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

Gender disparities in the mediating role of symptom knowledge level in reducing acute coronary syndrome (ACS) decision delay: Findings from a community-based study in China

BACKGROUND

Implementing training programs to educate patients on the prodromal symptoms of acute coronary syndrome (ACS) may assist patients in accurately recognizing these symptoms, and ultimately decrease their time delay in seeking emergency medical services (EMS). However, the effectiveness of this approach remains uncertain, particularly among the Chinese population.

METHODS

A cross-sectional study was conducted within 22 communities in Beijing, China between 2015 and 2018, with a total of 1099 participants recruited. The study utilized a standardized questionnaire to evaluate the presence of intentional decision delay in turning to EMS under a hypothetical chest pain, the participants' knowledge of ACS prodromal symptoms, and whether they had ever received any training programs aimed at increasing their symptom knowledge. Mediation analysis was performed with regression models and bootstrapping methods, and gender difference was further analyzed through moderated mediation analysis.

RESULTS

A total of 1099 participants (58.2% female, median [IQR] age 34 [20]) were included in the study. The results of the mediation analysis indicated that training programs were associated with a decrease risk in decision delay, with increased knowledge playing a mediating role (mediation effect/total effect = 36.59%, P < 0.0001). Gender modified this mediation effect, with it being observed only in the male group. Specifically, training programs were not found to significantly decrease decision delay among females (P > 0.05), even though they did improve women's knowledge of ACS prodromal symptoms (β = 0.57, P = 0.012).

CONCLUSION

The results suggested a relationship between prior training programs and reduced decision delay, with increased knowledge of prodromal symptoms of ACS serving as a mediator. However, the effect was only observed in male participants and not in female participants. This highlights the notion that mere transfer of knowledge regarding ACS prodromal symptoms may not be sufficient to mitigate decision delay in the female population. Further research is needed to corroborate these results and to gain deeper insights into the gender-specific barriers encountered in this study.

Theory-based cognitive-narrative intervention versus didactic education for promoting prompt care-seeking for acute myocardial infarction: A multisite mixed-methods randomized controlled trial

BACKGROUND

Prolonged delays by patients in making care-seeking decisions remain a significant obstacle to the effective management of acute myocardial infarction.

OBJECTIVES

This study aimed to compare the effects of a theory-based cognitive-narrative intervention with those of didactic education over a 24-month period on the participants' attitudes, beliefs, and knowledge regarding acute myocardial infarction, prehospital delay time, and the use of an ambulance. We also explored participants' engagement in the intervention.

DESIGN

This study adopted a sequential mixed-methods design comprising a multisite randomized controlled trial and a qualitative study.

METHODS

Community-dwelling adult patients with a prior history of acute myocardial infarction in the past year were recruited from four hospitals in Hong Kong. They were randomly assigned to an 8-week theory-based cognitive-narrative intervention that involved a vivid experience of complex decision-making or didactic education. The Acute Coronary Syndrome Response Index questionnaire was administered at baseline (T0) and at 3- (T1), 12- (T2), and 24-month (T3) follow-up time points. Prehospital delay time and the use of an ambulance were evaluated for those participants who had recurrent acute myocardial infarction attacks during the study period.

RESULTS

A total of 608 participants were randomly assigned to the theory-based cognitive-narrative intervention group (n = 304) or the didactic education group (n = 304). The intervention group reported greater improvements than the control group in their attitudes (β = -1.053, p = 0.002) and beliefs (β = -0.686, p = 0.041) regarding acute myocardial infarction and care-seeking at T1. These effects were sustained at T2 [attitudes (β = -0.797, p = 0.018); beliefs (β = -0.692, p = 0.047)] and T3 [attitudes (β = -0.717, p = 0.024); beliefs (β = -0.701, p = 0.032)]. Sixty-three participants experienced another acute myocardial infarction event by T2. The median delay times for the intervention and control groups were 3.13 h (interquartile range (IQR: 1.15-6.48)) and 4.82 h (IQR: 2.23-9.02), respectively. The prehospital delay time was significantly reduced in the intervention group compared with the control group (β = -0.07, p = 0.011). The qualitative findings echoed the quantitative findings, as participants indicated that the intervention helped them to understand the variable nature of the disease presentation, which enabled them to recognize the symptoms more readily.

CONCLUSION

The novel cognitive-narrative intervention used in this study effectively improved the participants' attitudes and beliefs regarding acute myocardial infarction and reduced the prehospital delay time.

TRIAL REGISTRATION

This study was registered with the International Clinical Trials Registry Platform of the World Health Organization (ChiCTR-IIC-17010576) on February 2, 2017; the first participant was recruited on January 11, 2018.

Experiences and perceptions of acute myocardial infarction patients with a prolonged decision-making phase of treatment seeking: A meta-synthesis

AIMS

To describe the experiences and perceptions of acute myocardial infarction (AMI) patients with a prolonged decision-making phase of treatment-seeking.

BACKGROUND

Previous attempts to reduce the treatment-seeking time of AMI have been less than optimal. Due to the coronavirus disease 2019 (COVID-19) pandemic, the situation of prehospital delay is possibly worse. Decisions to seek treatment are influenced by multiple factors and need individualised interventions. Understanding patients' external and internal experiences and psychological perceptions is essential.

DESIGN

Meta-synthesis.

DATA SOURCES

We searched PubMed, Embase, Cochrane Library, Web of Science, Scopus and four Chinese databases from inception to April 2022.

METHODS

We screened the retrieved articles with predetermined inclusion and exclusion criteria, and reviewed articles using Thomas and Harden's (BMC Medical Research Methodology, 2008 8, 45) qualitative thematic synthesis approach. The Joanna Briggs Institute critical appraisal tool for qualitative research was used to assess the quality of studies.

RESULTS

Twenty-one studies were included, identifying four themes and nine sub-themes. The four primary themes were difficulty recognising and attributing symptoms, attempt to act, unwillingness to change and self-sacrifice.

CONCLUSION

Deciding to seek treatment is a complex social and psychological process, which needs comprehensive interventions considering personal and sociocultural factors and factors related to the COVID-19 pandemic.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Details of interventions for decisions to seek treatment in AMI patients need to be further designed and evaluated.

IMPACT

Results would help healthcare professionals to implement individualised management of decision-making of treatment-seeking among AMI patients, and improve medical records of patients' prehospital experiences.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews 2020 checklist was used to report the findings.

PATIENT OR PUBLIC CONTRIBUTION

Two AMI patients contributed to the data synthesis by giving simple feedback about the final themes.

A protocol for the Heart Matters stepped wedge cluster randomised trial: The effectiveness of heart attack education in regions at highest-risk

AIM

To describe the Heart Matters (HM) trial which aims to evaluate the effectiveness of a community heart attack education intervention in high-risk areas in Victoria, Australia. These local government areas (LGAs) have high rates of acute coronary syndrome (ACS), out-of-hospital cardiac arrest (OHCA), cardiovascular risk factors, and low rates of emergency medical service (EMS) use for ACS.

METHODS

The trial follows a stepped-wedge cluster randomised design, with eight clusters (high-risk LGAs) randomly assigned to transition from control to intervention every four months. Two pairs of LGAs will transition simultaneously due to their proximity. The intervention consists of a heart attack education program delivered by trained HM Coordinators, with additional support from opportunistic media and a geo-targeted social media campaign. The primary outcome measure is the proportion of residents from the eight LGAs who present to emergency departments by EMS during an ACS event. Secondary outcomes include prehospital delay time, rates of OHCA and heart attack awareness. The primary and secondary outcomes will be analysed at the patient/participant level using mixed-effects logistic regression models. A detailed program evaluation is also being conducted. The trial was registered on August 9, 2021 (NCT04995900).

RESULTS

The intervention was implemented between February 2022 and March 2023, and outcome data will be collected from administrative databases, registries, and surveys. Primary trial data is expected to be locked for analysis by October 31st 2023, with a follow-up planned until March 31st 2024.

CONCLUSION

The results from this trial will provide high-level evidence the effectiveness of a community education intervention targeting regions at highest-risk of ACS and low EMS use.

Prevalence and determinants of delays in care among premature deaths due to acute cardiac conditions and stroke in residents of a district in India

Background

Lack of timely care is a predictor of poor outcomes in acute cardiovascular emergencies including stroke. We assessed the presence of delay in seeking appropriate care among those who died due to cardiac/stroke emergencies in a community in northern India and identified the reasons and determinants of this delay.

Methods

We conducted a social audit among all civil-registered premature (30-69 years) deaths due to acute cardiac event or stroke in the district. The three-delays model was used to qualitatively classify the delays in care-seeking-deciding to seek care, reaching the appropriate health facility (AHF) and initiating definitive treatment. Based on the estimated time from symptom onset to reaching AHF, we classified patients as early (reached within one hour) or delayed arrivers. We used mixed-effect logistic regression with postal code as a random effect to identify determinants of delayed arrival.

Findings

Only 10.8% of the deceased reached an AHF within one hour. We noted level-1 delay in 38.4% (60% due to non-recognition of seriousness); level-2 delay in 20% (40% due to going to an inappropriate facility) and level-3 delay in 10.8% (57% due to lack of affordability). Patients with a monthly family income of >270US$ (aOR 0.44; 95% CI 0.21-0.93) were less and those staying farther from AHF (aOR 1.12; 95% CI 1.01-1.25 for each Km) were more likely to have delayed arrival in AHF.

Interpretation

A small proportion of patients with cardiac and stroke emergencies reach health facility early with delays at multiple levels. Addressing the reasons for delay could prevent these deaths.

Funding

: Indian Council of Medical Research, New Delhi, India.

Association of pre‐hospital time intervals and clinical outcomes in ST‐elevation myocardial infarction patients

Study Objectives

Timely coronary reperfusion is critical for favorable outcomes after ST‐elevation myocardial infarction (STEMI). A substantial proportion of the total ischemic time is patient related, occurring before first medical contact (FMC). We aimed to expand the limited current understanding of the associations between prehospital intervals and clinical outcomes.

Methods

We conducted a retrospective analysis of consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) (January 2009–March 2016) and assessed the associations between prehospital intervals and the incidence of new heart failure, cardiogenic shock, and hospital length of stay (LOS), adjusting for important clinical variables.

Results

A total of 773 patients (77% men, median age 65 years) met eligibility criteria. The median pre‐911 activation interval was 29 minutes (interquartile range: 11, 89); the median 911 call to FMC interval was 12 minutes (interquartile range: 9, 15). In multivariable analysis, there was a V‐shaped relationship between the pre‐911 activation interval and outcomes: a lower likelihood of new heart failure (odds ratio [OR] 0.51; 95% confidence interval [CI]: 0.30, 0.87), cardiogenic shock (OR 0.40; 95% CI: 0.21, 0.75) and prolonged LOS (OR 0.24; 95% CI: 0.14, 0.42) for midrange intervals (11–88 minutes) when compared to the early (< 11‐minute) interval. There was no statistically significant relationship between total pre‐FMC time and FMC to device activation time.

Conclusions

Among ambulance‐transported STEMI patients receiving pPCI, the shortest and longest pre‐911 activation time intervals were associated with poorer outcomes. However, variation in post‐FMC interval alone was not associated with outcomes, suggesting that interventions to reduce pre‐FMC intervals must be prioritized.

Job Burnout Is Associated With Prehospital Decision Delay: An Internet-Based Survey in China

Background

Prehospital delay is associated with non-modifiable factors such as age, residential region, and disease severity. However, the impact of psychosocial factors especially for job burnout on prehospital decision delay is still little understood.

Method

This internet-based survey was conducted between 14 February 2021 and 5 March 2021 in China through the Wechat platform and web page. Self-designed questionnaires about the expected and actual length of prehospital decision time and the Chinese version of Maslach Burnout Inventory-General Survey, Type D Personality Scale-14, and Social Support Rating Scale were applied. A total of 1,039 general participants with a history of perceptible but tolerable body discomfort were included.

Results

The top six reasons for prehospital decision delay were: (1) endure until self-healing (50.7%), (2) too busy to ask for leave (40.3%), (3) process for seeing a doctor too complicated (35.8%), (4) too tired after work (26.2%), (5) worry about the expenditure (16.6%), and (6) fear of being identified as with serious problem (14.5%). The univariate analyses revealed that older age (p = 0.001), type D personality (p = 0.025), job burnout (p = 0.055), and worrying about expenditure (p = 0.004) were associated with prolonged prehospital decision time, while engaged in medical-related job (p = 0.028) and with more social support (p = 0.066) would shorten the delay. The multivariate analysis using logistic regression model with forward selecting method showed that age [per 10 years, odds ratio (OR) 1.19 (1.09–1.31), p < 0.001], job burnout [per 10 points in Maslach Burnout Inventory-General Survey (MBI-GS), OR 1.17 (1.04–1.31), p = 0.007], and worrying about expenditure [OR 1.75 (1.25–2.47), p = 0.001] were the three determinants for prehospital decision delay (>7 days). Mediating effects were analyzed by using bias-corrected percentile bootstrap methods (N = 10,000). Social support was found partially mediated the relationship between the determinants and prehospital decision time. The partial mediating effect of social support accounted for 24.0% of the total effect for job burnout and 11.6% for worrying about expenditure.

Conclusion

Psychosocial factors have a non-negligible impact on prehospital decision delay. The crucial part of prehospital decision delay may be the lack of motivation inside. Job burnout and lack of social support, as two commonly seen features in the modern world, should be given enough consideration in disease prevention and treatment.

Effect of Health Literacy on Decision Delay in Patients With Acute Myocardial Infarction

Background: Health literacy (HL) is a risk factor for adverse outcomes in patients with cardiovascular disease, and shorter pre-hospital delay time is crucial for successful treatment of acute myocardial infraction (AMI) patients. Most previous studies focused on the influencing factors of pre-hospital delay but ignore the essential contribution of decision delay.

Aims: Therefore, the purpose of this study was to explore the effect of HL on decision delay.

Methods: Continuously included AMI patients admitted to a grade A class three hospital in Chongqing. HL level was assessed using Brief Health Literacy Screen and categorized as adequate or inadequate. Mann-Whitney U-test and Chi-square test were used to compare the differences between groups, and binary logistic regression was used to analyze the association between HL and decision delay.

Results: A total of 217 AMI patients were enrolled in this study, including 166 males (76.5%) and 51 females (23.5%), with the median age was 68 years old; 135 (62.2%) patients had delayed decision-making while 82 (37.8%) did not; 157 (72.7%) patients had inadequate HL and 59 (27.3%) had adequate HL. The total HL score of non-delayed group was higher than that in delayed group (9.22 vs. 7.02, P < 0.000).

Conclusion: After adjusting for covariates, HL was significantly negatively associated with decision time. AMI patients with inadequate HL were more likely to delay seeking timely medical care.

Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome

Objective

Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian’s awareness of acute coronary syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia.

Methods

The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and (1) EMS arrival and (2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics.

Results

Between 2003 and 2015, there were 124 632 eligible ED presentations with ACS and 536 148 with U-CP. In patients with ACS, the campaign period was associated with an increase in ED presentations (incidence rate ratio: 1.11; 95% CI 1.07 to 1.15), a decrease in presentations via a GP (adjusted OR (AOR): 0.77; 95% CI 0.70 to 0.86) and an increase in EMS use (AOR: 1.10; 95% CI 1.05 to 1.17). Similar, but smaller associations were seen in U-CP.

Conclusions

The Warning Signs Campaign was associated with improvements in treatment seeking in patients with ACS—including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education needs to focus on improving EMS use in ACS patient groups where use remains low.

Recognizing a Heart Attack: Patients' Knowledge of Cardiovascular Risk Factors and Its Relation to Prehospital Decision Delay in Acute Coronary Syndrome

In acute coronary syndromes (ACSs), longer decision delay - the time patients wait before seeking medical attention after symptoms have started - increases the risk of complications and death. However, many patients wait much longer than recommended and research is needed investigating how patient decision delay can be reduced. In a cross-sectional study of 120 ACS survivors, we investigated the relationship between knowledge of cardiovascular risk factors and decision delay. Several days after the onset of a cardiac event, patients completed a questionnaire measuring demographics, decision delay, objective knowledge of cardiovascular risks factors and of ACS symptoms, and subjective perceptions of symptoms during the cardiac episode. Relevant clinical data were extracted from patients' medical records. In a multiple linear regression analysis, controlling for demographic and clinical factors, objective knowledge of cardiovascular risk factors and ACS symptoms, and subjective attributions of symptoms to a cardiac cause were related to shorter decision delays. Among patients with relatively high knowledge of risk factors, only 5% waited more than 1 h to seek help, compared to 22% among patients with relatively low knowledge. These results suggest that knowledge of the factors that increase the risk of developing cardiovascular disease could play a role in patient decision making during an acute cardiac event. We discuss methodological issues and potential underlying mechanisms related to decision heuristics and biases, which can inform future research.

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.

A systematic review of educational interventions aiming to reduce prehospital delay in patients with acute coronary syndrome

Interventions aiming at reducing prehospital delay (PHD) in patients with acute coronary syndrome (ACS) have yielded inconsistent findings. Therefore, we aimed to systematically review studies which investigated the impact of educational interventions on reducing PHD in patients with ACS. We searched four electronic databases (Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Embase, Cochrane) from inception throughout December 2016 for studies that reported the impact of either mass-media or personalised intervention on PHD. Reporting quality was assessed with the Template for Intervention Description and Replication checklist for interventional trials. Two reviewers screened 12 184 abstracts and performed full-text screening on 86 articles, leading to 34 articles which met our inclusion criteria. We found 18 educational interventions with a total of 180 914 participants (range: n=100-125 161) and a median of 1342 participants. Among these educational interventions, 13 campaigns employed a mass-media approach and five a personalised approach. Ten studies yielded no significant effects on the primary outcome while the remaining interventions reported a significant reduction with a decrease between 17 and 324 min (median reduction: 40 min, n=5). The success was partly driven by an increase in emergency medical services use. Two studies reported an increase in acute myocardial infarction knowledge. We observed no superiority of the personalised over the mass-media approach. Although methodological shortcomings and the heterogeneity of included interventions still do not allow definite recommendations for future campaigns, it becomes evident that either mass media or personalised interventions can be successful in reducing PHD, especially those who address behavioural consequences and psychological barriers (eg, denial) and provide practical action plan considerations as part of their campaign messages. CRD42017055684 (PROSPERO registration number).

Psychosocial markers of pre-hospital decision delay and psychological distress in acute coronary syndrome patients

Objectives Both pre-hospital decision delay - the time patients wait before seeking medical attention after symptoms have started - and high psychological distress after the cardiac episode predict poor prognosis of patients with acute coronary syndromes (ACS). We aimed to identify psychosocial markers of these prognostic factors. Design A cross-sectional study of 102 consecutive, clinically stable ACS survivors. Methods Participants completed a questionnaire measuring pre-hospital decision delay, psychological distress, and several known psychosocial factors related to cardiovascular health: type D personality, resilience, social support, and concerns during the cardiac event. Multiple linear regression and mediation analyses were conducted. Results Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress post-ACS, and these relationships were mediated by longer pre-hospital decision delay. In contrast, resilience was related to lower psychological distress. Social support and social concerns about help-seeking were not related to the outcome variables. Conclusions Type D personality may be a risk factor for more delayed help-seeking for an ACS and higher psychological distress after the cardiac event. Resilience, in contrast, emerged as a potential protective factor of patients' mental health after the cardiac event. Pre-hospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Statement of Contribution What is already known on this subject? Longer pre-hospital decision delay, that is waiting longer to seek medical attention after symptoms have started, predicts poor prognosis of acute coronary syndrome patients. High psychological distress post-ACS, such as the development of anxiety and/or depression, also predicts poor prognosis of these patients. What does this study adds? This study identifies several psychosocial markers of longer prehospital decision delay and high psychological distress post-ACS. Prehospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress, and these relationships were mediated by longer prehospital decision delay. Resilience was related to lower psychological distress post-ACS.

Variation and Disparities in Awareness of Myocardial Infarction Symptoms Among Adults in the United States

IMPORTANCE

Prompt recognition of myocardial infarction symptoms is critical for timely access to lifesaving emergency cardiac care. However, patients with myocardial infarction continue to have a delayed presentation to the hospital.

OBJECTIVE

To understand the variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the 2017 National Health Interview Survey among adult residents of the United States, assessing awareness of the 5 following common myocardial infarction symptoms among different sociodemographic subgroups: (1) chest pain or discomfort, (2) shortness of breath, (3) pain or discomfort in arms or shoulders, (4) feeling weak, lightheaded, or faint, and (5) jaw, neck, or back pain. The response to a perceived myocardial infarction (ie, calling emergency medical services vs other) was also assessed.

MAIN OUTCOMES AND MEASURES

Prevalence and characteristics of individuals who were unaware of myocardial infarction symptoms and/or chose not to call emergency medical services in response to these symptoms.

RESULTS

Among 25 271 individuals (13 820 women [51.6%; 95% CI, 50.8%-52.4%]; 17 910 non-Hispanic white individuals [69.9%; 95% CI, 68.2%-71.6%]; and 21 826 individuals [82.7%; 95% CI, 81.5%-83.8%] born in the United States), 23 383 (91.8%; 95% CI, 91.0%-92.6%) considered chest pain or discomfort a symptom of myocardial infarction; 22 158 (87.0%; 95% CI, 86.1%-87.8%) considered shortness of breath a symptom; 22 064 (85.7%; 95% CI, 84.8%-86.5%) considered pain or discomfort in arm a symptom; 19 760 (77.0%; 95% CI, 76.1%-77.9%) considered feeling weak, lightheaded, or faint a symptom; and 16 567 (62.6%; 95% CI, 61.6%-63.7%) considered jaw, neck, or back pain a symptom. Overall, 14 075 adults (53.0%; 95% CI, 51.9%-54.1%) were aware of all 5 symptoms, whereas 4698 (20.3%; 95% CI, 19.4%-21.3%) were not aware of the 3 most common symptoms and 1295 (5.8%; 95% CI, 5.2%-6.4%) were not aware of any symptoms. Not being aware of any symptoms was associated with male sex (odds ratio [OR], 1.23; 95% CI, 1.05-1.44; P = .01), Hispanic ethnicity (OR, 1.89; 95% CI, 1.47-2.43; P < .001), not having been born in the United States (OR, 1.85; 95% CI, 1.47-2.33; P < .001), and having a lower education level (OR, 1.31; 95% CI, 1.09-1.58; P = .004). Among 294 non-Hispanic black or Hispanic individuals who were not born in the United States, belonged to the low-income or lowest-income subgroup, were uninsured, and had a lower education level, 61 (17.9%; 95% CI, 13.3%-23.6%) were not aware of any symptoms. This group had 6-fold higher odds of not being aware of any symptoms (OR, 6.34; 95% CI, 3.92-10.26; P < .001) compared with individuals without these characteristics. Overall, 1130 individuals (4.5%; 95% CI, 4.0%-5.0%) chose a different response than calling emergency medical services in response to a myocardial infarction.

CONCLUSIONS AND RELEVANCE

Many adults in the United States remain unaware of the symptoms of and appropriate response to a myocardial infarction. In this study, several sociodemographic subgroups were associated with a higher risk of not being aware. They may benefit the most from targeted public health initiatives.

Prehospital and in-hospital delays to care and associated factors in patients with STEMI: an observational study in 101 non-PCI hospitals in China

OBJECTIVES

To describe the prehospital and in-hospital delays to care and factors associated with the delays among patients with ST-segment elevation myocardial infarction (STEMI) in non-percutaneous coronary intervention (PCI) hospitals in China.

DESIGN, SETTING AND PARTICIPANTS

We analysed data from a large registry-based quality of care improvement trial conducted from 2011 to 2014 among 101 non-PCI hospitals in China. A total of 7312 patients with STEMI were included. Prehospital delay was defined as time from symptom onset to hospital arrival >120 min, first ECG delay as time from arrival to first ECG >10 min, thrombolytic therapy delay as time from first ECG to thrombolytic therapy >10 min and in-hospital delay as time from arrival to thrombolytic therapy >30 min. Logistic regressions with generalised estimating equations were preformed to identify the factors associated with each delay.

RESULTS

The rates of prehospital delay, first ECG delay, thrombolytic therapy delay and in-hospital delay were 67.1%, 31.4%, 85.8% and 67.8%, respectively. Patients who were female, older than 65 years old, illiterate, farmers, onset during late night and forenoon, had heart rate ≥100 beats/m at admission were more likely and patients who had history of myocardial infarction, hypertension or SBP <90 mm Hg at admission were less likely to have prehospital delay. First ECG delay was more likely to take place in patients arriving on regular hours. Thrombolytic therapy delay rate was lower in patients who had prehospital delay or first ECG delay but higher in those with heart rate ≥100 beats/m at admission. In-hospital delay rate was lower in patients with a history of dyslipidaemia and those who arrived during regular hours.

CONCLUSION

Chinese patients with STEMI in low medical resource areas suffered severe prehospital and in-hospital delays to care. Future efforts should be made to improve the prehospital delay among vulnerable populations with low socioeconomic status.

TRIAL REGISTRATION NUMBER

NCT01398228; Post-results.

Inability to act was associated with an extended delay prior to care-seeking, in patients with an acute myocardial infarction

BACKGROUND

The out-of-hospital mortality in patients with acute myocardial infarction remains unchanged in contrast to a decrease in inhospital mortality. Interventions aiming to shorten patient delay have been largely unsuccessful. A deeper understanding is apparently needed on patients' appraisal prior to care-seeking.

AIM

To investigate whether appraisal processes influence patient delay, and if the questionnaire 'Patients' appraisal, emotions and action tendencies preceding care seeking in acute myocardial infarction' (PA-AMI) could discriminate between patients with prolonged care-seeking and those with a short delay.

METHODS

A cross-sectional study including 326 acute myocardial infarction patients filling out the validated questionnaire PA-AMI. The impact of subscales on delay was analysed by projection to latent structures regression. Discrimination opportunities between patients with short and long delays were analysed by projection to latent structures discriminant analysis.

RESULTS

The subscales 'perceived inability to act' and 'symptom appraisal' had a major impact on patient delay (P<0.0001). 'Perceived inability to act' had its main influence in patients with a delay exceeding 12 hours, and 'symptom appraisal' had its main influence in patients with a delay shorter than one hour.

CONCLUSION

Appraisal processes influence patient delay. Acute myocardial infarction patients with a prolonged delay were, besides a low perceived symptom severity and urgency to seek medical care, characterised by a perceived loss of control and ability to act. Therefore, future interventions aimed at decreasing delay should pay attention to appraisal processes, and perceived inability to act may be a sign of a health threat and therefore a signal to seek medical care.

The MEDEA FAR-EAST Study: Conceptual framework, methods and first findings of a multicenter cross-sectional observational study

BACKGROUND

The substantial increase in cardiovascular diseases (CVD) in China over the last three decades warrants comprehensive preventive primary and secondary strategies. Prolonged prehospital delay (PHD) has been identified as a substantial barrier to timely therapeutic interventions for acute myocardial infarction (AMI). Despite worldwide efforts to decrease the patient's decision-making time, minimal change has been achieved so far. Here, we aim to describe the conceptual framework and methods and outline key data of the MEDEA FAR-EAST Study, which aimed to elucidate in-depth barriers contributing to delay in Chinese AMI-patients.

METHODS

Data sources of this multicenter cross-sectional observational study are a standardized bedside interview, a self-administered tailored questionnaire tool and the patient chart. PHD was defined as the main outcome and triangulated at bedside. Standard operation procedures ensured uniform data collection by trained study personnel. The study was ethically approved by Tongji-Hospital and applied to all participating hospitals.

RESULTS

Among 379 consecutively screened patients, 296 (78.1%) fulfilled eligibility criteria. A total of 241 (81.4%) AMI-patients were male and 55 (18.6%) female. Mean age was 62.9 years. Prehospital delay time was assessed for 294 (99.3%) patients. Overall median PHD was 151 min with no significant sex difference. Symptom mismatch was present in 200 (69.7%) patients and 106 (39.0%) patients did not attribute their symptoms to cardiac origin. A total of 33 (12.4%) patients suffered from depression, 31 (11.7%) from anxiety and 141 (53.2%) patients employed denial as their major coping style.

CONCLUSION

This is the first study on prehospital delay with emphasis on psychological variables in Chinese AMI-patients. A comprehensive assessment tool to measure clinical and psychological factors was successfully implemented. Socio-demographic key data proved a good fit into preexisting Chinese literature. Potential barriers including cardiac denial and symptom-mismatch were assessed for the first time in Chinese AMI-patients. The pretested selection of instruments allows future in depth investigations into barriers to delay of Chinese AMI-patients and enables inter-cultural comparisons.

Ambulances are for emergencies: shifting attitudes through a research-informed behaviour change campaign

Background

In Victoria, Australia, emergency calls requesting an ambulance have been increasing at a rate higher than population growth. While most of these calls are for genuine emergencies, many do not require an immediate ambulance response. A collaborative research approach was undertaken to address this issue. The aim of this paper was to evaluate the effectiveness of applying a behaviour change approach to this challenge by first addressing antecedents of behaviour (attitudes, awareness and knowledge).

Methods

The project included a formative research phase to inform the design of a mass media campaign and subsequent evaluation of the campaign.

Results

Results indicated that the campaign was successful in increasing community attitudes towards ambulances as being for emergencies only, particularly among those familiar with the campaign material and with other health service options (such as telephone advice lines).

Conclusions

These findings provide support for adopting the Forum approach to increase the chances that a mass media campaign will achieve its stated objectives. Recommendations for future campaign activities are discussed.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0430-5) contains supplementary material, which is available to authorized users.

Reducing delay in patients with acute coronary syndrome and other time-critical conditions: a systematic review to identify the behaviour change techniques associated with effective interventions

Background

Time to treatment in many conditions, particularly acute coronary syndrome, is critical to reducing mortality. Delay between onset of symptoms and treatment remains a worldwide problem. Reducing patient delay has been particularly challenging. Embedding behaviour change techniques (BCTs) within interventions might lead to shorter delay.

Objective

To identify which BCTs are associated with reductions in patient delay among people with symptoms or conditions where time to treatment is critical.

Methods

The data sources were Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO. Study eligibility criteria include intervention evaluations (randomised controlled trials, controlled clinical trials and cohort studies) involving adults (aged >18 years) and including an outcome measure of patient delay up to August 2016. Study appraisal and synthesis methods include screening potential studies using a transparent, replicable process. Study characteristics, outcomes and BCTs were extracted from eligible studies.

Results

From 39 studies (200 538 participants), just over half (n=20) reported a significant reduction in delay. 19 BCTs were identified, plus 5 additional techniques, with a mean of 2 (SD=2.3) BCTs and 2 (SD=0.7) per intervention. No clear pattern between BCTs and effectiveness was found. In studies examining patient delay specifically, three of four studies that included two or more BCTs, in addition to the two most commonly used additional techniques, reported a significant reduction in delay.

Conclusions

Around half of the interventions to reduce prehospital delay with time-critical symptoms report a significant reduction in delay time. It is not clear what differentiates effective from non-effective interventions, although in relation to patient delay particularly additional use of BCTs might be helpful.

Trial registration number

CRD42014013106.

A modeling-based narrative intervention to promote timely care-seeking in patients with acute myocardial infarction: A pilot randomized controlled trial and feasibility analysis

BACKGROUND

Prolonged delay in seeking medical attention for acute myocardial infarction persists as a global phenomenon, which limits effective disease management. The effects of previous mass-media campaigns and psycho-educations have been minimal.

AIMS

This study aimed to develop a modeling-based narrative intervention, and to examine its feasibility and preliminary effects on care-seeking behavioral intention in Chinese acute myocardial infarction patients.

METHODS

The modeling-based narrative intervention was developed by integrating updated research evidence and participants' perspectives. Ten patients were invited to co-design the intervention. The narrative approach was adopted to engage patients in a mental rehearsal of the decision-making process through a virtual acute myocardial infarction attack experience. A pilot randomized controlled trial was adopted to examine the feasibility and preliminary effects of this intervention.

RESULTS

A total of 67 participants were randomly allocated to receive either the modeling-based narrative intervention ( n=34) or didactic education ( n=33). The intervention was feasible and well-accepted by the participants as evidenced by high attendance and participant satisfaction. They considered the intervention as informative and interesting. The majority of the participants in the intervention group expressed that they enjoyed the intervention. Although the preliminary data showed non-significant between-group differences, a more prominent improving trend for acute myocardial infarction knowledge, care-seeking attitudes and beliefs in the intervention group were evident.

CONCLUSIONS

This study is the first of its kind to adopt a novel narrative approach to optimize care-seeking behaviors among patients with acute myocardial infarction. The preliminary findings showed that this approach was highly feasible and accepted by patients.

Characteristics of patients with acute myocardial infarction contacting primary healthcare before hospitalisation: a cross-sectional study

Background

The characteristics of patients with on-going myocardial infarction (MI) contacting the primary healthcare (PHC) centre before hospitalisation are not well known. Prompt diagnosis is crucial in patients with MI, but many patients delay seeking medical care. The aims of this study was to 1) describe background characteristics, symptoms, actions and delay times in patients contacting the PHC before hospitalisation when falling ill with an acute MI, 2) compare those patients with acute MI patients not contacting the PHC, and 3) explore factors associated with a PHC contact in acute MI patients.

Methods

This was a cross-sectional multicentre study, enrolling consecutive patients with MI within 24 hours of admission to hospital from Nov 2012 until Feb 2014.

Results

A total of 688 patients with MI, 519 men and 169 women, were included; the mean age was 66±11 years. One in five people contacted PHC instead of the recommended emergency medical services (EMS), and 94% of these patients experienced cardinal symptoms of an acute MI; i.e., chest pain, and/or radiating pain in the arms, and/or cold sweat. Median delay time from symptom-onset-to-decision-to-seek-care was 2:15 hours in PHC patients and 0:40 hours in non-PHC patients (p<0.01). The probability of utilising the PHC before hospitalisation was associated with fluctuating symptoms (OR 1.74), pain intensity (OR 0.90) symptoms during off-hours (OR 0.42), study hospital (OR 3.49 and 2.52, respectively, for two of the county hospitals) and a final STEMI diagnosis (OR 0.58).

Conclusions

Ambulance services are still underutilized in acute MI patients. A substantial part of the patients contacts their primary healthcare centre before they are diagnosed with MI, although experiencing cardinal symptoms such as chest pain. There is need for better knowledge in the population about symptoms of MI and adequate pathways to qualified care. Knowledge and awareness amongst primary healthcare professionals on the occurrence of MI patients is imperative.

Impact of Reducing Pre-Hospital Delay in Response to Heart Attack Symptoms in Australia

BACKGROUND

This research estimates the broader socioeconomic impacts of reducing pre-hospital delay times across Australia in patients with heart attack symptoms.

METHODS

A cost benefit analysis (CBA) was undertaken to demonstrate the costs and benefits of a public awareness/education campaign to reduce pre-hospital delay time from 5.2hours (Base Case) to 4.1hours (Scenario 1) and 2.0hours (Scenario 2). All assumptions underlying the CBA are supported by academic literature. Financial impacts considered include campaign/public education costs, direct inpatient costs and long-term health care costs. Socioeconomic impacts considered include burden of disease, productivity losses, informal care costs and net deadweight loss.

RESULTS

The campaign is expected to generate an additional net benefit of $41.2-139.1 million in comparison to the Base Case, resulting in a benefit cost ratio (BCR) of 3.23-5.06. Disability Adjusted Life Years (DALYs) reduced by 6,046-7,575 years.

CONCLUSION

This research illustrates that an investment in public awareness/education campaign can generate considerable benefits, more than offsetting the costs associated with the campaign and keeping people living longer such as ongoing health care costs. However, significant effort, supplementary strategies and sustained investment will be required to ensure the impact and benefit is sustained over the long term.

The Effect of Media Campaigns, Patient Characteristics, and Presenting Symptoms on Prehospital Delay in Myocardial Infarction Patients: A Prospective Cohort Study

BACKGROUND

Delays in reperfusion therapy for myocardial infarction (MI) are associated with increased mortality and morbidity, and most of this delay is due to delay in patients initiating contact with emergency services. This study assesses the impact of the Australian National Heart Foundation media campaign and identifies patient characteristics and presenting symptoms that may contribute to delay.

METHODS

This prospective cohort study identified patients with a diagnosis of MI admitted to a single tertiary metropolitan hospital in Perth, Western Australia from July 2013 to January 2014. Patients were interviewed and responses were categorised to determine their reasons for delaying treatment and the impact of mass media campaigns. Delay times were analysed using multivariable linear regression models for the Whole Cohort (all patients admitted to the tertiary hospital, including patients from rural and peripheral hospitals) and the Direct Admission Cohort (patients admitted directly to the tertiary hospital).

RESULTS

Of 376 patients, 255 patients provided consent, and symptom onset-time was available for 175 patients. While almost two thirds of the cohort was aware of media campaigns, awareness was not associated with decreased prehospital delay. Median delay was 3.9hours for the Whole Cohort and 3.5hours for the Direct Admission Cohort. Delay was associated with being widowed, symptom onset on a weekday compared with weekend, past medical history of MI and coronary artery bypass graft, private compared with ambulance transport to hospital, and lack of symptoms of sweating and weakness. In addition, for the Direct Admission Cohort, age and income were also associated with delay.

CONCLUSIONS

This study did not find an association between awareness of media campaigns and delay. This study identified important characteristics and presenting symptoms that are associated with delay, and possibly relevant to future media campaigns.

The second myocardial infarction: Is there any difference in symptoms and prehospital delay compared to the first myocardial infarction?

BACKGROUND

Knowledge is limited concerning the type of symptoms and the time from onset of symptoms to first medical contact at first and second myocardial infarction in the same patient.

AIM

This study aimed to describe the type of symptoms and the time from onset of symptoms to first medical contact in first and second myocardial infarctions in men and women affected by two myocardial infarctions. Furthermore, the aim was to identify factors associated with prehospital delays ≥2 h at second myocardial infarction.

METHODS

A retrospective cohort study with 820 patients aged 31-74 years with a first and a second myocardial infarction from 1986 through 2009 registered in the Northern Sweden MONICA registry.

RESULTS

The most common symptoms reported among patients affected by two myocardial infarctions are typical symptoms at both myocardial infarction events. Significantly more women reported atypical symptoms at the second myocardial infarction compared to the first. Ten per cent of the men did not report the same type of symptoms at the first and second myocardial infarctions; the corresponding figure for women was 16.2%. The time from onset of symptoms to first medical contact was shorter at the second myocardial infarction compared to the first myocardial infarction. Patients with prehospital delay ≥2 h at the first myocardial infarction were more likely to have a prehospital delay ≥2 h at the second myocardial infarction.

CONCLUSIONS

Symptoms of second myocardial infarctions are not necessarily the same as those of first myocardial infarctions. A patient's behaviour at the first myocardial infarction could predict how he or she would behave at a second myocardial infarction.

Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival

BACKGROUND

Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors.

PURPOSE

The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy.

METHODS

About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32-74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics).

RESULTS

Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., OR_high-low = 3.84 [1.127, 11.65]).

CONCLUSIONS

Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.

Predictors of pre-hospital delay in Hong Kong Chinese patients with acute myocardial infarction

BACKGROUND

The pre-hospital delay to seek care remains the most significant barrier for effective management of acute myocardial infarction. Many of the previous studies mainly took place in Western countries. Few data are available about the care-seeking behavior of Hong Kong Chinese.

AIM

The purpose of this study was to identify the predictors of pre-hospital delay in care seeking among Hong Kong Chinese patients with acute myocardial infarction.

METHODS

Adult Chinese patients ( n=301) with a confirmed diagnosis of acute myocardial infarction were recruited from the cardiac units of three regional hospitals in Hong Kong. Various socio-demographic, clinical, symptom presentation characteristics and patient perceptual factors were considered as potential predictors. Multivariate analysis was conducted to identify the independent predictors with pre-hospital delay in care-seeking among acute myocardial infarction patients.

RESULTS

Perceived barriers to care seeking constituted the most significant predictor for longer pre-hospital delay in acute myocardial infarction patients. Female gender was also significant in predicting longer delay, whereas a greater extent of symptom congruence and a greater extent of typical symptom presentation were significantly associated with a shorter delay. The final model accounted for 49.6% of the variance in pre-hospital delay as a whole.

CONCLUSION

The most prominent predictors of pre-hospital delay are modifiable in nature, including the perceived barriers to care seeking and symptom congruence. Other sociodemographic and clinical factors also influence patients' decision. Although these are non-modifiable, our findings provide important insight for educating high-risk individuals.

Patients' knowledge about symptoms and adequate behaviour during acute myocardial infarction and its impact on delay time: Findings from the multicentre MEDEA Study

OBJECTIVE

We aimed to assess whether patients' knowledge about acute myocardial infarction (AMI) has an impact on the prehospital delay-time.

METHODS

This investigation was based on 486 AMI patients who participated in the cross-sectional Munich-Examination-of-Delay-in-Patients-Experiencing-Acute-Myocardial-Infarction (MEDEA) study. A modified German-version of the ACS-Response-Index Questionnaire was used. Multivariate logistic-regression models were used to identify factors associated with knowledge-level as well as the impact of knowledge-level on delay-time.

RESULTS

High AMI-knowledge shortened median delay-time in men (168[92-509] vs. 276[117-1519] mins, p=0.0069), and in women (189[101-601] vs. 262[107-951]mins, p=0.34). Almost half-of-patients (n=284,58%) demonstrated high AMI-knowledge. High-knowledge were independently associated with male-gender (OR=1.47[1.17-1.85]) and General-Practitioner as a knowledge-source (OR=1.42[1.14-1.77]). Old-age (OR=0.87[0.86-0.89]) and previous AMI-history/stent-placement (OR=0.65[0.46-0.93]) were significantly associated with lower-knowledge. Although the majority (476,98%) correctly recognized at least one AMI-symptom, 69(14.2%) patients correctly identified all AMI-symptoms. Additionally, one-in-three believed that heart-attack is always accompanied with severe chest-pain. Elderly-patients and women were more likely to be less-knowledgeable about atypical-symptoms (p=0.006), present with atypical AMI-presentation (p<0.001) and subsequently experience protracted delay-times (p<0.001).

CONCLUSIONS

Knowledge of AMI-symptoms remains to be substandard, especially knowledge of atypical-symptoms. Knowledge is essential to reduce delay-times, but it is not a panacea, since it is not sufficient alone to optimize prehospital delay-times.

Reducing patient delay in Acute Coronary Syndrome (RAPiD): research protocol for a web-based randomized controlled trial examining the effect of a behaviour change intervention

AIMS

To evaluate the efficacy of a behaviour change technique-based intervention and compare two possible modes of delivery (text + visual and text-only) with usual care.

BACKGROUND

Patient delay prevents many people from achieving optimal benefit of time-dependent treatments for acute coronary syndrome. Reducing delay would reduce mortality and morbidity, but interventions to change behaviour have had mixed results. Systematic inclusion of behaviour change techniques or a visual mode of delivery might improve the efficacy of interventions.

DESIGN

A three-arm web-based, parallel randomized controlled trial of a theory-based intervention.

METHODS

The intervention comprises 12 behaviour change techniques systematically identified following systematic review and a consensus exercise undertaken with behaviour change experts. We aim to recruit n = 177 participants who have experienced acute coronary syndrome in the previous 6 months from a National Health Service Hospital. Consenting participants will be randomly allocated in equal numbers to one of three study groups: i) usual care, ii) usual care plus text-only behaviour change technique-based intervention or iii) usual care plus text + visual behaviour change technique-based intervention. The primary outcome will be the change in intention to phone an ambulance immediately with symptoms of acute coronary syndrome ≥15-minute duration, assessed using two randomized series of eight scenarios representing varied symptoms before and after delivery of the interventions or control condition (usual care). Funding granted January 2014.

DISCUSSION

Positive results changing intentions would lead to a randomized controlled trial of the behaviour change intervention in clinical practice, assessing patient delay in the event of actual symptoms.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov: NCT02820103.

Testing a Model to Reveal the Predictive Mechanism of Care-Seeking Decisions Among Patients With Acute Myocardial Infarction

BACKGROUND

Extensive research has been conducted to examine the factors affecting care-seeking decisions in patients with acute myocardial infarction (AMI). Such a decision-making process is multifactorial, and its underlying mechanism is yet to be determined.

OBJECTIVES

Our aim was to test a theoretically integrated model to identify the mechanisms underlying patients' care-seeking decisions in the context of AMI.

METHODS

On the basis of both empirical and theoretical evidence, we proposed that patients' care-seeking decisions are driven by 2 sequential perceptual-cognitive processes concerned with illness labeling and interpretation, as well as the contextual influences of perceived barriers to care seeking and cues from others. A sample of 301 patients was recruited to test this model using structural equation modeling.

RESULTS

The model testing revealed good fit with the data (χ = 38.48, df = 30, P = .72; root-mean-square error of approximation = 0.03, normed fit index = 0.96, nonnormed fit index = 0.98, and comparative fit index = 0.99) and explained 46% of the variance in AMI care-seeking delay. Successful action relied on whether patients could correctly attribute the symptom experience to AMI, were aware of their own susceptibility to the condition, and had a good understanding of how the disease manifested itself. Lowering perceived barriers and positive cues from others in advising care seeking played favorable roles to promote care-seeking behaviors.

CONCLUSIONS

This integrative theoretical model is shown to be valid in explaining care-seeking delay among AMI patients and can guide the development of interventions to promote appropriate care-seeking behaviors among high-risk individuals.

Mass Media Campaigns' Influence on Prehospital Behavior for Acute Coronary Syndromes: An Evaluation of the Australian Heart Foundation's Warning Signs Campaign

Background

The aim of this study was to examine the awareness of a recent mass media campaign, and its influence on knowledge and prehospital times, in a cohort of acute coronary syndrome (ACS) patients admitted to an Australian hospital.

Methods and Results

We conducted 199 semistructured interviews with consecutive ACS patients who were aged 35 to 75 years, competent to provide consent, and English speaking. Questions addressed the factors known to predict prehospital delay, awareness of the campaign, and whether it increased knowledge and influenced actions. Multivariable logistic regression was used to examine the association between campaign awareness and a 1-hour delay in deciding to seek medical attention (patient delay) and a 2-hour delay in presenting to hospital (prehospital delay). The median age was 62 years (IQR=53 to 68 years), and 68% (n=136) were male. Awareness of the campaign was reported by 127 (64%) patients, with most of these patients stating the campaign (1) increased their understanding of what is a heart attack (63%), (2) increased their awareness of the signs and symptoms of heart attack (68%), and (3) influenced their actions in response to symptoms (43%). After adjustment for other predictors, awareness of the campaign was significantly associated with patient delay time of ≤1 hour (adjusted odds ratio [AOR]=2.25, 95% CI: 1.03 to 4.91, P=0.04) and prehospital delay time ≤2 hours (AOR=3.11, 95% CI: 1.36 to 7.08, P=0.007).

Conclusions

Our study showed reasonably high awareness of the warning signs campaign, which was significantly associated with shorter prehospital decision-making and faster presentation to hospital.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

How can we optimize the processes of care for acute coronary syndromes to improve outcomes?

Acute coronary syndromes (ACS), either ST-elevation myocardial infarction or non-ST-elevation ACS, are still one of the most common cardiac emergencies with substantial morbidity and mortality. The availability of evidence-based treatments, such as early and intense platelet inhibition and anticoagulation, and timely reperfusion and revascularization, has substantially improved outcomes in patients with ACS. The implementation of streamlined processes of care for patients with ST-elevation myocardial infarction and non-ST-elevation ACS over the last decade including both appropriate tools, especially cardiac troponin, for rapid diagnosis and risk stratification and for decision support, and the widespread availability of modern antithrombotic and interventional treatments, have reduced morbidity and mortality to unprecedented low levels. These changes in the process of care require a synchronized approach, and research using a team-based strategy and effective regional networks has allowed healthcare systems to provide modern treatments for most patients with ACS. There are still areas needing improvement, such as the delivery of care to people in rural areas or with delayed time to treatment.