Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction: A Report by the National Heart Attack Alert Program

The Effect of Education and Counselling on Knowledge, Attitudes and Beliefs about Responses to Acute Myocardial Infarction Symptoms

The time that elapses from the onset of symptoms of acute myocardial infarction (AMI) to treatment has a significant effect on mortality and morbidity. This study reports the effectiveness of an education and counselling intervention on knowledge, attitudes and beliefs about AMI symptoms and the appropriate response to symptoms. The intervention was tested in a randomised controlled trial of 200 people with a history of coronary heart disease (CHD). The groups were equivalent at baseline on study outcomes, clinical history and sociodemographic characteristics with the exception of more women in the intervention group (38% vs. 24%). The results of repeated measures ANOVA showed that the intervention resulted in improved knowledge of CHD, AMI symptoms and the appropriate response to symptoms that was sustained to 12 months (p=0.02). There were no differences between groups' attitudes and beliefs over time. It is concluded that a short individual teaching and counselling intervention resulted in improved knowledge of CHD, AMI symptoms and the appropriate response to symptoms in people at risk of AMI sustained to 12 months.

Angina at Low heart rate And Risk of imminent Myocardial infarction (the ALARM study): a prospective, observational proof-of-concept study

Background

Myocardial infarction (MI) is often preceded by unstable angina. Helping patients identify the onset of unstable angina rather than MI may result in earlier treatment and improve outcomes. Unstable angina is angina occurring at a lower-than-usual workload. Since heart rate (HR) is correlated with degree of exertion, we hypothesised that angina occurring at low HR is a warning signal for unstable angina and MI.

Methods

In this prospective study, 111 patients with acute coronary syndrome (ACS) or prognostically significant coronary disease were recruited. Each patient’s HR was measured using a portable electrocardiogram (ECG) recorder after regular class III exercise on the Canadian Cardiovascular Society Angina Grading Scale and the cumulative moving average and three-sigma (standard deviation) range were calculated for each new measurement. The HR was subsequently measured at the beginning of angina; a HR lower than the preceding three-sigma ranges for class III or anginal HR was regarded as a ‘warning signal’. The proportion of warning signals associated with ACS occurring in the following 2 weeks was compared with that for non-warning signals.

Results

Nine cases of ACS occurred in eight patients. Two cases were preceded by warning signals; a signal marked the onset of ACS in a third patient, and four patients failed to make anginal ECG recordings. There were 591 documented episodes of angina during the study and ECGs were available for 383 (64.8 %) of these of which 55 were warning signals. Of these warning signals, 4 occurred in the 2 weeks preceding ACS, compared with 4 of 328 non-warning signals (odds ratio, 6.4; 95 % confidence interval, 1.5–26.2; p = 0.01; positive predictive value, 7.3 %; negative predictive value, 98.8 %).

Conclusions

Low HR angina may identify unstable angina and serve as an early warning for MI. In addition, angina that does not occur at a low heart rate indicates that ACS is very unlikely.

Prehospital thrombolysis: an idea whose time has come

Aggressive reperfusion therapy for myocardial infarction (MI) characterized by acute ST-segment elevation leads to improved patient outcome. Furthermore, use of thrombolytic therapy is highly time-dependent: reperfusion therapy is beneficial within 12 h, but the earlier it is administered, the more beneficial it is. Thus, the focus of both prehospital and emergency department management of patients with acute MI is on rapid identification and treatment. There are many components to the time delays between the onset of symptoms of acute MI and the achievement of reperfusion in the occluded infarct-related artery. Time delays occur with both the patient and the prehospital emergency medical system, although patient delays are more significant. This article focuses on the prehospital management of acute MI, including (1) the rationale for rapid reperfusion in patients with acute MI, (2) the factors related to time delays in patient presentation to the hospital, and (3) strategies for reducing time delays, both patient- and medical system-based.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Patients' and relatives' thoughts and actions during and after symptom presentation for an acute myocardial infarction

BACKGROUND

Relatives play an important role in deciding to seek medical care after the onset of symptoms of an acute myocardial infarction (AMI).

OBJECTIVE

The aim of this study was to gain deeper understanding of how AMI patients and their relatives think and act during and after onset of symptoms.

METHODS

Six focus group interviews were conducted with AMI patients (N=13) and relatives (N=14). Manifest content analysis was used to analyse the transcribed data.

RESULTS

The AMI patients experienced a variety of symptoms and both patients and relatives often felt uncertain about the origin of the symptoms, interpreted them as less serious conditions and tried to alleviate the discomfort in various ways. When symptoms continued the patients consulted a relative, who often decided to seek care. Many considered waiting for an ambulance was too long and the relative often drove the patients to the hospital.

CONCLUSION

Patients as well as relatives were insecure about AMI symptoms and how to act. All patients contacted a relative, who was more eager than the patient to seek help. Many preferred to go in their own car to the hospital, believing it to be faster than an ambulance. Information about AMI symptoms and recommended action should be given to the public and to AMI patients and their relatives.

ST-segment-elevation myocardial infarction: guidelines and the challenge of real-world patient care

ST-segment-elevation myocardial infarction (STEMI) is a serious condition that requires early, aggressive management to reduce infarction damage and the risk of mortality. Although evidence-based guidelines recognize the clear benefits of early, effective reperfusion in STEMI, a number of barriers interfere with prompt delivery of care. Delays in treatment that exceed current evidence-based recommendations often plague reperfusion with either fibrinolytic therapy or percutaneous coronary intervention (PCI). Treatment delays and STEMI outcomes have improved with the coordination of STEMI management by involving active participation from community-based emergency technicians, on-site emergency physicians, interventional cardiologists, nurses, ancillary PCI staff, and hospital administrators. Under investigation are new therapeutic strategies that take advantage of improved coordination of care, such as the administration of bolus fibrinolytic therapy in the prehospital environment followed by immediate transfer of the patient for PCI. This approach may shorten the time to effective reperfusion and improve outcomes. Ongoing studies will help in determining the role this facilitated-PCI strategy may play in effective management of STEMI.

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

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Factors influencing emergency department arrival time and in-hospital management of patients with acute myocardial infarction

Reperfusion of the infarct-related artery in the very first hour ("golden hour") of acute myocardial infarction (AMI) significantly reduces mortality rates. Several factors may delay the initiation of reperfusion therapy (ie, thrombolytic therapy or primary percutaneous transluminal coronary angioplasty [PCTA]), most of which are related to patients. A total of 520 patients with suspected AMI were evaluated in the emergency department of Dokuz Eylül University Hospital between March 1996 and October 1999. After inclusion criteria were applied, the study consisted of 178 patients with a history of AMI. Analyzed data that affected patients' arrival to the hospital were obtained from responses to a questionnaire. The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, Ill), version 11.0, was used for all statistical analyses. The mean "symptom onset-hospital arrival time" was 188+/-325 min for the entire study group. The median delay was 110 min (approximately 2 h). Only 39 (22%) patients arrived to the hospital within the first hour. The mean time needed for late responders (n=109, 74%) (hospital arrival later than 1 h after symptom onset) to arrive was 245-/+363 min. According to the results of this study, many patients with AMI who may be eligible for reperfusion therapy miss the "golden hour" because of late hospital arrival. Some groups of patients (ie, elderly, women, those with diabetes) were especially late in arriving. To reduce such delays, training programs may be advised to focus on these groups of patients. Arrival times to the hospital during AMI can be greatly improved by efficient public education programs targeted to these groups.

Acute coronary syndromes in the emergency department: diagnostic characteristics, tests, and challenges

Failure to diagnose patients who have acute coronary syndromes (ACSs)-either acute myocardial infarction (AMI) or unstable angina pectoris (UAP)-who present to the emergency department (ED) remains a serious public health issue. Better understanding of the pathophysiology of coronary artery disease has allowed the adoption of a unifying hypothesis for the cause of ACSs: the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis. Thus, physicians have come to appreciate UAP and AMI as parts of a continuum of ACSs. This article reviews the state of the art regarding the diagnosis of ACSs in the emergency setting and suggests reasons why missed diagnosis continues to occur, albeit infrequently.

Use of an air ambulance system improves time to treatment of patients with acute myocardial infarction

OBJECTIVE

The aim of this study was to clarify whether a helicopter ambulance system (doctor helicopter system; DHS) could shorten the time interval to coronary intervention in the treatment of patients with acute myocardial infarction (AMI), in comparison with ground ambulance (GA).

METHODS

The time from the emergency call to coronary angiography (CAG time) or to percutaneous coronary intervention (PCI time), and the inhospital outcome were evaluated in 76 AMI patients. Twenty patients were transported by DHS, and the other 56 were by GA.

RESULTS

Both CAG time and PCI time were significantly shorter in the DHS (98.8+/-29.2 min, and 169.6+/-57.4 min) than those of the GA (126.6+/-48.7 min, and 203.2+/-57.0 min; p<0.05) group. Inhospital mortality was lower in the DHS (5.0%) versus the GA (10.7%) group.

CONCLUSION

Use of DHS shortened the time interval to coronary intervention and also improved the inhospital prognosis of AMI patients.

Medical Error Prevention in ED Triage for ACS: Use of Cardiac Care Decision Support and Quality Improvement Feedback

Medical errors in the care of patients who present with acute coronary syndrome (ACS)include errors in emergency department (ED) triage, such as the decision to send home a patient who presents with ACS or to hospitalize a patient who does not have ACS to the cardiac care unit (CCU), and errors in treatment, such as the failure to promptly use reperfusion therapy for patients who present with ST-elevation acute myocardial infarction(AMI). ECG-based acute cardiac ischemia time-insensitive predictive instrument(ACI-TIPI) and thrombolytic predictive instruments (TPIs), with a linked TIPI information system (TIPI-IS), provide real-time, concurrent, and retrospective decision support tools and feedback for the prevention of medical errors in the care of patients who present with ACS. In real-time, ACI-TIPI probabilities printed on the ECG header for the ED physician, provide an additional piece of information for triage decision making, and the ACI-TIPI Risk Management form reduces liability risk by prompting consideration and documentation of key clinical factors in the diagnosis of ACI. Also in real-time, the TPI increases overall coronary reperfusion therapy use. Concurrent flagging by TIPI-IS uses electronically acquired ECG and hospital data to provide concurrent alerts about potential misdiagnosis or mis-triage of patients with ACS. Retrospectively TIPI-IS-based feedback reports allow performance improvement. These examples of information technology tools integrated into ECG equipment already used in hospitals to deliver patient care demonstrate the potential to adapt other existing equipment or other patient care activities to enhance patient safety and error reduction.

Knowledge of heart attack symptoms in older men and women at risk for acute myocardial infarction

PURPOSE

Coronary heart disease is the number one cause of death for both men and women. While adults 65 years of age and older comprise the largest percentage of those who experience an acute myocardial infarction (AMI), investigators to date have failed to examine the knowledge of this population about AMI symptoms. The purpose of this study was to document knowledge about cardiovascular disease and AMI symptoms in older individuals with coronary heart disease to identify the characteristics associated with increased knowledge of cardiovascular disease.

METHODS

A descriptive design was used with a convenience sample of (N = 115) older adults at risk for AMI. Data were collected during face-to-face interviews in the participants' homes and analyzed using frequencies, percentages, chi, and multiple regression analysis.

RESULTS

Men and women were not significantly different in their knowledge of AMI symptoms except for jaw pain. More than 95% of the both men and women knew typical symptoms of AMI, such as chest pain, pressure, shortness of breath, arm or shoulder pain, and sweating. Less than 75% of both men and women knew that symptoms such as neck pain, nausea or vomiting, back pain, heartburn, and jaw pain could be symptoms of AMI. Thirty-one percent did not know about reperfusion therapies in the treatment of AMI. Having a cardiologist involved in care was weakly predictive of less knowledge.

CONCLUSIONS

Education and counseling of older patients at high risk for heart disease is complex, but should emphasize atypical symptoms and treatment options.

[Questionnaire for patients with ischaemic cardiopathy on their reaction to various alarm symptoms]

OBJECTIVES

To find the degree of information that patients with ischaemic cardiopathy (IC) possess and their behaviour on alarm symptoms (thoracic pain of ischaemic profile under stress, at rest, worsening under stress and for over 20'), how they manage sub-lingual nitro-glycerine (SLNTG), and the source of their information.

DESIGN

Transversal descriptive study based on personal interview and our own questionnaire, from September to December 2001.

SETTING

Primary Care. Six clinics in three urban Health Areas.Participants. Randomised sample of 98 patients with IC (stable angina, unstable angina, angina with infarct).

MEASUREMENTS AND RESULTS

93 people (57 male, 36 women) were surveyed. Their average age was 71 19.34 had diagnosis of infarct. 17.2% (95% CI, 9.5%24.9%) had no SLNTG available. 78.5% (95% CI; 70.2%-86.8%) and 81.7% (95% CI; 73.8%-89.6%) of those with angina under stress or at rest, respectively, did not know when to attend the hospital Emergency department. 37.8% (95% CI, 26.8%-48.8%) with steady stress angina would attend a hospital or their doctor urgently. 100% of patients had received no information on angina at rest, under steady stress and for over 20'. There was no difference in behaviour before stress angina between patients who had been informed by Primary Care and those informed by Specialists. There was a difference, though, for good use of SLNTG between infarct and non-infarct patients (p = 0.003).

CONCLUSIONS

Our cardiopaths do not recognise alarm signals quickly; and so do not benefit as well as they might from hospital treatment. No doctor (Primary Care or specialist) informed them of the different ways to confront stable and unstable angina. Only a very small number used SLNTG in stress angina properly and knew when to attend Casualty. There is an urgent need to improve the health education of our cardiopaths.

Dialing 911: a call to action

Cardiovascular disease and stroke are the nation's leading causes of disability and death. Scientific advances have provided newer treatments that, when applied effectively and in time, save a significant number of lives. Multiple factors in our system of delivery impede our ability to apply effective treatments, but with an analysis of the components of care, each of us can take leadership roles in our communities to improve the chain of survival. These elements and the science supporting each are briefly reviewed.

Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program

BACKGROUND

The use of critical pathways for a variety of clinical conditions has grown rapidly in recent years, particularly pathways for patients with acute coronary syndromes (ACS). However, no systematic review exists regarding the value of critical pathways in this setting.

METHODS

The National Heart Attack Alert Program established a Working Group to review the utility of critical pathways on quality of care and outcomes for patients with ACS. A literature search of MEDLINE, cardiology textbooks, and cited references in any article identified was conducted regarding the use of critical pathways for patients with ACS.

RESULTS

Several areas for improving the care of patients with ACS through the application of critical pathways were identified: increasing the use of guideline-recommended medications, targeting use of cardiac procedures and other cardiac testing, and reducing the length of stay in hospitals and intensive care units. Initial studies have shown promising results in improving quality of care and reducing costs. No large studies designed to demonstrate an improvement in mortality or morbidity were identified in this literature review.

CONCLUSIONS

Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes.

Bridging the gap with new strategies in acute ST elevation myocardial infarction: bolus thrombolysis, glycoprotein IIb/IIIa inhibitors, combination therapy, percutaneous coronary intervention, and "facilitated" PCI

Achieving early reperfusion with thrombolytic agents or primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) is the cornerstone of current therapy. Two advances in pharmacologic therapy are: (1) bolus thrombolysis, which simplifies therapy, reduces door-to-needle time, and reduces the potential for medication errors, and (2) Low-dose fibrinolytic therapy combined with a glycoprotein (GP) IIb/IIIa inhibitor which can achieve higher rates of reperfusion than fibrinolytic therapy alone. In addition, the IIb/IIIa inhibitor as part of the reperfusion regimen will support any acute-phase interventions that are performed. The combination of fibrinolytic therapy and GP IIb/IIIa inhibition to "facilitate" PCI is being examined in TIMI-14, SPEED, and GUSTO IV. Early findings in the SPEED trial have shown promising results with "facilitated" PCI when patency is achieved before PCI is attempted. Results of these trials will further define the role of combination therapy in facilitating mechanical interventions.