODS

In the ALERTS (AngeLmed Early Recognition and Treatment of STEMI) pivotal study, subjects at high risk for recurrent ACS events (n = 907) were randomized to control (Alarms OFF) or treatment groups for 6 months, after which alarms were activated in all subjects (Alarms ON). Emergency department (ED) visits with standard-of-care cardiac test results were independently adjudicated as true- or false-positive ACS events. Alarm-to-door (A2D) and symptom-to-door (S2D) times were calculated for true-positive ACS ED visits triggered by 3 possible prompts: alarm only, alarms + symptoms, or symptoms only.

RESULTS

The Alarms ON group showed reduced delays, with 55% (95% confidence interval [CI]: 46% to 63%) of ED visits for ACS events <2 h compared with 10% (95% CI: 2% to 27%) in the Alarms OFF group (p < 0.0001). Results were similar when restricted to myocardial infarction (MI) events. Median pre-hospital delay for MI was 12.7 h for Alarms OFF and 1.6 h in Alarms ON subjects (p < 0.0089). Median A2D delay was 1.4 h for asymptomatic MI. Median S2D delay for symptoms-only MI (no alarm) in Alarms ON was 4.3 h.

CONCLUSIONS

Intracardiac monitoring with real-time alarms for ST-segment shift that exceeds a subject's self-normative ischemia threshold level significantly reduced the proportion of pre-hospital delays >2 h for ACS events, including asymptomatic MI, compared with symptoms-only ED visits in Alarms OFF. (AngeLmed for Early Recognition and Treatment of STEMI [ALERTS]; NCT00781118).

Psychological and cognitive factors related to prehospital delay in acute coronary syndrome: A systematic review

BACKGROUND

In acute coronary syndrome the time elapsed between the start of symptoms and the moment the patient receives treatment is an important determinant of survival and subsequent recovery. However, many patients do not receive treatment as quickly as recommended, mostly due to substantial prehospital delays such as waiting to seek medical attention after symptoms have started.

OBJECTIVE

To conduct a systematic review with meta-analysis of the relationship between nine frequently investigated psychological and cognitive factors and prehospital delay.

DESIGN

A protocol was preregistered in PROSPERO [CRD42018094198] and a systematic review was conducted following PRISMA guidelines.

DATA SOURCES

The following databases were searched for quantitative articles published between 1997 and 2019: Medline (PubMed), Web of Science, Scopus, Psych Info, PAIS, and Open grey.

REVIEW METHODS

Study risk of bias was assessed with the NIH Quality Assessment Tool for Observational, Cohort, and Cross-Sectional Studies. A best evidence synthesis was performed to summarize the findings of the included studies.

RESULTS

Forty-eight articles, reporting on 57 studies from 23 countries met the inclusion criteria. Studies used very diverse definitions of prehospital delay and analytical practices, which precluded meta-analysis. The best evidence synthesis indicated that there was evidence that patients who attributed their symptoms to a cardiac event (n = 37), perceived symptoms as serious (n = 24), or felt anxiety in response to symptoms (n = 15) reported shorter prehospital delay, with effect sizes indicating important clinical differences (e.g., 1.5-2 h shorter prehospital delay). In contrast, there was limited evidence for a relationship between prehospital delay and knowledge of symptoms (n = 18), concern for troubling others (n = 18), fear (n = 17), or embarrassment in asking for help (n = 14).

CONCLUSIONS

The current review shows that symptom attribution to cardiac events and some degree of perceived threat are fundamental to speed up help-seeking. In contrast, social concerns and barriers in seeking medical attention (embarrassment or concern for troubling others) may not be as important as initially thought. The current review also shows that the use of very diverse methodological practices strongly limits the integration of evidence into meaningful recommendations. We conclude that there is urgent need for common guidelines for prehospital delay study design and reporting.

Medical technology in rehabilitational counseling from the “Electronic Healthcare” perspective

Aim.To evaluate the readiness of acute coronary syndrome patients to distant physical rehabilitation (DPR) during the office rehabilitational counseling (ORC).

Material and methods.Open retrospective study included data of 148 patients (117 males, 31 female), who had participated in ORC with the aim to include to DPR. Main part of ORC was conducted in the format of physician work with a computerized algorithm. Completeness of data to form the programs of physical rehabilitation (PR) was assessed manually with reviewing of the discharge summaries. Clinical status was assessed, and if necessary, the 6 minute walking test was conducted. Motivational component was assessed by the results of questionnaire “Program of calculation of motivational readiness of patients to adhere clinician recommendations”. Cognition was assessed with MMSE.

Results.The part of “electronic” discharge summaries was 88,5%. Analysis of availability of epicrise data for algorithm modules showed that only 134 patients (97,3%) had complete data in clinical diagnosis. Also, an insufficiency was shown for number of stress tests with ECG registration: 22 (14,9%), but 96 (64,9%) with 6-minute test. In 30 patients (20,2%) the data on exercise tests was lacking. Data on PR regimen and related assessment of individual exercise tolerance was found in 34 (23% of ORC); and all who passed in-hospital stage. To the program of DPR about 1/3 (31,1%) of ORC participants were included. Under the framework of ORC, PR programs were created for all patients. By the results of investigation, a generalized clinical and instrumental characteristics of DPR patients were formulated, with added motivational and psychological specificities.

Conclusion.It is found that in every 5th myocardial infarction patient discharged from hospital, there is lack of data on individual PR parameters that significantly reduces the ability of primary care physician in prescription and implementation of PR events. Usage of eHealth instruments at outpatient stage of cardiorehabilitation make it to solve these issues of ORC, which has as its tasks the PR programs formulation and evaluation of patient readiness for ORC participation.

One in four major ischaemic heart disease events are fatal and 60% are pre-hospital deaths: a national data-linkage study (ANZACS-QI 8)

Aims

The aim of this study is to determine proportions of major ischaemic heart disease (IHD) events that are fatal and where they occur, in an era of rapidly falling IHD mortality.

Methods and Results

Individual person linkage of national data sets identified all IHD hospitalizations and deaths in New Zealand from December 2008 to November 2010. Outcome measures were proportions of people: (i) hospitalized with IHD and alive at 28 days; (ii) hospitalized with IHD and died within 28 days; (iii) hospitalized for a non-IHD cause and died from IHD within 28 days; and (iv) not hospitalized and died from IHD. Three event definitions were used [broad-balanced: IHD deaths and IHD hospitalizations, unbalanced: IHD deaths and myocardial infarction (MI) hospitalizations, and narrow-balanced: MI deaths and MI hospitalizations]. About 37 867 IHD hospitalizations and 9409 IHD deaths were identified using the broad IHD definition. Approximately one-quarter of IHD events were fatal: 4% were deaths within 28 days of an IHD hospitalization, 6% were IHD deaths within 28 days of a non-IHD hospitalization, and 14% were non-hospitalized IHD deaths. Using different event definitions, overall case fatality varied from 24–25% (broad and narrow balanced) to 37–39% (unbalanced), whereas the proportion of all deaths that were non-hospitalized was approximately 60%. Forty per cent of deaths were first-ever events that manifested as non-hospitalized IHD deaths.

Conclusion

About one-quarter of IHD are fatal, although the proportion is dependent on disease definitions and age. About 60% of all IHD deaths occur out of hospital, and of these 60% are in people not previously hospitalized for IHD.

Denial of a sleep deprivation message: situational and dispositional influences on message rejection

Two studies investigated situational and dispositional influences on rejection of a sleep deprivation warning message for young adults. The hassle of protection (Study 1) and the self-relevance of the problem (Study 2) were manipulated; the disposition to use denial (threat orientation) for warning messages was measured. In both studies, it was found that both dispositional denial and the situational manipulation (more protection-hassle or self-relevance) showed at least one denial effect by reducing perceived susceptibility, perceived severity, or credibility. Indirect (mediational) effects were tested with the bootstrap method. In Study 1, judgments of credibility and severity mediated the effects of the hassle manipulation and denial orientation on message outcomes. In Study 2, credibility mediated the effects of the self-relevance manipulation and denial orientation on message outcomes of intentions to change and priority given to sleep. These studies show that both situational and dispositional sources of denial work in similar ways by lowering key message judgments and that the lower judgments lead to less priority given to a health risk and lower intentions to protect oneself.

The prevalence of medication nonadherence in post-myocardial infarction survivors and its perceived barriers and psychological correlates: a cross-sectional study in a cardiac health facility in Malaysia

BACKGROUND

Although evidence-based practice has shown the benefits of prescribed cardioprotective drugs in post-myocardial infarction (MI) survivors, adherence rates remain suboptimal. The aim of this study was to determine the prevalence and factors associated with medication nonadherence among post-MI survivors in Malaysia.

MATERIALS AND METHODS

This cross-sectional study was conducted from February to September 2016 among 242 post-MI survivors aged 24-96 years at the cardiology outpatient clinic in a Malaysian cardiac specialist center. The study utilized an interviewer-administered questionnaire that consisted of items adapted and modified from the validated Simplified Medication Adherence Questionnaire, sociodemographics, health factors, perceived barriers, and novel psychological attributes, which employed the modified Confusion, Hubbub, and Order Scale and the Verbal Denial in Myocardial Infarction questionnaire.

RESULTS

The prevalence of medication nonadherence was 74%. In the multivariable model, denial of illness (AOR 1.2, 95% CI 0.9-1.8; P=0.032), preference to traditional medicine (AOR 8.7, 95% CI 1.1-31.7; P=0.044), lack of information about illness (AOR 3.3, 95% CI 1.1-10.6; P=0.045), fear of side effects (AOR 6.4, 95% CI 2.5-16.6; P<0.001), and complex regimen (AOR 5.2, 95% CI 1.9-14.2; P=0.001) were statistically significant variables associated with medication nonadherence.

CONCLUSION

The relatively higher medication-nonadherence rate in this study was associated with patient-, provider-, and therapy-related factors and the novel psychological attribute denial of illness. Future research should explore these factors using robust methodological techniques to determine temporality among these factors.

Is denial a maladaptive coping mechanism which prolongs pre-hospital delay in patients with ST-segment elevation myocardial infarction?

OBJECTIVE

During an acute myocardial infarction, patients often use denial as a coping mechanism which may provide positive mood regulating effects but may also prolong prehospital delay time (PHD). However, empirical evidences are still sparse.

METHODS

This cross-sectional study included 533 ST-elevated myocardial infarction (STEMI) patients from the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Data on sociodemographic, clinical and psycho-behavioral characteristics were collected at bedside. The outcome was assessed using the Cardiac Denial of Impact Scale (CDIS) with the median split as cutoff point. A total of 206 (41.8%) STEMI patients were thus classified as deniers.

RESULTS

Deniers were less likely to suffer from major depression (p=0.04), anxiety (p=0.01) and suboptimal well-being (p=0.01) compared to non-deniers during the last six months prior to STEMI. During STEMI, they were less likely to perceive severe pain strength (p=0.04) and racing heart (p=0.02). Male deniers were also less likely to perceive shortness of breath (p=0.03) and vomiting (p=0.01). Denial was not associated with overall delay time. However, in the time window of 3 to 24h, denial accounted for roughly 40min extra delay (356 vs. 316.5min p=0.02 n=196).

CONCLUSIONS

Denial not only contributes to less suffering from acute heart related symptoms and negative affectivity but also leads to a clinically significant delay in the prevalent group.

Cardiac Denial and Psychological Predictors of Cardiac Care Adherence in Adults With Congenital Heart Disease

The current study examined cardiac denial and psychological predictors (i.e., depression, anxiety) of health outcomes including medical nonadherence and physical health in a sample of 80 adults with congenital heart disease (ACHD). Results indicated that denial of impact was elevated in this patient group compared with reference groups, and denial was negatively associated with depression and anxiety at ps < .01. Results indicated that depression, anxiety, and denial predicted unique variance in medical nonadherence, and gender moderated the relationships between these psychological factors and nonadherence. For depression, men and women showed similar relationships between depression and nonadherence at high levels of depression; however, at low levels of depression (i.e., a more normal mood state), men were less adherent compared with women. For anxiety, men and women did not differ in adherence at low levels of anxiety; however, men experiencing high anxiety were less adherent compared with women experiencing high anxiety. Implications of this study are discussed including the role of gender and denial and the impact of denial functioning to reduce negative affect. Depression was the only significant predictor of physical functioning. Results of this study suggest that psychological interventions aimed at depression and anxiety may function differently across gender to improve patient medical adherence and improve physical functioning in ACHD.

Psychological coping and recurrent major adverse cardiac events following acute coronary syndrome

BACKGROUND

Depressed mood and stress are associated with recurrent adverse outcomes following acute coronary syndrome (ACS), but the impact of psychological coping style has not been evaluated in detail.

AIMS

We tested the relationship between task-oriented coping and event-free survival following ACS.

METHOD

We followed 158 patients with ACS for an average of 59.8 months for major adverse cardiac outcomes. Psychological coping was assessed with the Coping Inventory of Stressful Situations.

RESULTS

Compared with patients in the lower half of the distribution, those reporting higher task-oriented coping had a reduced hazard of adverse cardiac events (hazard ratio (HR) = 0.28, 95% CI 0.11-0.68, P = 0.005) independently of demographic, clinical and behavioural covariates. The combination of low task-oriented coping and high depressive symptoms showed a strong association with adverse outcomes (HR = 6.25, 95% CI 1.88-20.82, P = 0.003).

CONCLUSIONS

The tendency to cope using task-oriented strategies may promote event-free survival following ACS.

Differences in the treatment and evolution of acute coronary syndromes according to gender: what are the causes?

AIMS AND OBJECTIVES

The objectives of this study were to analyse the differences in the treatment and the evolution of acute coronary syndromes according to the gender of the patient and to determine the likely causes of these differences.

BACKGROUND

Epidemiological studies confirm the differences in the course and treatment of acute coronary syndromes according to factors such as gender and age. The factors associated with the observed gender-based differences are not known.

DESIGN AND METHODS

This prospective study was conducted on 596 patients treated in the Hospital Emergency Service of the Hospital Complex of Navarra, Spain, from 1 January 2012 to April 2013 with acute coronary syndromes. A bivariate and logistic analysis has been made by adjusting the age and severity of process to know the differences by gender.

RESULTS

A total of 71·8% (n = 428) were men, and the remaining 28·2% (168) were women. The mean age of the men was 66·4 ± 12·7 years, and the mean age of the women was 72·5 ± 13·9 years. We found that antiplatelet drugs (68·4 vs. 22·7%), blockers (70 vs. 25·4%), ACE inhibitors (56·2 vs. 15·6%), fibrinolysis (17·2 vs. 4·5%, p = 0·025) and primary angioplasty (AP) (38·7 vs. 16·3%, p = 0·008) were less frequently administered to women compared with men. We observed an additional delay in the demand for health care in women with acute coronary syndromes compared with men.

CONCLUSIONS

There is an association between treatment differences and gender. The delay in the request of health care in women is observed to be the largest correlating factor, in addition to voluntary discharge in women affected by acute coronary syndromes.

RELEVANCE TO CLINICAL PRACTICE

Delays in seeking medical care or voluntary discharge are likely factors related to worse outcomes in women. These factors should be explored, and the results should be made available to the public, particularly to women.

Factors associated with longer delays in reperfusion in ST-segment elevation myocardial infarction

Background/objectives

The goal of this paper is to identify the predictors of delay in total ischemia time that would be the focus of improvement efforts in patients with ST-segment elevation myocardial infarction.

Methods

Data was collected retrospectively through the patient's clinical records and by direct telephone interview.

Total ischemic time was categorized in two classes according to the elapsed time since symptom presentation until restored flow, less than 6 h and 6 h or less. Logistic regression analysis was applied to evaluate the relationship between total ischemic time and a set of variables. Discrimination ability of the model was also assessed, as well as sensitivity and specificity, through ROC curves.

Results

Data from 128 patients, 74.22% males and 25.78% females, were analyzed. The average age was approximately 62 years (± 13.6).

Six variables associated with total ischemia were selected in the final model: the patient age, the level of pain intensity, the region of origin, the socioeconomic status, the activity that the patient was performing at the time of symptoms onset, and the fact that the patient has been transferred from another hospital.

Conclusion

The identification of variables associated with the total ischemia time allows the recognition of patients with possibility of worse prognosis, for which should be directed educational efforts and also the identification of variables that can be modified to optimize the therapy.

Use of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n=83) were compared to self-transported patients (n=226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB >90 minutes. A higher percentage of EMS-transported patients reached the time goal of DTB <90 minutes compared to self-transported patients (83.1 versus 54.3%; p<0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p<0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p<0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9-4.7) versus 4.3 (2.6-9.1); p<0.001]. Independent correlates of DTB times >90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p<0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p<0.001). Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature

BACKGROUND

Patients' treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research.

METHODS AND RESULTS

We reviewed the English-language literature from 1998-2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing.

CONCLUSION

We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.

Cognitive and emotional factors affecting avoidable decision-making delay in acute myocardial infarction male adults

BACKGROUND

To study the potentially avoidable decision-making delay in acute myocardial infarction (AMI) adults male with different psychological characteristics a nationwide multicentre study was conducted in Italy by the 118 Coronary Care Units (CCUs).

METHOD

929 AMI patients consecutively presented to the CCU in a conscious condition less than two hours, 2-6 hours, 6-12 hours, and more than 12 hours after symptom onset and completing the Disease Distress Questionnaire (DDQ) were enrolled in a multicentre case-control study. The DDQ collects information regarding the decision time to seek help, and includes a set of items assessing psychological factors and pain-related symptoms. The relationship between the perceived threat and the delay due to decision-making was evaluated by means of a multivariate model using LISREL 8 structural equation modelling.

RESULTS

The delay significantly correlated with perceived threat, which was mainly related to somatic awareness. It was only slightly related to pain and was not associated with any of the other variables. Perceived threat was also related to psychological upset, fear and health worries, the first of which was considerably influenced by emotional instability.

CONCLUSION

Somatic awareness is the main dimension affecting perceived threat, but subjective pain intensity affects the delay both directly and indirectly. The core of the model is the relationship between perceived threat and the delay due to decision-making. The importance of subjective pain intensity is well documented, but it is still not clear how subjective and objective pain interact.

A review of interventions aimed at reducing pre-hospital delay time in acute coronary syndrome: what has worked and why?

BACKGROUND

Delay in seeking treatment for acute coronary syndrome (ACS) symptoms is a well recognised problem. While the factors that influence pre-hospital delay have been well researched, to date this information alone has been insufficient in altering delay behaviour.

AIM

This paper reports the results of a critical appraisal of previously tested interventions designed to reduce pre-hospital delay in seeking treatment for ACS symptoms.

METHODS

The search was confined to interventions published between 1986 and the present that were written in English and aimed at reducing pre-hospital delay time. The following databases were searched using keywords: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pubmed, Academic Search Premier, Ovid, Cochrane, British Nursing Index, and Google Scholar. A total of eight intervention studies were identified as relevant. This review was developed following a systematic comparative analysis of those eight studies.

RESULTS

Seven of the eight interventions were based on mass media campaigns. One campaign was targeted at individuals. All were aimed at raising ACS symptom awareness and/or increasing prompt action in the presence of symptoms. Only two studies reported a statistically significant reduction in pre-hospital delay time.

CONCLUSION

In response to concerns about prolonged pre-hospital delay time in ACS, interventions targeting the problem have been developed. The literature indicates that responses to symptoms depend on a variety of factors. In light of this, interventions should include the scope of factors that can potentially influence pre-hospital delay time and ideally target those who are at greatest risk of an ACS event.

Acute coronary syndrome: factors affecting time to arrival in a diverse urban setting

This study seeks to better understand how individuals of different cultural/ethnic backgrounds in an urban setting assess the signs and symptoms of Acute Coronary Syndrome (ACS) and the ensuing decision to take urgent action. Few studies exist which examine these differences and enhance understanding of how to address these differences and, ultimately, reduce morbidity and mortality from ACS. Face-to-face interviews were conducted with a convenience sample of urban patients of different cultural and socioeconomic backgrounds regarding their actions upon recognition of ACS signs and symptoms. Patients (423) with presumed or diagnosed ACS were interviewed within 12 h of arrival at the urban emergency rooms. Among the different cultural groups, Haitians delayed the longest (median) from symptom onset to hospital arrival (8.24 h), followed by Caribbeans (7.83 h), African Americans (6.62 h) and Hispanics (6.00 h). Although these delay intervals were not statistically significant across groups, each racial/ethnic group sought care well beyond the recommended time period of 3 h after initial recognition of ACS signs and symptoms. Among all the cultural groups, the two key factors motivating early arrival were being employed and taking positive actions. ACS symptom perception by different cultural groups appears to play an important role in the decision to seek emergency treatment. This is an area that has not been widely studied among or within different cultural/ethnic groups. As such, further research is needed to delineate these concepts and actions and to provide opportunities for appropriate education.

Avoidance Denial Versus Optimistic Denial in Reaction to the Threat of Future Cardiovascular Disease

Two distinctly different denial-based threat orientations (avoidance denial and optimistic denial) were examined using a message about the future risk of cardiovascular disease (CVD) for young adults. Participants ( N = 101) completed measures of denial-based dispositional threat orientations, current eating, comparative risk, and objective risk for CVD. They then read a high-threat message about CVD and rated their reactions of threat, denial, and worry. One month later, eating patterns in the past month were assessed. Both types of dispositional denial processes were associated with more self-distancing denial, but showed distinctly different, sometimes opposite, patterns of relationships with perceptions of threat, worry, and optimistic self-risk for CVD. In addition, the two denial-based processes were driven by different factors. The implications of these two denial-based threat orientations for the development of theory on denial and health messages, as well as the design of messages to change behavior, are discussed.

Awareness of heart attack symptoms among US adults in 2007, and changes in awareness from 2001 to 2007

OBJECTIVE

Timely access to emergency care, prompt receipt of advanced treatment and survival from heart attack is dependent on both the early recognition of heart attack symptoms, by both victims and bystanders, and by immediately calling the emergency services. The objective of this study is to measure the awareness of heart attack symptoms and the emergency response among US adults.

METHOD

We analyzed data from the Behavioral Risk Factor Surveillance System's module on heart attack and stroke, which was conducted in 17 states/territories in 2001 and 12 states/territories in 2007. The module included five questions related to heart attack symptoms, one decoy question and one question regarding the first action to take if someone is having a heart attack. Age-adjusted prevalence of awareness was estimated, and odds ratios were calculated. Differences between 2001 and 2007 were assessed for five states that used the module in both years.

RESULTS

In 2007, among 76,864 adults, awareness of individual heart attack symptoms ranged from 49% (pain in jaw, neck or back) to 92% (chest pain). Although 97% of adults recognized at least one symptom, only 10.7% recognized all five symptoms, knew that 'sudden trouble seeing in one or both eyes' was not a symptom of heart attack and recognized the need to call the emergency services. This estimate varied significantly by age, sex, race/ethnicity and level of education. The estimate was significantly higher for women (12.2%) than men (7.7%), White (11.6%) than Black (5.7%) or Hispanic people (4.5%), those with a higher level of education (13.5%) than lower educational level (4.5%) and for those with coronary heart disease (16.2%) than without the disease (9.5%). Comparison of awareness between 2001 (the referent) and 2007, in five states, revealed that awareness of all symptoms and calling the emergency services, were 9.7 and 10.3% for 2001 and 2007, respectively (p < 0.01). Compared to 2001, the odds ratio of awareness in 2007 was 1.08 (95% CI: 0.99-1.19) after controlling for socioeconomic and clinical characteristics.

CONCLUSION

Awareness of all heart attack symptoms among adults in 12 states was low and little improvement was observed between 2001 and 2007. Accordingly, both clinicians and public health officials should seek ways in order to increase public awareness of the symptoms of heart attack. Special efforts should be focused on men, Black and Hispanic people and those with only modest levels of education.

Causal attributions among patients undergoing coronary artery bypass surgery: gender aspects and relation to depressive symptomatology

Causal attributions made by patients for their coronary heart disease may contribute to gender differences in emotional adjustment. The purpose of this study was to determine gender differences in causal attributions and to analyze the associations between causal attributions and depressive symptomatology in patients undergoing coronary artery bypass graft (CABG) surgery. Nine hundred and seventy-nine patients (mean age 66.8 years, 19.9% women) completed a modified version of the Illness Perception Questionnaire (IPQ) and the depression module of the Patient Health Questionnaire (PHQ-9) 1-3 days before CABG-surgery and 1 year after surgery. Men were more likely to name their health behavior (men: 40.2%, women: 26.9%, P < .001) as a cause of disease, whereas women were more likely to cite destiny (women: 34.7%, men: 25.7%, P = .012). Regression analyses showed cross-sectional and longitudinal associations of attributions with depressive symptomatology which were independent of gender, sociodemographic and clinical variables. Attribution to personality and stress were associated with an increase in depressive symptomatology. Causal attributions may present a valuable approach for identifying patients at risk for depression and the implementation of targeted interventions.

Time to treatment for acute coronary syndromes: the cost of indecision

BACKGROUND AND RESEARCH OBJECTIVES

: Multiple sociodemographic and environmental factors have been associated with urgent treatment-seeking behaviors for patients experiencing acute coronary syndromes (ACSs). However, variables that directly affect the decision to seek care in the emergency department (ED) have been less well defined. The objective of this study was to explore the factors associated with a decision to seek care for symptoms of ACSs and to describe patient characteristics associated with time to presentation.

SUBJECTS AND METHODS

: A cross-sectional, descriptive design was used. The nonprobability sample included 256 patients admitted to the hospital with ACSs. The study was conducted on cardiac step-down units at 2 large urban medical centers. Reasons for seeking care were elicited during structured interviews in the patient's room. These factors and other patient characteristics were treated as predictor variables in an analysis of time from symptom onset to arrival in the ED.

RESULTS AND CONCLUSIONS

: Five categories of decision making were identified through descriptive content analyses and were labeled new onset of chest pain, ongoing evaluation of symptom severity, symptoms other than chest pain that worsened or were unrelieved, externally motivated, and internally motivated. Median time from symptom onset to arrival in the ED was 9.5 hours for women and 6 hours for men. Patients who experienced constant pain (hazard ratio, 1.44; P =.01) and those with ST-segment elevation myocardial infarction (hazard ratio, 1.59; P = .004) sought treatment significantly sooner than patients with intermittent pain. Older patients sought treatment later (hazard ratio, 0.99; P = .02). Patients who are older and experience intermittent pain should be encouraged to seek emergent treatment for symptoms that may represent ACSs. New evidence of patients' decision-making processes and dangerous delay in time to treatment provides knowledge needed to counsel patients about the benefits of seeking care quickly when symptoms begin.