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

Symptom clusters and unplanned hospital readmission in Chinese patients with acute myocardial infarction on admission

Backgroud

Acute myocardial infarction (AMI) has a high morbidity rate, high mortality rate, high readmission rate, high health care costs, and a high symptomatic, psychological, and economic burden on patients. Patients with AMI usually present with multiple symptoms simultaneously, which are manifested as symptom clusters. Symptom clusters have a profound impact on the quality of survival and clinical outcomes of AMI patients.

Objective

The purpose of this study was to analyze unplanned hospital readmissions among cluster groups within a 1-year follow-up period, as well as to identify clusters of acute symptoms and the characteristics associated with them that appeared in patients with AMI.

Methods

Between October 2021 and October 2022, 261 AMI patients in China were individually questioned for symptoms using a structured questionnaire. Mplus 8.3 software was used to conduct latent class analysis in order to find symptom clusters. Univariate analysis is used to examine characteristics associated with each cluster, and multinomial logistic regression is used to analyze a cluster membership as an independent predictor of hospital readmission after 1-year.

Results

Three unique clusters were found among the 11 acute symptoms: the typical chest symptom cluster (64.4%), the multiple symptom cluster (29.5%), and the atypical symptom cluster (6.1%). The cluster of atypical symptoms was more likely to have anemia and the worse values of Killip class compared with other clusters. The results of multiple logistic regression indicated that, in comparison to the typical chest cluster, the atypical symptom cluster substantially predicted a greater probability of 1-year hospital readmission (odd ratio 8.303, 95% confidence interval 2.550-27.031, P < 0.001).

Conclusion

Out of the 11 acute symptoms, we have found three clusters: the typical chest symptom, multiple symptom, and atypical symptom clusters. Compared to patients in the other two clusters, those in the atypical symptom cluster-which included anemia and a large percentage of Killip class patients-had worse clinical indicators at hospital readmission during the duration of the 1-year follow-up. Both anemia and high Killip classification suggest that the patient's clinical presentation is poor and therefore the prognosis is worse. Intensive treatment should be considered for anemia and high level of Killip class patients with atypical presentation. Clinicians should focus on patients with atypical symptom clusters, enhance early recognition of symptoms, and develop targeted symptom management strategies to alleviate their discomfort in order to improve symptomatic outcomes.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Association Between Primary Care Practice Telehealth Use and Acute Care Visits for Ambulatory Care-Sensitive Conditions During COVID-19

IMPORTANCE

During the COVID-19 pandemic, many primary care practices adopted telehealth in place of in-person care to preserve access to care for patients with acute and chronic conditions. The extent to which this change was associated with their rates of acute care visits (ie, emergency department visits and hospitalizations) for these conditions is unknown.

OBJECTIVE

To examine whether a primary care practice's level of telehealth use is associated with a change in their rate of acute care visits for ambulatory care-sensitive conditions (ACSC visits).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis used a difference-in-differences study design to analyze insurance claims data from 4038 Michigan primary care practices from January 1, 2019, to September 30, 2020.

EXPOSURES

Low, medium, or high tertile of practice-level telehealth use based on the rate of telehealth visits from March 1 to August 31, 2020, compared with prepandemic visit volumes.

MAIN OUTCOMES AND MEASURES

Risk-adjusted ACSC visit rates before (June to September 2019) and after (June to September 2020) the start of the COVID-19 pandemic, reported as an annualized average marginal effect. The study examined overall, acute, and chronic ACSC visits separately and controlled for practice size, in-person visit volume, zip code-level attributes, and patient characteristics.

RESULTS

A total of nearly 1.5 million beneficiaries (53% female; mean [SD] age, 40 [22] years) were attributed to 4038 primary care practices. Compared with 2019 visit volumes, median telehealth use was 0.4% for the low telehealth tertile, 14.7% for the medium telehealth tertile, and 39.0% for the high telehealth tertile. The number of ACSC visits decreased in all tertiles, with adjusted rates changing from 24.3 to 14.9 per 1000 patients per year (low), 23.9 to 15.3 per 1000 patients per year (medium), and 27.5 to 20.2 per 1000 patients per year (high). In difference-in-differences analysis, high telehealth use was associated with a higher ACSC visit rate (2.10 more visits per 1000 patients per year; 95% CI, 0.22-3.97) compared with low telehealth practices; practices in the middle tertile did not differ significantly from the low tertile. No difference was found in ACSC visits across tertiles when acute and chronic ACSC visits were examined separately.

CONCLUSIONS AND RELEVANCE

In this cohort study that used a difference-in-differences analysis, the association between practice-level telehealth use and ACSC visits was mixed. High telehealth use was associated with a slightly higher overall ACSC visit rate than low telehealth practices. The association of telehealth with downstream care use should be closely monitored going forward.

Sex Differences in Implantation and Outcomes of Cardiac Resynchronization Therapy in Real-World Settings: A Systematic Review of Cohort Studies

Background

Evidence from randomized trials is conflicting on the effects of cardiac resynchronization therapy (CRT) by sex, and differences in access are unknown. We examined sex differences in the implantation rates and outcomes in patients treated with CRT using cohort studies.

Methods

We followed a pre-specified protocol (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42020204804). MEDLINE, Embase, and Web of Science were searched for cohort studies from January 2000 to June 2020 that evaluated the response to CRT in patients ≥ 18 years old and reported sex-specific information in any language.

Results

We included 97 studies (1,172,654 men and 486,553 women). Men received CRT more frequently than women (median ratio, 3.16; 25th to 75th interquartile range, 2.48-3.62). In the unadjusted analysis, men had a greater long-term all-cause mortality rate after CRT, compared with women (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.38-1.63; P < 0.001). Adjustment for confounders did not affect the strength or direction of association (HR, 1.45; 95% CI, 1.32-1.59; P < 0.001). Women achieved a greater rate of improvement in left ejection fraction compared with men (HR, 4.66; 95% CI, 4.23-5.13; P < 0.001). Men had a lower risk of a pneumothorax (relative risk, 0.21; 95% CI, 0.13-0.34; P < 0.001]); otherwise, there were no differences in complications.

Conclusions

We found in this large meta-analysis that men were more often implanted with CRT than women, yet men had a higher long-term all-cause mortality following CRT, compared with women, and smaller improvement in left ventricular ejection fraction. Reasons for this difference in implantation rates of CRT in real-world practice need to be investigated.

Unusual Fatigue and Failure to Utilize EMS Are Associated With Prolonged Prehospital Delay for Suspected Acute Coronary Syndrome

BACKGROUND

Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS), but efficacy is time dependent. The aim of this study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS, stratified by final diagnosis (ACS vs. no ACS).

METHODS

A heterogeneous sample of emergency department (ED) patients with symptoms suggestive of ACS was enrolled at 5 US sites. Accelerated failure time models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis.

RESULTS

Enrolled were 609 (62.5%) men and 366 (37.5%) women, predominantly white (69.1%), with a mean age of 60.32 (±14.07) years. Median delay time was 6.68 (confidence interval 1.91, 24.94) hours; only 26.2% had a prehospital delay of 2 hours or less. Patients presenting with unusual fatigue [time ratio (TR) = 1.71, P = 0.002; TR = 1.54, P = 0.003, respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR = 1.93, P < 0.001; TR = 1.71, P < 0.001, respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR = 0.65, P = 0.013 and TR = 0.67, P = 0.022, respectively). Predictors of shorter delay for patients ruled out for ACS were chest pain and sweating (TR = 0.071, P = 0.025 and TR = 0.073, P = 0.032, respectively).

CONCLUSION

Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is important for patients with possible ACS symptoms. Calling 911 can be positively framed to at-risk patients and the community as having advanced care come to them because EMS capabilities include 12-lead ECG acquisition and possibly high-sensitivity troponin assays.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

Can people apply 'FAST' when it really matters? A qualitative study guided by the common sense self-regulation model

Background

Early identification of stroke symptoms and rapid access to the emergency services increases an individual’s chance of receiving thrombolytic therapy and reduces the likelihood of infirmity. The UK’s national stroke campaign ‘Act FAST’ was developed to increase public awareness of stroke symptoms and highlighted the importance of rapid response by contacting emergency services. No study to date has assessed if and how people who experienced or witnessed stroke in line with the campaigns’ symptoms of the FAST acronym (i.e., facial weakness, arm weakness, slurred speech, and time) may use this FAST in their response.

Methods

Semi-structured interviews with 13 stroke patients and witnesses were conducted. Interviews were theory-guided based on the Common Sense Self-Regulation Model, to understand the appraisal process of the onset of stroke symptoms and how this impacted on participants’ ability to apply their knowledge of the FAST campaign.

Results

The majority of patients (n = 8/13) failed to correctly identify stroke and reported no impact of the campaign on their stroke recognition and response. Inability to identify stroke, perceiving symptoms to lack severity and lack of control contributed to a delay in seeking medical attention.

Conclusion

Stroke witnesses and patients predominantly fail to identify stroke which suggest a lack of FAST application when it matters. Inaccurate risk perceptions and lack of physical control both play central roles in influencing the formation of illness representation not associated with an appropriate emergency response.

External Validation of START nomogram to predict 3-Month unfavorable outcome in Chinese acute stroke patients

BACKGROUND

Recently, the NIHSS STroke Scale score, Age, pre-stroke mRS score, onset-to-treatment Time (START nomogram) predicts 3-month functional outcome after intravenous thrombolysis in ischemic stroke patients. However, this model has not yet been an external validation. We aim to validate the performance of START nomogram.

METHODS

Data were derived from the stroke center of the Nanjing First Hospital (China). Patients who lacked the necessary data to calculate the nomogram and missed 3-month modified Ranking scale scores were excluded. Modified Rankin Scale score more than 2 at 3-month was assessed as an unfavorable outcome. We used areas under the receiver operator characteristic curves (AUC-ROC) to quantify the prognostic value. Calibration was assessed by calibration plots and Hosmer-Lemeshow (HL) goodness of fit test.

RESULT

The final cohort included 306 eligible patients. For 3-month unfavorable outcome, the AUC-ROC of the START nomogram was .766 (95%CI: .7013-.8304, P < .0001), suggesting good discrimination in the START nomogram. It also showed good calibration (HL goodness of fit test P = .1261) in the external validation sample.

CONCLUSION

The START nomogram with good predictive performance is a reliable and simple clinical instrument to predict unfavorable outcome after acute stroke.

The Quality of Symptoms in Women and Men Presenting to the Emergency Department With Suspected Acute Coronary Syndrome

INTRODUCTION

More than 5.5 million patients present to emergency departments in the United States annually for potential acute coronary syndrome (ACS); however, diagnosing ACS remains a challenge in emergency departments. Our aim was to describe the quality of symptoms (chest discomfort/description of pain, location/radiation, and overall symptom distress) reported by women and men ruled-in and ruled-out for ACS in emergency departments.

METHODS

The sample consisted of 1,064 patients presenting to emergency departments with symptoms that triggered cardiac workups. Trained research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to emergency departments.

RESULTS

The sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; P = 0.002) and was a significant predictor for an ACS diagnosis in men (odds ratio [OR], 1.10; confidence interval [CI], 1.03-1.17; P = 0.003). Women also reported more chest pressure (51.75% vs. 44.65; P = 0.02) compared with men, and chest pressure was a significant predictor for a diagnosis of ACS (OR, 1.61; CI, 1.03-2.53; P = 0.02).

DISCUSSION

Higher levels of symptom distress may help ED personnel in making a decision to evaluate a patient for ACS, and the presence of chest pressure may aid in making a differential diagnosis of ACS.

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

Prognostic models for complete recovery in ischemic stroke: a systematic review and meta-analysis

Background

Prognostic models have been increasingly developed to predict complete recovery in ischemic stroke. However, questions arise about the performance characteristics of these models. The aim of this study was to systematically review and synthesize performance of existing prognostic models for complete recovery in ischemic stroke.

Methods

We searched journal publications indexed in PUBMED, SCOPUS, CENTRAL, ISI Web of Science and OVID MEDLINE from inception until 4 December, 2017, for studies designed to develop and/or validate prognostic models for predicting complete recovery in ischemic stroke patients. Two reviewers independently examined titles and abstracts, and assessed whether each study met the pre-defined inclusion criteria and also independently extracted information about model development and performance. We evaluated validation of the models by medians of the area under the receiver operating characteristic curve (AUC) or c-statistic and calibration performance. We used a random-effects meta-analysis to pool AUC values.

Results

We included 10 studies with 23 models developed from elderly patients with a moderately severe ischemic stroke, mainly in three high income countries. Sample sizes for each study ranged from 75 to 4441. Logistic regression was the only analytical strategy used to develop the models. The number of various predictors varied from one to 11. Internal validation was performed in 12 models with a median AUC of 0.80 (95% CI 0.73 to 0.84). One model reported good calibration. Nine models reported external validation with a median AUC of 0.80 (95% CI 0.76 to 0.82). Four models showed good discrimination and calibration on external validation. The pooled AUC of the two validation models of the same developed model was 0.78 (95% CI 0.71 to 0.85).

Conclusions

The performance of the 23 models found in the systematic review varied from fair to good in terms of internal and external validation. Further models should be developed with internal and external validation in low and middle income countries.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1032-5) contains supplementary material, which is available to authorized users.

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.

The association of posttraumatic stress disorder and chronic medical conditions by ethnicity

Our study extends the literature on associations between posttraumatic stress disorder (PTSD) and chronic medical conditions by assessing differences in the magnitude of these relations by ethnicity. We examined group differences in the magnitude of the relation between PTSD and chronic medical conditions (cardiovascular disease [CVD], hypertension, obesity, diabetes). We obtained data from Latino (n = 3,224) and non-Latino white (n = 4,180) respondents from the Collaborative Psychiatric Epidemiology Surveys. Logistic regression models were constructed to test for the modification of the effect of PTSD on chronic medical conditions by ethnicity, and then by nativity. Unadjusted models revealed significant interactions between Latino ethnicity and PTSD for odds of diabetes (OR = 2.18 [Latino] v. 0.81 [non-Latino white]), CVD (OR = 3.23 [Latino] v. 1.28 [non-Latino white]), and hypertension (OR = 1.61 [Latino] v. 0.98 [non-Latino white]). Among U.S.-born Latinos, we found a significant interaction between ethnicity and PTSD for odds of CVD (OR = 4.18 [Latino] v. 1.28 [non-Latino white]) and diabetes (OR = 2.27 [Latino] v. 0.81 [non-Latino white]). These findings attenuated in adjusted models with the exception of differences in PTSD and odds of diabetes among Latinos (including aggregated group & U.S.-born) compared to non-Latino whites. Our findings support the need for further research on the complex relations between PTSD and chronic conditions, including the investigation of conditional risk by Latino sub-groups.

Older Adults at Risk for Atrial Fibrillation Lack Knowledge and Confidence to Seek Treatment for Signs and Symptoms

Early detection of atrial fibrillation (AF) is crucial for averting AF-related stroke and heart failure, but treatment is delayed when AF is not recognized. The critical need for early detection and treatment requires education to promote AF awareness. Knowledge deficits, attitudes, and beliefs about AF that should be addressed to improve awareness and reduce treatment-seeking delay in older adults at risk for developing AF have not been well documented. The purpose of this study was to describe knowledge, treatment-seeking attitudes, and beliefs about AF in adults ⩾ 65 years old and identify demographic characteristics associated with knowledge, attitudes, and beliefs. Patients with no history of AF recruited from an academic medical center were interviewed using the Knowledge, Attitudes, and Beliefs about Atrial Fibrillation Survey. Data were analyzed using descriptive statistics and independent t tests. Participants (N = 180) were 63% male with a mean age of ±3.± 6.0 years, and 52% held ⩾ 4-year college degree. About one third could not identify common symptoms of AF including palpitations (31%), chest pain (36%), dyspnea (30%), and fatigue (35%). A majority (84%) lacked confidence to recognize AF, and 58% were not sure when they should seek care for AF symptoms. Nearly a third (32%) believed palpitations are always present with AF, and 74% believed that low energy would not be their only symptom of AF. Higher scores for AF Symptom Knowledge (p = .02) were observed in females, and General Knowledge about AF was greater for younger participants (p < .001). Participants lacked knowledge and confidence to aid decision-making for treatment-seeking for symptoms of AF and held inaccurate beliefs about AF that could hinder early treatment-seeking. Programs to promote AF awareness should explain the spectrum of symptoms that may be manifested by AF and include action plans for responding to symptoms.

Acute myocardial infarction hospital admissions and deaths in England: a national follow-back and follow-forward record-linkage study

BACKGROUND

Little information is available on how primary and comorbid acute myocardial infarction contribute to the mortality burden of acute myocardial infarction, the share of these deaths that occur during or after a hospital admission, and the reasons for hospital admission of those who died from acute myocardial infarction. Our aim was to fill in these gaps in the knowledge about deaths and hospital admissions due to acute myocardial infarction.

METHODS

We used individually linked national hospital admission and mortality data for England from 2006 to 2010 to identify all primary and comorbid diagnoses of acute myocardial infarction during hospital stay and their associated fatality rates (during or within 28 days of being in hospital). Data were obtained from the UK Small Area Health Statistics Unit and supplied by the Health and Social Care Information Centre (now NHS Digital) and the Office of National Statistics. We calculated event rates (reported as per 100 000 population for relevant age and sex groups) and case-fatality rate for primary acute myocardial infarction diagnosed during the first physician encounter or during subsequent encounters, and acute myocardial infarction diagnosed only as a comorbidity. We also calculated what proportion of deaths from acute myocardial infarction occurred in people who had been in hospital on or within the 28 days preceding death, and whether acute myocardial infarction was one of the recorded diagnoses in such admissions.

FINDINGS

Acute myocardial infarction was diagnosed in the first physician encounter in 307 496 (69%) of 446 744 admissions with a diagnosis of acute myocardial infarction, in the second or later physician encounter in 52 374 (12%) admissions, and recorded only as a comorbidity in 86 874 (19%) admissions. Patients with comorbid diagnoses of acute myocardial infarction had two to three times the case-fatality rate of patients in whom acute myocardial infarction was a primary diagnosis. 135 950 deaths were recorded as being caused by acute myocardial infarction as the underlying cause of death, of which 66 490 (49%) occurred in patients who were in hospital on the day of death or in the 28 days preceding death. AMI was the primary diagnosis in 32 695 (49%) of these 66 490 patients (27 678 [42%] diagnosed in the first physician encounter and 5017 [8%] in a second or subsequent encounter), was a comorbid diagnosis in 12 118 (18%), and was not mentioned at all in the remaining 21 677 (33%). The most common causes of admission in people who did not have an acute myocardial infarction diagnosis but went on to die of acute myocardial infarction as the underlying cause of death were other circulatory conditions (7566 [35%] of 21 677 deaths), symptomatic diagnoses including non-specific chest pain, dyspnoea and syncope (1368 [6%] deaths), and respiratory disorders (2662 [12%] deaths), mainly pneumonia and chronic obstructive airways disease.

INTERPRETATION

As many acute myocardial infarction deaths occurring within 28 days of being in hospital follow a non-acute myocardial infarction admission as follow an acute myocardial infarction admission. These people are often diagnosed with other circulatory disorders or symptoms of circulatory disturbance. Further investigation is needed to establish whether there are symptoms and information that can be used to predict the risk of a fatal acute myocardial infarction in such patients, which can contribute to reducing the mortality burden of acute myocardial infarction.

FUNDING

Wellcome Trust, Medical Research Council, Public Health England, National Institute for Health Research.

Facilitators of and barriers to emergency medical service use by acute ischemic stroke patients: A retrospective survey

OBJECTIVE

The objective of the study was to identify facilitators and barriers to emergency medical service use among acute ischemic stroke patients in Korea.

METHODS

This paper presents a secondary analysis of a retrospective survey that collected data from questionnaires and medical records. Among 233 acute ischemic stroke patients enrolled in a large-scale study, 160 patients who had arrived at a hospital within 72 h after symptom onset were included in the data analysis.

RESULTS

Users of emergency medical services needed a shorter time than non-users to arrive at hospital (140 min vs. 625 min., p = 0.001) and were more likely to arrive at hospital within 3 h of symptom onset (51.9% vs. 31.5%, p = 0.013). For those who first contacted emergency medical service, the facilitators of emergency medical service use were the presence of hemiparesis (p = 0.003), bilateral paralysis (p = 0.040), and loss of balance (p = 0.021). The predominant barrier was the failure to recognize the urgency of symptoms (p = 0.006).

CONCLUSIONS

The use of emergency medical services reduced prehospital delay and increased the likelihood of patient arrival at hospital within 3 h. Given that experiencing typical stroke symptoms was a facilitator of emergency medical service use yet failure to recognize the urgency of symptoms was a barrier, public awareness should be raised as regards stroke symptoms and the benefits of using emergency medical services.

Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology

INTRODUCTION

The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services' (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms.

OBJECTIVES

The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics.

METHODS

Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history).

RESULTS

In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47minutes for ambulance patients versus 53minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED.

DISCUSSION

Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS '911' system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain.

Telemedicine with clinical decision support for critical care: a systematic review

BACKGROUND

Telemedicine applications aim to address variance in clinical outcomes and increase access to specialist expertise. Despite widespread implementation, there is little robust evidence about cost-effectiveness, clinical benefits, and impact on quality and safety of critical care telemedicine. The primary objective was to determine the impact of critical care telemedicine (with clinical decision support available 24/7) on intensive care unit (ICU) and hospital mortality and length of stay in adults and children. The secondary objectives included staff and patient experience, costs, protocol adherence, and adverse events.

METHODS

Data sources included MEDLINE, EMBASE, CINAHL, Cochrane Library databases, Health Technology Assessment Database, Web of Science, OpenGrey, OpenDOAR, and the HMIC through to December 2015. Randomised controlled trials and quasi-experimental studies were eligible for inclusion. Eligible studies reported on differences between groups using the telemedicine intervention and standard care. Two review authors screened abstracts and assessed potentially eligible studies using Cochrane guidance.

RESULTS

Two controlled before-after studies met the inclusion criteria. Both were assessed as high risk of bias. Meta-analysis was not possible as we were unable to disaggregate data between the two studies. One study used a non-randomised stepped-wedge design in seven ICUs. Hospital mortality was the primary outcome which showed a reduction from 13.6 % (CI, 11.9-15.4 %) to 11.8 % (CI, 10.9-12.8 %) during the intervention period with an adjusted odds ratio (OR) of 0.40 (95 % CI, 0.31-0.52; p = .005). The second study used a non-randomised, unblinded, pre-/post-assessment of telemedicine interventions in 56 adult ICUs. Hospital mortality (primary outcome) reduced from 11 to 10 % (adjusted hazard ratio (HR) = 0.84; CI, 0.78-0.89; p = <.001).

CONCLUSIONS

This review highlights the poor methodological quality of most studies investigating critical care telemedicine. The results of the two included studies showed a reduction in hospital mortality in patients receiving the intervention. Further multi-site randomised controlled trials or quasi-experimental studies with accompanying process evaluations are urgently needed to determine effectiveness, implementation, and associated costs.

TRIAL REGISTRATION

PROSPERO CRD42014007406.

Pre-hospital Delay after Acute Ischemic Stroke in Central Urban China: Prevalence and Risk Factors

Timely thrombolytic treatment is paramount after acute ischemic stroke (AIS); however, a large proportion of patients experience substantial delays in presentation to hospital. This study evaluates the prevalence and risk factors in pre-hospital delays after AIS in central urban China. AIS patients from 66 hospitals in 13 major cities across Hubei Province, between October 1, 2014 and January 31, 2015 were interviewed and their medical records were reviewed to identify those who suffered pre-hospital delays. Bivariate and multivariate analyses were undertaken to determine the prevalence rates and the risk factors associated with pre-hospital delays. A total of 1835 patients were included in the analysis, with 69.3 % patients reportedly arrived at hospital 3 or more hours after onset and 55.3 % patients arrived 6 or more hours after onset. Factors associated with increased pre-hospital delays for 3 or more hours were as follows: patient had a history of stroke (odds ratio (OR), 1.319, P = 0.028), onset location was at home (OR, 1.573, P = 0.002), and patients rather than someone else noticed the symptom onset first (OR, 1.711; P < 0.001). In contrast, knowing someone who had suffered a stroke, considering any kind of the symptoms as severe, transferring from a community-based hospital factors, calling emergency number (120), and shorter distance from the onset place to the first hospital were independently associated with decreased pre-hospital delays. These findings indicate that pre-hospital delays after AIS are common in urban central China, and future intervention programs should be focused on public awareness of stroke and appropriate response.

Fatigue, dyspnea, and intermittent symptoms are associated with treatment-seeking delay for symptoms of atrial fibrillation before diagnosis

BACKGROUND

Delay in seeking treatment for symptoms of atrial fibrillation (AF) at onset results in a missed opportunity for vital early treatment of AF which is important for reducing stroke, tachycardia induced heart failure, and treatment-resistant AF. Little is known about factors that contribute to treatment-seeking delay for symptoms of AF.

PURPOSE

The purpose of this study was to identify factors associated with treatment-seeking delay for symptoms of AF before diagnosis.

METHODS

For this descriptive study, 150 participants with recently detected AF completed structured interviews to collect data about symptoms, symptom characteristics, symptom representation regarding cause, seriousness, controllability of symptoms, responses to symptoms before diagnosis, and time from symptom onset to treatment-seeking. Chi-square analysis was used to identify factors associated with delay (>1 week) versus no delay (⩽1 week) in treatment-seeking after symptom onset.

RESULTS

Participants were 51% female (n=76) with a mean age of 66.5 (standard deviation (SD)±11.1) years. A majority (70%, n=105) delayed treatment-seeking. Factors associated with delay included experiencing fatigue, dyspnea, intermittent symptoms, attributing symptoms to deconditioning, overwork, inadequate sleep, and perceiving symptoms as not very serious and amenable to self-management. Responses such as a wait and see approach, working through symptoms, reporting no fear of symptoms, or attempting to ignore symptoms were associated with delay.

CONCLUSION

Experiencing fatigue, dyspnea and intermittent symptoms produced symptom representations and emotional and behavioral responses associated with treatment-seeking delay. There is a critical need to develop and test educational interventions to increase awareness of the spectrum and characteristics of AF symptoms and appropriate treatment-seeking behaviors.

Development and initial testing of the stroke rapid-treatment readiness tool

No instruments are currently available to help health systems identify target areas for reducing door-to-needle times for the administration of intravenous tissue plasminogen activator to eligible patients with ischemic stroke. A 67-item Likert-scale survey was administered by telephone to stroke personnel at 252 U.S. hospitals participating in the “Get With The Guidelines-Stroke” quality improvement program. Factor analysis was used to refine the instrument to a four-factor 29-item instrument that can be used by hospitals to assess their readiness to administer intravenous tissue plasminogen activator within 60 minutes of patient hospital arrival.

Cross-cultural adaptation of the stroke action test for Italian--speaking people

Background

Assessing the level of public stroke awareness is a prerequisite for development of community educational campaigns aimed at reducing prehospital delay of stroke patients. The Stroke Action Test (STAT) is a validated instrument specifically developed in the United States with the objective to assess the public’s readiness to respond to stroke. Our purpose was to perform the cross-cultural adaptation of the original version of STAT to be applied to the Italian population.

Methods

The process of cross-cultural adaptation has been performed according to guidelines, intended for questionnaires of self-report health status measures, following five steps: forward translation, synthesis, back translation, approval by an Expert Committee and test of the pre-final version. For this last step, 31 adults were asked to rate each item in terms of adequacy of content, clarity of wording and usefulness, according to a 3-point scale. The final version has been administered to a sample of 202 volunteers to assess its acceptability and reliability in terms of the internal consistency.

Results

The pre-final version of the STAT was developed taking into accounts few and minimal discrepancies between the two back translations and the original version of the instrument. Most items were judged as adequate, easy to understand and useful, according to the frequency of high scores (>50 %) given by the adaptation sample. As for further testing of the adapted final version, completeness of item response was very good. Distribution of scores ranged from 0 to 100 %, without any floor or ceiling effect, with a percentage of the lowest scoring of 1.5 % for the 28-item test and 2.5 % for the 21-item test and a percentage of the highest scoring of 1 % for both tests. Internal consistency was high for both the 28-item and 21-item tests (Cronbach alpha = 0.85 and 0.84, respectively).

Conclusions

The process used to perform the cross-cultural adaptation of the questionnaire was successful. The Italian version of STAT demonstrated good acceptability and psychometric properties and is now available to assess stroke awareness in Italian people.

Social interactions at the onset of rheumatoid arthritis and their influence on help-seeking behaviour: A qualitative exploration

OBJECTIVES

To explore how social interactions at the onset of rheumatoid arthritis (RA) influence help-seeking behaviour from the perspectives of those with RA and their significant others (family and friends).

METHODS

Nineteen semi-structured qualitative interviews were undertaken with people recently diagnosed with RA and their significant others. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

Significant others' initial appraisals of symptoms led them to provide practical support with daily activities rather than advice to seek help. People with RA described difficulties in communicating the severity of their symptoms and often attempted to hide their symptoms from others. Significant others also reacted negatively, expressing disbelief and dismissing symptoms. On occasion, early symptoms were even described as the catalyst for the breakdown of relationships. On reflection, significant others expressed guilt about their initial reactions and wished that they had recognized the need for intervention earlier. When symptoms had advanced and were more obvious, significant others often strongly advised that help should be sought and, in some cases, physically escorted the patient to their medical appointment. In many instances, people with RA described significant others as the catalyst for eventually seeking help.

CONCLUSIONS

Significant others play an important role in influencing help-seeking behaviour; this has implications for theoretical models of help-seeking and the development of help-seeking interventions. A negative consequence of social interactions resulted from a lack of understanding and knowledge about RA among significant others, highlighting the need for greater public awareness about the early symptoms of RA.

Stroke warning campaigns: delivering better patient outcomes? A systematic review

Background

Patient delay in presenting to hospital with stroke symptoms remains one of the major barriers to thrombolysis treatment, leading to its suboptimal use internationally. Educational interventions such as mass media campaigns and community initiatives aim to reduce patient delays by promoting the signs and symptoms of a stroke, but no consistent evidence exists to show that such interventions result in appropriate behavioral responses to stroke symptoms.

Methods

A systematic literature search and narrative synthesis were conducted to examine whether public educational interventions were successful in the reduction of patient delay to hospital presentation with stroke symptoms. Three databases, MEDLINE, CINAHL, and PsycINFO, were searched to identify quantitative studies with measurable behavioral end points, including time to hospital presentation, thrombolysis rates, ambulance use, and emergency department (ED) presentations with stroke.

Results

Fifteen studies met the inclusion criteria: one randomized controlled trial, two time series analyses, three controlled before and after studies, five uncontrolled before and after studies, two retrospective observational studies, and two prospective observational studies. Studies were heterogeneous in quality; thus, meta-analysis was not feasible. Thirteen studies examined prehospital delay, with ten studies reporting a significant reduction in delay times, with a varied magnitude of effect. Eight studies examined thrombolysis rates, with only three studies reporting a statistically significant increase in thrombolysis administration. Five studies examined ambulance usage, and four reported a statistically significant increase in ambulance transports following the intervention. Three studies examining ED presentations reported significantly increased ED presentations following intervention. Public educational interventions varied widely on type, duration, and content, with description of intervention development largely absent from studies, limiting the potential replication of successful interventions.

Conclusions

Positive intervention effects were reported in the majority of studies; however, methodological weaknesses evident in a number of studies limited the generalizability of the observed effects. Reporting of specific intervention design was suboptimal and impeded the identification of key intervention components for reducing patient delay. The parallel delivery of public and professional interventions further limited the identification of successful intervention components. A lack of studies of sound methodological quality using, at a minimum, a controlled before and after design was identified in this review, and thus studies incorporating a rigorous study design are required to strengthen the evidence for public interventions to reduce patient delay in stroke. The potential clinical benefits of public interventions are far-reaching, and the challenge remains in translating knowledge improvements and correct behavioral intentions to appropriate behavior when stroke occurs.

Symptom Representation and Treatment-Seeking Prior to Diagnosis of Atrial Fibrillation

Early treatment-seeking for symptoms of atrial fibrillation (AF) is critical to avert AF-related stroke and heart failure, but early treatment is hindered if symptoms are not accurately interpreted. The purpose of this research was to describe symptom representation and treatment-seeking responses prior to diagnosis of AF. For this descriptive study, 150 participants were surveyed to describe the type and temporality of symptoms, perceptions regarding the cause, seriousness, controllability of symptoms, and responses to symptoms prior to diagnosis. Participants' mean age was 66.5 years, and 51% were female. Participants perceived symptoms as having nondisease-based causes, as not very serious, and as amenable to self-management. The majority took a wait and see response with 69% waiting more than 1 week after symptom onset to seek treatment. Lack of recognition of the seriousness of symptoms of AF and delayed treatment put patients at risk of poorer outcomes.

Patients' experiences from symptom onset to initial treatment for atrial fibrillation

AIMS AND OBJECTIVES

To describe patients' experiences from symptom onset to initial treatment for atrial fibrillation.

BACKGROUND

The estimated number of individuals with atrial fibrillation globally in 2010 was 33·5 million. World-wide, each year, new cases of atrial fibrillation approach 5 million, and prevalence will increase 2·5-fold by 2050. As a result, clinicians worldwide will treat a growing number of patients with atrial fibrillation. Early intervention to promote atrial fibrillation self-management is critical to reduce associated complications of stroke and heart failure. Greater understanding of patients' experiences from symptom onset to initial treatment for atrial fibrillation is needed to guide development of interventions to promote early effective self-management.

DESIGN

A descriptive qualitative design was used.

METHODS

Twenty females and 21 males at an academic medical centre were interviewed using open-ended questions to explore their experiences from symptom onset to initial treatment for atrial fibrillation. Data were analysed using qualitative content analysis.

RESULTS

Participants' mean age was 64·3 (SD = 10·1) years. Four themes were identified: (1) misinterpreting symptoms; (2) discovering the meaning of atrial fibrillation; (3) facing fears, uncertainty, and moving to acceptance; and (4) receiving validation and reassurance. Participants lacked knowledge of atrial fibrillation and took cues from providers' responses to appraise symptoms and diagnosis. Fear and uncertainty were reduced when providers initiated prompt treatment and took time to explain atrial fibrillation. Patients appreciated receiving clear information about atrial fibrillation, were engaged in learning, and motivated to participate in their care.

CONCLUSIONS

Providers played a critical role in helping patients to develop an accurate understanding of atrial fibrillation, to cope with the new diagnosis, and motivated them to engage in effective self-management.

RELEVANCE TO CLINICAL PRACTICE

Insight into participant experiences from symptom onset to initial treatment for atrial fibrillation may inform development of interventions to promote effective atrial fibrillation self-management.

Essential service standards for equitable national cardiovascular care for Aboriginal and Torres Strait Islander people

Cardiovascular diseases (CVD) constitute the largest cause of death for Aboriginal and Torres Strait Islander people and remain the primary contributor to life expectancy differentials between Aboriginal and Torres Strait Islander and non-Indigenous Australians. As such, CVD remains the most critical target for reducing the life expectancy gap. The Essential Service Standards for Equitable National Cardiovascular Care for Aboriginal and Torres Strait Islander people (ESSENCE) outline elements of care that are necessary to reduce disparity in access and outcomes for five critical cardiovascular conditions. The ESSENCE approach builds a foundation on which the gap in life expectancy between Aboriginal and Torres Strait Islander and non-Indigenous Australians can be reduced. The standards purposefully focus on the prevention and management of CVD extending across the continuum of risk and disease. Each of the agreed essential service standards are presented alongside the most critical targets for policy development and health system reform aimed at mitigating population disparity in CVD and related conditions.

Knowledge of thrombolytic therapy for acute ischemic stroke among community residents in western urban China

BACKGROUND AND PURPOSE

Thrombolytic therapy rate for acute ischemic stroke remains low, and improving public awareness of thrombolytic therapy may be helpful to reduce delay and increase chances of thrombolytic therapy. Our purpose was to survey the level of knowledge about thrombolytic therapy for acute ischemic stroke among community residents in Yuzhong district, Chongqing, China.

METHODS

In 2011, a population-based face-to-face interview survey was conducted in Yuzhong district, Chongqing. A total of 1500 potential participants aged ≥18 years old were selected using a multi-stage sampling method.

RESULTS

A total of 1101 participants completed the survey. Only 23.3% (95% CI = 20.8 to 25.8) were aware of thrombolytic therapy for acute ischemic stroke, of whom 59.9% (95% CI = 53.9 to 65.9) knew the time window. Awareness of thrombolytic therapy was higher among young people, those with higher levels of education and household income, those with health insurance, and those who knew all 5 stroke warning signs, while awareness of the time window was higher among those aged 75 years or older. Multivariate logistic regression analysis showed that awareness of thrombolytic therapy was independently associated with age, education level, health insurance and knowledge of stroke warning signs (P<0.05).

CONCLUSIONS

In this population-based survey the community residents have poor awareness of thrombolytic therapy for acute ischemic stroke.

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.

Persistent racial disparity in stroke hospitalization and economic impact in young adults in the buckle of stroke belt

BACKGROUND AND PURPOSE

Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina.

METHODS

Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430-434, 436, 437.1). Age- and race-stroke-specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites.

RESULTS

Of the 84,179 stroke hospitalizations, 31,137 (37.0%) were from patients aged<65 years and 29,846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged≥65 years) for both blacks and whites (P<0.001) but increased among the younger group (aged<65 years; P=0.004); however, this increase was mainly driven by a 17.3% rise among blacks (P=0.001), with no difference seen among whites (P=0.84). Of hospital charges totaling $2.77 billion, $453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged<65 years). Thirty-day stroke mortality rates decreased in all age-race-stroke-specific groups (P<0.001).

CONCLUSIONS

The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.

Gender differences in factors associated with prehospital delay among acute coronary syndrome patients in Pakistan

PURPOSE

To identify gender differences in prehospital delay time (PDT) and its associated factors among acute coronary syndrome (ACS) patients.

DESIGN

Descriptive cross-sectional comparative study.

METHODS

This study was conducted among 249 ACS patients at two tertiary care hospitals of a large metropolitan city of Pakistan. Data were collected through the modified Response to Symptoms Questionnaire.

RESULTS

The median PDT of women was found to be 7 hours, compared to 3.5 hours among men (p = .001). Results of the regression analysis indicated that most women delayed because of social factors, such as attendants' responses to their symptoms (p = .002), and because they were worried about expenses required for the treatment (p = .002); yet, most men delayed owing to individual factors, such as waiting for symptoms to subside (p< .001), and not recognizing the symptoms as being cardiac related (p< .001). Having anxiety and lack of knowledge about symptoms was associated with extended PDT among both genders.

CONCLUSION

Women delayed longer than men in seeking treatment for their ACS symptoms. Different factors were associated with PDT in women and men. This study may provide important insights for designing interventional studies to reduce PDT in Pakistani ACS patients.

Cluster dyads of risk factors and symptoms are associated with major adverse cardiac events in patients with acute myocardial infarction

The purpose of this study was to examine the cluster dyads of risk factors and symptoms and their impact on the incidence of 12 month major adverse cardiac events (MACEs) among patients with first-time myocardial infarction (MI). In a descriptive study, a total of 522 patients completed semi-structured interviews for data on risk factors and symptoms. Patients were followed for 12 months to determine MACEs. Latent class cluster analysis was performed to identify risk factor clusters and symptom clusters. Logistic regression analysis was performed to determine the impact of cluster dyads on 12 month MACEs. There were 436 event-free survivors and 86 patients with MACEs for 12 months. Ten risk factors and 14 symptoms were clustered into two (dyslipidemia/smoking, hypertension/diabetes dominant) and three (typical, multiple, atypical) memberships, respectively. Six cluster dyads which were generated based on the association between risk factors and symptom clusters were a significant predictor of 12 month MACEs, with the incidence occurring three times higher in a dyad of hypertension/diabetes-and-atypical symptoms than a dyad of dyslipidemia/smoking-and-typical symptoms (odds ratio = 3.10, P = 0.01), after adjustment for age, gender and a type of MI diagnosis. The information on cluster dyads suggests that health-care providers need to consider both risk factors and symptoms at hospital presentation for risk stratification to prevent adverse outcomes.

Knowledge of stroke symptoms and treatment among community residents in Western Urban China

BACKGROUND

Prehospital delay is still now the main barrier in receiving acute stroke therapy. Increase public awareness of stroke warning signs may help to activate emergency medical services and reduce prehospital delay. Our objectives were to survey the recognition of stroke warning signs among residents of Yuzhong District in Chongqing, China, and determine the proportion of these residents who would make an emergency call (120, in China) if suddenly faced with unexpected stroke warning signs and analyze the relationship between recognition of stroke warning signs and the response of calling for emergency assistance.

METHODS

In 2011, a population-based face-to-face interview survey using a multistage sampling method was conducted in Yuzhong District, Chongqing. We assessed residents' recognition of stroke warning signs and the proportion of those who would call the emergency number, 120, if suddenly encountering unexpected stroke warning signs. The association between the knowledge of stroke warning signs and activation of 120 was examined.

RESULTS

A total of 1101 participants completed the questionnaire. Only 15.6% of respondents knew all 5 stroke warning signs; 17.6% reported that they would call 120 for all 5 stroke warning signs. Recognition of stroke warning signs was associated with the response of calling 120 (odds ratios, 1.92-3.34). Even among those who knew all 5 warning signs of stroke, only 35.5% (95% confidence interval, 28.3-42.6) would call 120 for all 5 signs.

CONCLUSIONS

Residents of the examined district in Chongqing exhibited low recognition of stroke warning signs and low awareness of appropriate emergency responses to stroke-related symptoms.

Can a media campaign change health service use in a population with stroke symptoms? Examination of the first Irish stroke awareness campaign

BACKGROUND

Mass media campaigns for stroke awareness encourage the public to recognise stroke symptoms and respond to stroke in a timely manner. However, there is little evidence to suggest that media messages can influence behaviour after stroke onset. The F.A.S.T. (Face Arm Speech Time) test is a common stroke recognition tool used in public education campaigns.

OBJECTIVE

To assess the impact of the F.A.S.T. campaign on health service use in Ireland, which has had no previous exposure to a F.A.S.T. media campaign.

METHODS

An interrupted time series design was used to detect behaviour change after the introduction of the first Irish F.A.S.T. campaign in presentations of patients with suspected stroke to two emergency departments (EDs), serving a population of about 580 000.

RESULTS

There was a significant change in ED attendance of patients with reported stroke symptoms after the introduction of the F.A.S.T. campaign (β=0.84, 95% CI 0.43 to 1.24; p<0.001), although this was not sustained. ED presentation within 3.5 h was associated with emergency medical services activation (OR=3.1, p<0.001) and self-referral to the ED (OR=2.67, p<0.001).

CONCLUSIONS

This first Irish F.A.S.T. campaign had an initial impact on ED attendance of patients with stroke symptoms. However, the campaign effects were not sustained in the long term. Results indicate that prehospital delay in accessing acute stroke services is a complex process with involvement of factors other than stroke knowledge and intention to call 911.

Cognitive function and treatment adherence in older adults with heart failure

OBJECTIVE

Treatment recommendation and guidelines for patients with heart failure (HF) can be complex, and past work has shown that patients with HF demonstrate low rates of adherence to recommended health behaviors. Although previous work has identified several medical, demographic, and psychosocial predictors of the capacity to adhere to treatment recommendations of persons with HF, little is known about the contribution of cognitive impairment to reported treatment adherence in this population.

METHODS

A total of 149 persons with HF (mean [standard deviation] = 68.08 [10.74] years) completed a brief fitness assessment and neuropsychological testing. Treatment adherence was assessed using the Heart Failure Compliance Questionnaire, a brief measure that asks participants to report their adherence to a variety of recommended health behaviors (i.e., medication management, diet, and exercise, among others).

RESULTS

The percentage of participants who reported poor overall adherence was 16.1%, with particularly high rates of nonadherence to dietary and exercise recommendations. Hierarchical regression analyses adjusting for possible confounds revealed that reduced performance on attention (β = .26, p = .01), executive function (β = .18, p = .04), and language (β = .22, p = .01) was associated with poorer overall adherence. Follow-up analyses showed that these cognitive domains were associated with behaviors such as keeping doctor appointments, medication management, and dietary recommendations (p < .05 for all).

CONCLUSIONS

The current findings demonstrate that cognitive function is an independent contributor to adherence in older adults with HF. Prospective studies that objectively measure treatment adherence are needed to clarify these findings and identify possible strategies to improve outcomes in this population.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00871897.

Quality of life of elderly ischaemic stroke patients one year after thrombolytic therapy. A comparison between patients with and without thrombolytic therapy

Background

An observational study to examine whether thrombolytic therapy in stroke patients realizes better quality of life outcomes compared to patients without thrombolytic therapy one year after stroke. We also examined whether daily functioning, mental functioning and activities improved after thrombolytic treatment.

Methods

A total of 88 stroke patients were interviewed at home one year post-stroke. Health-related quality of life (HRQOL) was assessed using the RAND-36, disability with the Barthel Index, depression and anxiety with the Hospital Anxiety and Depression Scale, and a questionnaire about patient way of life was completed. People aged under 60, moving to a nursing home or with a haemorrhage were excluded.

Results

The thrombolysis group (TG) had more severe stroke (higher NIHSS) scores and were younger than the group without thrombolytic therapy (WTG). The primary outcome was HRQOL, which was high and nearly identical in both groups, however the TG had significantly better HRQOL for the ‘mental health’ and ‘vitality’ scales. Patients who stopped or reduced their hobbies because of stroke had a significantly worse HRQOL.

One year after stroke, more patients in the TG were totally or severely ADL dependent (12% TG and 0% WTG, p = 0.022). The level of dependence decreased in the TG (p = 0.042) and worsened in the WTG (p < 0.001) after one year. Being more dependent is related to diminishing daily occupations in both groups. In the TG the level of dependence had less impact on visiting family and friends and going on holiday. The prevalence of anxiety disorder and depression was low compared to other studies and there is no significant difference between the two groups.

Conclusion

No major differences in the primary outcome (HRQOL) could be found between the two groups. In addition, no essential difference could be found in mental functioning and participation. We expected that patients undergoing thrombolytic therapy would have worse quality of life because of the greater initial severity of their stroke. Therefore, thrombolytic therapy seems to be of great importance in achieving better quality of life in ischemic stroke patients who respond to this therapy.

Stroke awareness: surveillance, educational campaigns, and public health practice

Stroke is a leading cause of death and disability in the United States. However, there is limited public knowledge about stroke signs and symptoms and the importance of seeking immediate medical care. Educational efforts such as stroke awareness campaigns are one way of informing the public about stroke symptoms and the need for early medical treatment following their onset. In this article, we present recent surveillance data concerning public awareness of stroke symptoms; summarize findings from 12 studies of the effectiveness of stroke awareness campaigns; and describe the efforts by three states to develop, implement, and evaluate heart disease and stroke programs, and the lessons to be learned from their experiences.

Non-symptom-related factors contributing to delay in seeking medical care by patients with heart failure: a narrative review

BACKGROUND

Delay in seeking timely medical care by patients with acute coronary syndrome and stroke has been well established in the literature, but less is known about delay in care-seeking behavior by patients with heart failure (HF). The purpose of this narrative review was to synthesize the literature regarding non-symptom-related factors that contribute to delay in seeking medical care for HF symptoms.

METHODS AND RESULTS

A literature search of Scopus, Medline, and Pubmed was conducted for published articles from database inception to July 2009. Available evidence has shown that non-symptom-related factors, such as HF severity, HF history, age, and ethnocultural background, were related to delay in certain studies; however, null results have also been reported. Other non-symptom-related factors, such as male gender, initial contact with a primary care physician, arriving in the emergency department by means other than ambulance, and patient responses such as self-care, low anxiety, and hopelessness, may play a role in longer delay.

CONCLUSIONS

Although this review identified several non-symptom-related factors that may be implicated in care-seeking delay, health care professionals should be vigilant in identifying all high-risk individuals and educating them about warning signs of HF. Moreover, access to outpatient chronic disease management programs that may have potential to reduce care-seeking delay behavior should be explored.

Sex differences in health care-seeking behavior for acute coronary syndrome in a low income country, Peru

OBJECTIVE

: Recognizing reasons for prehospital delay after symptoms of acute coronary syndrome (ACS) is established in developed countries yet evidence from Latin America is limited. We aimed to assess ACS symptom recognition, health care-seeking behavior, and confidence in local health care facilities to take care of ACS by gender in a sample of Peruvians.

METHODS

: A community-based interview survey in a peri-urban area in Lima, Peru. The 24-item study instrument included vignettes and questions assessing identification of urgent and emergent ACS symptoms, anticipated help-seeking behaviors, and confidence in local health care facilities.

RESULTS

: In the study population (90 people; 45.6% men; mean age, 43.5 years), women were 4 times less likely to correctly attribute symptoms of chest pain to the heart (OR = 0.23; 95% CI: 0.063-0.87; P = 0.03). Women were much more likely to respond that a man would "Seek help" (OR = 4.54; 95% CI: 1.21-16.90; P = 0.024) and that "Yes," a woman would be less likely to seek help for chest pain symptoms (OR = 3.26; 95% CI: 1.13-9.41 P = 0.029) after adjusting for age, education level, age at migration, and history of chest pain. Women were less likely than men to think that their local Health Care Post would help them if they had a heart attack (2.1% vs. 14.6%; P = 0.04), and only 18.7% of women believed that their local emergency room would help them.

CONCLUSIONS

: Our findings suggest women are less likely to seek help for chest pain and women and men in a peri-urban area in Peru are not confident in their local health care facility to treat urgent or emergent ACS symptoms.

The impact of the intensity of fear on patient's delay regarding health care seeking behavior: a systematic review

OBJECTIVES

This systematic review focuses on the role of the intensity of fear in patient's delay in cancer and in myocardial infarction.

METHODS

In a search of literature published between 1990 and June 2009, 161 articles were found. After the use of inclusion and exclusion criteria, 11 articles in cancer and 4 articles in myocardial infarction remained.

RESULTS

High levels of fear are associated with earlier help-seeking in both diseases; for low levels of fear, the picture is unclear.

CONCLUSION

The level of fear is an important factor, which should be taken into account when facilitating help-seeking by patients.

Length of delay in seeking medical care by patients with heart failure symptoms and the role of symptom-related factors: a narrative review

AIMS

The delay in seeking timely medical care by patients with acute coronary syndrome and stroke is well established. Less is known about the delay in patients with heart failure (HF). Reducing the delay in seeking care and the early initiation of treatment is associated with improved outcomes in patients with HF. The purpose of this narrative review was to describe the length of the delay in seeking care for HF symptoms and identify symptom-related factors that contribute to the delay in seeking medical care.

METHODS AND RESULTS

A literature search was conducted to identify English language studies that (i) describe the length of care-seeking delay for HF symptoms and/or (ii) identify symptom-related factors that contribute to delay in seeking medical care. The results of this review demonstrate that upon hospital admission patients report wide variations in median symptom time course from 2 h to 7 days from the onset of symptoms to hospital admission. The ability of patients to recognize, interpret, and appraise HF symptoms has been demonstrated to be limited. Symptom characteristics such as dyspnoea, oedema, orthopnoea, higher somatic awareness, higher symptom distress, nocturnal symptom onset, and the pattern of symptom onset were related to longer delay in care-seeking for HF symptoms. Furthermore, cognitive responses to HF may also play an important role in symptom appraisal.

CONCLUSION

Delays in seeking care for HF symptoms have been shown to range from hours to days from symptom onset to hospital admission. Healthcare professionals should therefore be more vigilant in identifying high-risk individuals and educating them about the warning signs of HF. Moreover, access to outpatient chronic disease management programmes may have the potential to reduce these delays.

Differences in mortality in acute coronary syndrome symptom clusters

BACKGROUND

The timely and accurate identification of symptoms of acute coronary syndrome (ACS) is a challenge for patients and clinicians. It is unknown whether response times and clinical outcomes differ with specific symptoms. We sought to identify which ACS symptoms are related-symptom clusters-and to determine if sample characteristics, response times, and outcomes differ among symptom cluster groups.

METHODS

In a multisite randomized clinical trial, 3522 patients with known cardiovascular disease were followed up for 2 years. During follow-up, 331 (11%) had a confirmed ACS event. In this group, 8 presenting symptoms were analyzed using cluster analysis. Differences in symptom cluster group characteristics, delay times, and outcomes were examined.

RESULTS

The sample was predominantly male (67%), older (mean 67.8, S.D. 11.6 years), and white (90%). Four symptom clusters were identified: Classic ACS characterized by chest pain; Pain Symptoms (neck, throat, jaw, back, shoulder, arm pain); Stress Symptoms (shortness of breath, sweating, nausea, indigestion, dread, anxiety); and Diffuse Symptoms, with a low frequency of most symptoms. Those in the Diffuse Symptoms cluster tended to be older (P = .08) and the Pain Symptoms group was most likely to have a history of angina (P = .01). After adjusting for differences, the Diffuse Symptoms cluster demonstrated higher mortality at 2 years (17%) than the other 3 clusters (2%-5%, P < .001), although prehospital delay time did not differ significantly.

CONCLUSION

Most ACS symptoms occur in groups or clusters. Uncharacteristic symptom patterns may delay diagnosis and treatment by clinicians even when patients seek care rapidly. Knowledge of common symptom patterns may facilitate rapid identification of ACS.

Hospital stroke volume and case-fatality revisited

BACKGROUND

A few studies have found an inverse association between hospital patient volume and case-fatality among stroke patients. However, the different stroke categorizations used in these studies might have influenced the findings. Furthermore, the relevance of the association observed remains questionable given that the relatively small magnitude may not support volume-based referral policies. We re-examined this association in a large nationwide study, paying attention to the influence of volume categorizations.

METHODS

Applying multilevel logistic regression, we re-examined the relationship between hospital stroke volume and 7-day case-fatality using admissions data obtained from Statistics Netherlands on 73,077 stroke patients for the years 2000 to 2004. Different cut-offs were used to categorize hospitals in volume groups. We also examined the implications of a volume based referral strategy.

RESULTS

Stroke patients in high-volume hospitals had decreased risk of dying within 7 days of admission even when different hospital categorizations are applied. For instance, the odds ratio was 0.45(95% CI 0.20-0.99) in high-volume(>200 case-volume) versus low-volume(<50 case-volume) hospitals, but 0.89(95% CI 0.79-1.00) in high-volume(>250 case-volume) versus low-volume (< or =250 case-volume) hospitals. Ignoring travel time and workload implications an optimistic volume-based referral policy would save 183 patients when all patients are referred to the >200 case-volume hospital. A nontransfer policy aimed at reducing mortality by 10% in all those hospitals would save 1260 patients.

CONCLUSION

Stroke patients in low-volume versus high-volume hospitals have higher odds of dying. This finding may not lend itself to a substantial volume-based referral strategy.

Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach

AIM

To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. BACKGROUND. Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management.

DESIGN

Systematic review.

METHOD

The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage).

RESULTS

Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase.

CONCLUSIONS

Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design.

RELEVANCE TO CLINICAL PRACTICE

To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family.

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

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