Why do acute myocardial infarction patients not call an ambulance? An interview with patients presenting to hospital with acute myocardial infarction symptoms

"Recognition of heart attack symptoms and treatment-seeking behaviors: a multi-center survey in Tehran, Iran"

BACKGROUND

In acute myocardial infarction (AMI), timely recognition of symptoms and early hospital presentation positively affect patient morbidity and mortality. Due to the high burden of ischemic heart disease in Iran, this study aimed to identify factors affecting the level of knowledge, responses at the time of AMI onset, and sources of health information among the Iranian population.

METHOD

This cross-sectional study was conducted in three tertiary hospitals in Tehran, Iran. An expert-validated questionnaire was used to obtain data. A total of 400 individuals were enrolled.

RESULT

Among the respondents, 285 people(71.3%) considered "chest pain or discomfort," and 251 (62.7%) regarded "pain or discomfort in the arm or shoulder" as MI symptoms. Approximately 288 (72.0%) respondents had poor knowledge of the AMI symptoms. Knowledge of symptoms was higher among those with higher levels of education, those with medical-associated jobs, and those who resided in the capital areas. Major risk factors identified by the participants were: anxiety (340)(85.0%), obesity (327)(81.8%), an unhealthy diet (325)(81.3%), and the presence of high LDL levels (258)(64.5%) and Diabetes Mellitus (164)(41.0%) were less appreciated. Calling an ambulance (286)(71.5%) was the most common treatment-seeking behavior in the case of a suspected heart attack.

CONCLUSION

It is vital to educate the general population about AMI symptoms, particularly those with comorbidities at the greatest risk for an AMI episode.

Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.

Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes

BACKGROUND

Out-of-hours (OOH) healthcare services in Western countries are often differentiated into out-of-hours primary healthcare services (OOH-PC) and emergency medical services (EMS). Call waiting time, triage model and intended aims differ between these services. Consequently, the care pathway and outcome could vary based on the choice of entrance to the healthcare system. We aimed to investigate patient pathways and 1- and 1-30-day mortality, intensive care unit (ICU) stay and length of hospital stay for patients with acute myocardial infarction (AMI), stroke and sepsis in relation to the OOH service that was contacted prior to the hospital contact.

METHODS

Population-based observational cohort study during 2016 including adult patients from two Danish regions with an OOH service contact on the date of hospital contact. Patients <18 years were excluded. Data was retrieved from OOH service databases and national registries, linked by a unique personal identification number. Crude and adjusted logistic regression analyses were performed to assess mortality in relation to contacted OOH service with OOH-PC as the reference and cox regression analysis to assess risk of ICU stay.

RESULTS

We included 6826 patients. AMI and stroke patients more often contacted EMS (52.1 and 54.1%), whereas sepsis patients predominately called OOH-PC (66.9%). Less than 10% (all diagnoses) of patients contacted both OOH-PC & EMS. Stroke patients with EMS or OOH-PC & EMS contacts had higher likelihood of 1- and 1-30-day mortality, in particular 1-day (EMS: OR = 5.33, 95% CI: 2.82-10.08; OOH-PC & EMS: OR = 3.09, 95% CI: 1.06-9.01). Sepsis patients with EMS or OOH-PC & EMS contacts also had higher likelihood of 1-day mortality (EMS: OR = 2.22, 95% CI: 1.40-3.51; OOH-PC & EMS: OR = 2.86, 95% CI: 1.56-5.23) and 1-30-day mortality. Risk of ICU stay was only significantly higher for stroke patients contacting EMS (EMS: HR = 2.38, 95% CI: 1.51-3.75). Stroke and sepsis patients with EMS contact had longer hospital stays.

CONCLUSIONS

More patients contacted OOH-PC than EMS. Sepsis and stroke patients contacting EMS solely or OOH-PC & EMS had higher likelihood of 1- and 1-30-day mortality during the subsequent hospital contact. Our results suggest that patients contacting EMS are more severely ill, however OOH-PC is still often used for time-critical conditions.

Emergency Medical Services Utilization and Outcomes of Patients with ST-Elevation Myocardial Infarction in Lebanon

BACKGROUND

Arrival of patients with ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) results in shorter reperfusion times and lower mortality in developed countries.

OBJECTIVES

This study examines EMS use by STEMI patients in Lebanon and associated clinical outcomes.

METHODS

A retrospective observational study with chart review was carried out for STEMI patients arriving to the Emergency Department of a tertiary care center in Lebanon between January 1, 2013 and August 31, 2016. A descriptive analysis was done and followed by a bivariate analysis comparing two groups of patients (EMS vs. Non-EMS).

RESULTS

A total of 280 patients were included in the study. They were mostly male (71.8%). Mean age was 65.1 years (95% confidence interval [CI] 63.4-66.9). Only 12.5% (95% CI 8.6-16.4) presented by EMS. Chest pain (81.1%) was the most common presenting symptom. Anterior myocardial infarction was the most common electrocardiogram (ECG) diagnosis (51.4%). Most patients were admitted (98.2%), and 72.0% of these patients were treated with primary percutaneous coronary intervention. Cardiogenic shock was the most frequent in-hospital complication (6.2%). The mortality rate was 7.1%. Mean door-to-ECG and door-to-balloon times were 10.8 (95% CI 7.1-14.4) min and 106.2 (95% CI 95.9-116.6) min, respectively. Patients' characteristics, presenting symptoms, outcomes, and performance metrics were similar between the two groups.

CONCLUSION

EMS is underutilized by STEMI patients in Lebanon and is not associated with improvement in clinical outcomes. Medical oversight and quality initiatives focusing on outcomes of patients with timely sensitive emergencies are needed to advance the prehospital care system in Lebanon.

The association between ethnicity and delay in seeking medical care for chest pain: a systematic review

BACKGROUND

Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, and chest pain is one of the most common symptoms of ACSs. A rapid response to chest pain by patients and appropriate management by health professionals are vital to improve survival rates.People from different ethnic groups are likely to have different perceptions of chest pain, its severity and the need for urgent treatment. These differences in perception may contribute to differences in response to chests pain and precipitate unique coping strategies. Delay in seeking medical care for chest pain in the general population has been well documented; however, limited studies have focused on delay times within ethnic groups. There is little research to date as to whether ethnicity is associated with the time taken to seek medical care for chest pain. Consequently, addressing this gap in knowledge will play a crucial role in improving the health outcomes of culturally and linguistically diverse (CALD) patients suffering from chest pain and for developing appropriate clinical practice and public awareness for these populations.

OBJECTIVES

The current review aimed to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among CALD populations.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Patients from different ethnic minority groups presenting to emergency departments (EDs) with chest pain.

TYPES OF EXPOSURE

The current review will examine studies that evaluate the association between ethnicity and delay in seeking medical care for chest pain among CALD populations.

TYPES OF STUDIES

The current review will consider quantitative studies including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies.

OUTCOMES

The current review will consider studies that measure delay time as the main outcome. The time will be measured as the interval between the time of symptom onset and time to reach an ED.

SEARCH STRATEGY

A comprehensive search was undertaken for relevant published and unpublished studies written in English with no date restriction. All searches were conducted in October 2014. We searched the following databases: MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, ProQuest (health databases only), Informit, Sociological Abstracts, Scopus and Web of Science. The search for unpublished studies included a wide range of 'gray literature' sources including national libraries, digital theses repositories and clinical trial registries. We also targeted specific health research, specialist cardiac, migrant health, and emergency medicine organizational websites and/or conferences. We also checked the reference lists of included studies and contacted authors when further details about reported data was required to make a decision about eligibility.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to being included in the review. Validity was assessed using standardized critical appraisal instruments from the Joanna Briggs Institute. Adjudication was produced by the third reviewer.

DATA EXTRACTION

Data were extracted from included articles by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

The extracted data were synthesized into a narrative summary. Meta-analysis could not be performed due to the heterogeneity of study protocols and methods used to measure outcomes.

RESULTS

A total of 10 studies, with a total of 1,511,382 participants, investigating the association between ethnicity and delay met the inclusion criteria. Delay times varied across ethnic groups, including Black, Hispanic, Asian, South Asian, Southeast Asian and Chinese. Seven studies reported delay in hours and ranged from 1.90 to 3.10 h. Delay times were longer among CALD populations than the majority population. The other three studies reported delay time in categories of time (e.g. <1, <4 and <6 h) and found larger proportions of later presentations to the EDs among ethnic groups compared with the majority groups.

CONCLUSION

There is evidence of an association between ethnicity and time taken in seeking medical care for chest pain, with patients from some ethnic minorities (e.g. Black, Asian, Hispanic and South Asian) taking longer than those of the majority population. Health promotions and health campaigns focusing on these populations are indicated.

Barriers to the use of emergency medical services for ST-elevation myocardial infarction: Determining why many patients opt for self-transport

RATIONALE, AIMS, AND OBJECTIVES

Access to timely ST-elevation myocardial infarction (STEMI) care is facilitated by paramedics and emergency medical services (EMS). However, a large proportion of STEMI patients do not access care through EMS. This study sought to identify patient-reported factors for their decision to use (or not use) EMS.

METHODS

Semi-structured interviews were conducted with a sample of STEMI patients admitted to a large tertiary care centre between November 2011 and January 2012. Participants were grouped according to mode of transportation to hospital at time of index event (EMS vs self-transport). Participant responses were classified using a published framework (modified for a STEMI population) as barriers or facilitators to EMS use, and compared between groups.

RESULTS

Data were collected on 61 patients (32 EMS, 29 self-transport). Mean age was 60.3 (SD 11.5), and 23% were female. EMS users were more likely to have a Killip Class >1 (25% vs 4%; P = 0.03). Self-transport patients were more likely to perceive EMS as slower (48% vs 0%) and express concerns over resources misuse (34% vs 3%; P = 0.002), when compared to EMS patients. Patients who accessed EMS were more likely to acknowledge the benefits of EMS (44% vs 7%; P = 0.001) and were more likely to have been encouraged by a family member to call EMS (34% vs 4%; P = 0.003).

CONCLUSIONS

STEMI patient perceptions are a key factor in determining EMS use. Health care stakeholders should target the identified barriers to improve utilization of EMS, and develop strategies to optimize care for patients who do not access EMS.

The barriers associated with emergency medical service use for acute coronary syndrome: the awareness and influence of an Australian public mass media campaign

BACKGROUND

Emergency medical services (EMS) transport to hospital is recommended in acute coronary syndrome (ACS) guidelines, but only half of patients with ACS currently use EMS. The recent Australian Warning Signs campaign conducted by the Heart Foundation addressed some of the known barriers against using EMS. Our aim was to examine the influence of awareness of the campaign on these barriers in patients with ACS.

METHODS

Interviews were conducted with patients admitted to an Australian tertiary hospital between July 2013 and April 2014 with a diagnosis of ACS. Patient selection criteria included: aged 35-75 years, competent to provide consent, English speaking, not in residential care and medically stable. Multivariable logistic regression was used to examine factors associated with EMS use.

RESULTS

Only 54% of the 199 patients with ACS interviewed used EMS for transport to hospital. Overall 64% of patients recalled seeing the campaign advertising, but this was not associated with increased EMS use (52.0%vs56.9%, p=0.49) or in the barriers against using EMS. A large proportion of patients (43%) using other transport thought it would be faster. Factors associated with EMS use for ACS were: age >65 years, ST-elevation myocardial infarction, a sudden onset of pain and experiencing vomiting.

CONCLUSION

In medically stable patients with ACS, awareness of the Australian Warning Signs campaign was not associated with increased use of EMS or a change in the barriers for EMS use. Future education strategies could emphasise the clinical role that EMS provide in ACS.

Factors Associated With Emergency Services Use by Patients With Recurrent Myocardial Infarction: From the Monitoring Trends and Determinants in Cardiovascular Disease/Cooperative Health Research in the Region of Augsburg Myocardial Infarction Registry

BACKGROUND

Although emergency medical services (EMS) use is the recommended mode of transport in case of acute coronary symptoms, many people fail to use this service.

OBJECTIVE

The objective of this study was to determine factors associated with EMS use in a population-based sample of German patients with recurrent acute myocardial infarction (AMI).

METHODS

The sample consisted of 998 persons with a first and recurrent AMI, recruited from 1985 to 2011. Logistic regression modeling adjusted for sociodemographic, situational, and clinical variables, previous diseases, and presenting AMI symptoms was applied.

RESULTS

Emergency medical services was used by 48.8% of the patients at first, and 62.6% at recurrent AMI. In first AMI, higher age, history of hyperlipidemia, ST-segment elevation AMI, more than 4 presenting symptoms, symptom onset in daytime, and later year of AMI were significantly related with EMS use. Pain in the upper abdomen and pain between the shoulder blades were significantly less common in EMS users. In recurrent AMI, EMS use at first AMI, presence of any other symptom except chest pain, ST-segment elevation myocardial infarction, and later year of AMI were significantly related with EMS use. Significant predictors of EMS use in recurrent AMI in patients who failed to use EMS at first AMI were unmarried, experience of any symptom except chest symptoms at reinfarction, bundle branch block (first AMI), any in-hospital complication (first AMI), longer duration between first and recurrent AMI, and later year of reinfarction.

CONCLUSIONS

Patients with AMI and their significant others may profit by education about the benefits of EMS use.

Cardiac troponin testing for diagnosis of acute coronary syndromes in primary care

OBJECTIVE

To examine the use of cardiac troponin (cTn) testing for acute coronary syndrome (ACS) diagnosis in primary care.

DESIGN AND SETTING

Prospective cohort study; general practitioner-initiated cTn tests conducted from 24 September 2009 to 3 September 2010 in Perth, Western Australia. Patient outcomes were obtained from linked data sources for up to 12 months after the final test. Clinical information and outcomes were compared with data from emergency department patients with ACS symptoms.

PARTICIPANTS

369 patients with samples collected at community laboratories. Requesting GPs provided the clinical context for testing.

MAIN OUTCOME MEASURES

Cardiovascular risk status, symptoms prompting cTn testing; estimated ACS likelihood and referral decision before and after testing; result turnaround time; hospital presentations, procedures and mortality.

RESULTS

Of the 328 GPs who received a survey request, 124 (37.8%) responded. 122 of 124 test results (98.4%) were negative. Based on clinical risk factors, 71 of 104 patients (68.2%) were at high or intermediate risk of ACS. 69 of 124 patients (55.6%) had typical ischaemic pain and 62 of 124 patients (50.0%) were tested within 48 hours of symptom onset (23.4% within 12 hours, with no serial testing). Test results affected GPs' estimation of ACS likelihood (P < 0.01) but not their referral decisions (P = 0.23). 94 of 355 patients (26.5%) presented to hospital with cardiovascular symptoms or diagnoses during follow-up; 27 of 355 patients (7.6%) had at least one ACS, 13 of 255 (3.7%) within 30 days of testing.

CONCLUSIONS

GP-initiated cTn testing involves patients at high risk of ACS. ACS and associated adverse outcomes can occur in patients undergoing testing, even when the cTn test result is negative. Potential gaps exist in physicians' understanding of the limitations of cTn testing, and cTn test results have minimal influence on their management of patients. GPs may benefit from guidance about ordering cTn testing.

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

Background

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

Methods and Results

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

Conclusions

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

Ambulance use in acute coronary syndrome in Ireland: A cross-sectional study

BACKGROUND

As myocardial salvage is time dependent, prompt emergency department attendance is imperative in the presence of unresolved acute coronary syndrome symptoms. Although ambulance use is the recommended mode of transport during an acute coronary syndrome event, people regularly have misperceptions about its role. Consequently, many fail to use this service when warranted.

AIM

To evaluate factors associated with ambulance usage among patients admitted to emergency departments with acute coronary syndrome symptoms in Ireland.

METHODS

Patients (N=1947) diagnosed with acute coronary syndrome were recruited across five hospitals. The ACS Response Index was used to identify mode of transport to access the emergency department, symptom context and experience and the rationale for non-ambulance use. Using logistic regression, predictors of ambulance use were identified.

RESULTS

Only 40.1% of the sample used an ambulance. The primary reason for non-ambulance use was the perception that it was unwarranted (31%). A further 23.8% thought another mode of transportation would be faster. Independent predictors of ambulance usage differed among the three sub-diagnoses of acute coronary syndrome. For each group, visiting the general practitioner with symptoms was associated with a greater likelihood of not using an ambulance.

CONCLUSION

The use of ambulance services is not positively embraced by the public. Furthermore, it appears that general practitioners may not always promote its use, particularly in the early stages of acute coronary syndrome symptom onset. The findings from our study suggest that a public education drive is necessary to promote ambulance usage during an acute coronary syndrome event.

Use of emergency medical services in the second gulf registry of acute coronary events

Data are scarce regarding emergency medical service (EMS) usage by patients with acute coronary syndrome (ACS) in the Arabian Gulf region. This 9-month in-hospital prospective ACS registry was conducted in Arabian Gulf countries, with 30-day and 1-year follow-up mortality rates. Of 5184 patients with ACS, 1293 (25%) arrived at the hospital by EMS. The EMS group (vs non-EMS) was more likely to be male, have cardiac arrest on presentation, be current or exsmokers, and have moderate or severe left ventricular dysfunction and ST-segment elevation myocardial infarction (STEMI). The EMS group had higher crude mortality rates during hospitalization and after hospital discharge but not after adjustment for clinical factors and treatments. The EMSs are underused in the Arabian Gulf region. Short- and long-term mortality rates in patients with ACS are similar between those who used and did not use EMS. Quality improvement in the EMS infrastructure and establishment of integrated STEMI networks are urgently needed.

Acute myocardial infarction--from territory to definitive treatment in an Italian province

RATIONALE, AIMS AND OBJECTIVES

Early reperfusion is the key to therapeutic success in acute myocardial infarction (AMI). The duration of the process is influenced by various factors which in most of the cases are not easily modifiable. The aim of this study is to analyse AMI treatment process duration to identify determining factors. The objective is to better exploit time intervals imposed by spatial distance from the hospital.

METHOD

One-year data regarding acute coronary syndromes with elevated ST segment for patients presenting to Policlinico teaching hospital (Modena, Italy) have been studied. Patients were divided into two groups for hospital access: A - ambulance access to Policlinico emergency room (ER); B - self-referral to ER.

RESULTS

A total of 141 patients have undergone percutaneous transluminal coronary angioplasty for AMI at Policlinico, 106 males, 35 females (58.1% males in group A, 82.7% in B, P 0.002), with an average age of 66.09 ± 14.30 years in group A and 60.90 ± 13.47 in B (P 0.047). Mean pre-hospital time for group A was 122.54 ± 130.69 minutes and B 171.49 ± 353.60 (P 0.25), mean hospital time in group A was 196.03 ± 67.66 and B 255.14 ± 113.16 (P<0.001), mean total time in group A was 318.56 ± 146.91 and B 426.63 ± 382.01 (P 0.02).

DISCUSSION

Data show that group B suffered on average a 108-minute delay from symptoms insurgence to definitive treatment. The duration of hospital time plays more important role in this finding than distance from the medical facility. In fact, on the ambulance a medical crew starts the diagnostic and therapeutic process relieving ER from initial evaluation.

An organized system of emergency care for patients with myocardial infarction: a reality?

An organized system of emergency care is an essential requirement for the modern treatment of ST-elevation acute myocardial infarction. There is a strong need to deliver reperfusion therapy as soon as possible, with primary percutaneous coronary intervention being the preferred option if performed in a timely manner and thrombolytic therapy, particularly in the prehospital setting, being a good alternative if the primary percutaneous coronary intervention-related delay exceeds the equipoise. In this situation, emergency medical services have a primary role in rescuing patients from cardiac arrest, performing prehospital diagnosis, triage and treatment and safely transporting them to the most appropriate cardiological center, including interhospital transfer. A complete reorganization of the healthcare systems in different countries is frequently needed to build an ST-elevation acute myocardial infarction system of care, focusing on fast transport, use of telemedicine and diversion protocols to skip the unsuited centers.

Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States

BACKGROUND

Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.

OBJECTIVE

To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE).

METHODS

Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).

RESULTS

Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03-1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48-2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34-1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02-1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09-1.51), and current smoking (OR 1.30; 95% CI 1.13-1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.

CONCLUSION

Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

Knowledge and attitudes toward seeking medical care for AMI-symptoms

BACKGROUND

Time is crucial when an acute myocardial infarction (AMI) occurs, but patients often wait before seeking medical care.

AIM

To investigate and compare patients' and relatives' knowledge of AMI, attitudes toward seeking medical care, and intended behaviour if AMI-symptoms occur.

METHODS

The present study was a descriptive, multicentre study. Participants were AMI-patients ≤ 75 years (n = 364) and relatives to AMI-patients (n = 319). Questionnaires were used to explore the participants' knowledge of AMI and attitudes toward seeking medical care.

RESULTS

Both patients and relatives appeared to act more appropriate to someone else's chest pain than to their own. Patients did not have better knowledge of AMI-symptoms than relatives. Women would more often contact someone else before seeking medical care. A greater percentage of elderly (65-75 years), compared to younger individuals, reported that they would call for an ambulance if chest pain occurred.

CONCLUSIONS

There were only minor differences between patients and relatives, regarding both knowledge and attitudes. It seems easier to act correctly as a bystander than as a patient. Therefore, in order to decrease patients' delay time it is important to educate relatives as well as patients on how to respond to symptoms of an AMI.

The causes of prehospital delay in myocardial infarction

INTRODUCTION

The elapsed time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with myocardial infarction. The patients' own decision time is the most important component of prehospital delay.

METHODS

Selective literature review based on the references in a meta-analysis, complemented by a PubMed search on the expression "prehospital delay" in combination with "myocardial infarction," "acute coronary syndrome," "psychological factors," "gender," and "public campaign." A total of 73 papers addressing factors that influence prehospital delay were selected.

RESULTS

The reasons for delays of more than 120 minutes in a patient with symptoms of myocardial infarction reaching the hospital are still not sufficiently elucidated. Patients' uncertainty about their symptoms, advanced age, and female sex are three factors that appear to be associated with longer delays.

DISCUSSION

Factors influencing prehospital delay operate at the following levels: the perception of acute symptoms, the recognition of the importance of these symptoms, and the decision to call for help. Intervention trials should consider these levels in meeting the needs of clinically relevant subpopulations.

Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested.

Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression.

Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient’s hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured.

Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01–0.49), palpitations (β = 0.31; CI = 0.06–0.56), nausea (β = 0.37; CI = 0.10–0.65), numbness in the hands (β = 0.29; CI = 0.02–0.57), and unusual fatigue (β = 0.60; CI = 0.27–0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women.

Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear.