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

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Understanding College Students' Healthcare Avoidance: From Early Maladaptive Schemas, through Healthcare Institutional Betrayal and Betrayal Trauma Appraisal of Worst Healthcare Experiences

Understanding healthcare avoidance among college students is critical. In this study, we consider two broad cognitive contributors to greater healthcare avoidance: specific early maladaptive schema and negative appraisals of students' prior worst healthcare experiences. From schema theory, we proposed college students holding greater levels of two early maladaptive schema (disconnection/rejection and impaired autonomy/performance EMS) would be more likely to appraise their problematic healthcare experience as both containing healthcare institutional betrayal (HIB) behaviors and as traumatic and betrayal-inducing; both EMS and these appraisals would predict healthcare avoidance. Using a cross-sectional survey in a large, diverse college student sample (n = 1383, 61.1% female, 18.9% African American, 7.2% Asian, 6.4% Hispanic/Latino), as predicted, both EMS were significantly related to healthcare avoidance. Furthermore, a sequential mediation model was supported, indicating students holding greater EMS of disconnection/rejection or impaired autonomy/rejection reported more HIB in their worst healthcare experience, and appraised that experience as more betraying. Taken altogether, this model accounted for 23% of the variance in students' reports of healthcare avoidance. Core beliefs formed early in life may be a foundational lens through which potentially traumatic healthcare experiences are processed in ways that can impact emerging adults' future healthcare engagement. Findings also support the importance of addressing HIB actions and repairing trauma appraisals accrued during problematic healthcare experiences to prevent healthcare avoidance by emerging adults.

Women Acute Myocardial Infarction-Identifying and Understanding the Gender Gap (WAMy-GAP): A Study Protocol

Barriers to accessing care and misinterpretations of ischemic heart disease symptoms due to lack of awareness contribute to women's delay in seeking care. Women may delay seeking treatment for up to 3 h or even up to 5 days. They often perceive themselves to be at low risk of cardiovascular disease (CVD) and prioritize family responsibilities or household chores. The causes of this delay are multifactorial and influence the decision-making process, particularly in the pre-hospital phase. The objective of this study protocol is to evaluate prodromal symptoms and identify risk behaviors in women with acute myocardial infarction (AMI). This is a protocol for a multicenter study that will be conducted using the mixed-method methodology using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) to evaluate symptoms and semi-structured interviews to investigate behaviors. This study protocol is intended to fill an important knowledge gap on premonitory and acute symptoms of AMI in women in Italy, as well as to understand the causes and mechanisms underlying delays in accessing healthcare services during an acute event such as AMI. The investigation of this issue will facilitate the removal of gender-related inequalities in the diagnosis and treatment of acute myocardial infarction while also fostering dialogue on the barriers to behavior change.

Treatment seeking experiences of ACS patients in Yogyakarta, Indonesia during COVID-19 pandemic: A qualitative study

Delay in treatment seeking is recognized as a major contributor for Acute Coronary Syndrome (ACS) mortality in Indonesia. Despite the significance of timely treatment, decline in admission and delay in presentation of patients with ACS were consistently reported during the COVID-19 pandemic. These suggested that treatment seeking performance of patients during the pandemic might be different from the previous period. This qualitative study aimed to explore treatment seeking behaviour, barriers in seeking medical treatment, and experiences of patients with ACS in Yogyakarta, Indonesia during COVID-19 pandemic. In depth-interviews were carried out with 30 patients, who were hospitalized with ACS at one of the three selected hospitals in Yogyakarta during the pandemic period. Thematic analysis was performed to create vital explanations for treatment seeking practices of patients with ACS during pandemic. Three significant themes were identified: treatment seeking decisions, barriers in seeking medical treatment during COVID-19, and experiencing both good and bad impression from entering and staying in the hospital. The intensity of ACS symptoms and fear of COVID-19 infection dominated the delay in seeking medical treatment. Strict safety measures, religious belief, and fear of ACS helped patients overcome barriers and seek medical treatment during pandemic. ACS patients also had convenient medical care during the pandemic and believed medical staff would provide excellent care to them. However, visit restriction policy could cause psychological discomfort. Increase awareness of ACS symptoms and the risk of delays ACS treatment are essential to support patients' decisions to seek medical helps in a timely manner at any situations including pandemic. Interventions aim at alleviating psychological distress should also be designed and implemented to improve treatment experiences of ACS patients, who sought medical treatment during the pandemic crisis.

Evaluating Algorithmic Bias in 30-Day Hospital Readmission Models: Retrospective Analysis

BACKGROUND

The adoption of predictive algorithms in health care comes with the potential for algorithmic bias, which could exacerbate existing disparities. Fairness metrics have been proposed to measure algorithmic bias, but their application to real-world tasks is limited.

OBJECTIVE

This study aims to evaluate the algorithmic bias associated with the application of common 30-day hospital readmission models and assess the usefulness and interpretability of selected fairness metrics.

METHODS

We used 10.6 million adult inpatient discharges from Maryland and Florida from 2016 to 2019 in this retrospective study. Models predicting 30-day hospital readmissions were evaluated: LACE Index, modified HOSPITAL score, and modified Centers for Medicare & Medicaid Services (CMS) readmission measure, which were applied as-is (using existing coefficients) and retrained (recalibrated with 50% of the data). Predictive performances and bias measures were evaluated for all, between Black and White populations, and between low- and other-income groups. Bias measures included the parity of false negative rate (FNR), false positive rate (FPR), 0-1 loss, and generalized entropy index. Racial bias represented by FNR and FPR differences was stratified to explore shifts in algorithmic bias in different populations.

RESULTS

The retrained CMS model demonstrated the best predictive performance (area under the curve: 0.74 in Maryland and 0.68-0.70 in Florida), and the modified HOSPITAL score demonstrated the best calibration (Brier score: 0.16-0.19 in Maryland and 0.19-0.21 in Florida). Calibration was better in White (compared to Black) populations and other-income (compared to low-income) groups, and the area under the curve was higher or similar in the Black (compared to White) populations. The retrained CMS and modified HOSPITAL score had the lowest racial and income bias in Maryland. In Florida, both of these models overall had the lowest income bias and the modified HOSPITAL score showed the lowest racial bias. In both states, the White and higher-income populations showed a higher FNR, while the Black and low-income populations resulted in a higher FPR and a higher 0-1 loss. When stratified by hospital and population composition, these models demonstrated heterogeneous algorithmic bias in different contexts and populations.

CONCLUSIONS

Caution must be taken when interpreting fairness measures' face value. A higher FNR or FPR could potentially reflect missed opportunities or wasted resources, but these measures could also reflect health care use patterns and gaps in care. Simply relying on the statistical notions of bias could obscure or underplay the causes of health disparity. The imperfect health data, analytic frameworks, and the underlying health systems must be carefully considered. Fairness measures can serve as a useful routine assessment to detect disparate model performances but are insufficient to inform mechanisms or policy changes. However, such an assessment is an important first step toward data-driven improvement to address existing health disparities.

Perceived barriers of access to health and nutrition services under drought and food insecurity emergency in north-east Uganda: a qualitative study

BACKGROUND

In the face of drought and food insecurity emergency, evidence on access to health and nutrition services is important. Karamoja is one of the regions that have experienced extreme drought and food insecurity emergency in Uganda. As a part of the drought and food insecurity emergency response, World Health Organization (WHO) with Ministry of Health (MoH) has designed and implemented a qualitative study in 15 districts that have experienced drought and food insecurity emergency in north-east Uganda. Thus, we aimed to explore the barriers of access to health and nutrition services in drought and food insecurity emergency affected districts in north-east Uganda.

METHODS

We employed a descriptive qualitative study design. We interviewed 30 patients and 20 Village Health Teams (VHT) from 15 districts. We employed an in-depth interview with semi-structured questions to collect data until information saturation reached. We used thematic data analysis approach by ATLAS.ti version 7.5.1.8 software.

RESULTS

Of the 30 interviewed subjects, 15 were female, and the median age of the subjects was 29 years with interquartile range (IQR) of 23 to 37 years. Majority (68.8%) of subjects reported that access to health and nutrition services was harder to them. Four themes: sociocultural and economic; environmental; health system, and individual related factors were identified as the barriers of access to health and nutrition services.

CONCLUSION

The present study identified several modifiable barriers that hinder access to health and nutrition services in drought and food insecurity affected districts. Comprehensive interventions aimed at addressing sociocultural, economic, environmental, health system and subject related challenges are required to improve access to health and nutrition services in drought and food insecurity affected setups.

Retrospective review of non-ST segment elevation acute coronary syndrome presenting to the emergency department of a major tertiary center in Saudi Arabia

BACKGROUND

Acute coronary syndrome (ACS) comprises a spectrum of diseases ranging from unstable angina (UA), non-ST elevation myocardial infarction (non-STEMI) and ST elevation myocardial infarction (STEMI). Treatment of ACS without STEMI (NSTEMI-ACS) can vary, depending on the severity of presentation and multiple other factors.

OBJECTIVE

Analyze the NSTEMI-ACS patients in our institution.

DESIGN

Retrospective observational.

SETTING

A tertiary care institution with accredited chest pain center.

PATIENTS AND METHODS

The travel time from ED booking to the final disposition for patients presenting with chest pain was retrieved over a period of 6 months. The duration of each phase of management was measured with a view to identify the factors that influence their management and time from the ED to their final destination. The data was analyzed using descriptive statistics.

MAIN OUTCOME MEASURES

Travel time from ED to final destination.

SAMPLE SIZE

300 patients.

RESULTS

The majority of patients were males (64%) between 61 and 80 years of age (45%). The median disposition time (from ED booking to admission order by the cardiology team) was 5 hours and 19 minutes. Cardiology admissions took 10 hours and 20 minutes from ED booking to the inpatient bed. UA was diagnosed in 153 (51%) patients and non-STEMI in 52 (17%). Coronary catheterization was required in 79 (26%) patients, 24 (8%) had coronary artery bypass grafting (CABG) and 8 (3%) had both catheterization and CABG.

CONCLUSION

The time from ED booking to final destination for NSTEMI-ACS patients is delayed due to multiple factors, which caused significant delays in overall management. Additional interventional steps can help improve the travel times, diagnosis, management and disposition of these patients.

LIMITATIONS

Single center study done in a tertiary care center so the results from this study may not be extrapolated to other centers.

S-nitrosylation of AMPKγ impairs coronary collateral circulation and disrupts VSMC reprogramming

Collateral circulation is essential for blood resupply to the ischemic heart, which is dictated by the contractile phenotypic restoration of vascular smooth muscle cells (VSMC). Here we investigate whether S-nitrosylation of AMP-activated protein kinase (AMPK), a key regulator of the VSMC phenotype, impairs collateral circulation. In rats with collateral growth and development, nitroglycerin decreases coronary collateral blood flow (CCBF), inhibits vascular contractile phenotypic restoration, and increases myocardial infarct size, accompanied by reduced AMPK activity in the collateral zone. Nitric oxide (NO) S-nitrosylates human recombinant AMPKγ1 at cysteine 131 and decreases AMP sensitivity of AMPK. In VSMCs, exogenous expression of S-nitrosylation-resistant AMPKγ1 or deficient NO synthase (iNOS) prevents the disruption of VSMC reprogramming. Finally, hyperhomocysteinemia or hyperglycemia increases AMPKγ1 S-nitrosylation, prevents vascular contractile phenotypic restoration, reduces CCBF, and increases the infarct size of the heart in Apoe-/- mice, all of which is rescued in Apoe-/-/iNOSsm-/- mice or Apoe-/- mice with enforced expression of the AMPKγ1-C130A mutant following RI/MI. We conclude that nitrosative stress disrupts coronary collateral circulation during hyperhomocysteinemia or hyperglycemia through AMPK S-nitrosylation.

Social Support Networks Among Black Caregivers of Persons With Memory Problems

Positive social support can predict health outcomes in populations that experience significant burdens, such as minority caregivers. The purpose of the current study was to detail the social network (SN) of 36 Black family caregivers (FCGs) for persons with memory problems (PWMP) and examine differences in SN support depending on FCG gender and relationship to the care recipient. Participants were recruited from the Alzheimer's family program at the University of Alabama at Birmingham and the local community. FCGs were categorized into adult children (ACH), grandchildren and in-law children, and friends and other relatives. FCGs described the amount of adequate support they receive for different types of support from their SN. Female FCGs reported higher levels of support overall, with the largest effect sizes including social (d = 0.63), emotional (d = 0.64), and financial (d = 0.38) support. The largest effect size comparison of caregiver relationship type was in social support, with the ACH group reporting the lowest levels of adequate social support compared to the other two groups (d = 0.48). Findings suggest that different types of Black FCGs face unique challenges depending on their gender and familial relationship to the care recipient. [Journal of Gerontological Nursing, 50(1), 22-29.].

Ethnic differences of the care pathway following an out-of-hospital cardiac event: A systematic review

AIM

This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations.

METHODS

A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines.

RESULTS

Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies.

CONCLUSION

The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations.

French lay Persons' judgments of the possibility of a heart attack when experiencing various physical manifestations

Background

The aim of the study was to characterize the different ways in which, based on certain physical manifestations that an individual suddenly experiences, people judge the possibility that these manifestations indicate the onset of a heart attack.

Methods

One hundred ninety-four French adults--plus six physicians--were presented with a set of realistic vignettes composed by orthogonally crossing the levels of four factors: the type of pain felt, and the presence or absence of nausea, excess sweating, and of difficulty breathing.

Results

Four qualitatively different reactions were found among the lay people. The majority reaction (54%) was close to the physicians' reaction. It consisted of suspecting a heart attack as soon as intense pain occurs in the chest or back. The second reaction (25%) retained from the first one only the idea that a heart attack should be suspected if the pain is localized to the chest. The third reaction (14%) reflected some people's uncertainty in the face of disturbing manifestations that they find difficult to interpret. The fourth reaction (7%) was that no set of symptoms could mean, for them, the onset of a heart attack.

Conclusion

Only about half of the participants appeared to be able to consider unpleasant physical manifestations as a whole and integrate that information into an overall warning judgment that can lead into prompt life-saving actions. We recommend that judgment training on warning symptoms and signs be performed, especially for high-risk patients, in the offices of primary care providers and specialists.

Prevalence and factors associated with pre-hospital delay among acute stroke patients at Mulago and Kiruddu national referral hospitals, Kampala: a cross-sectional study

BACKGROUND

Despite advancements in acute stroke care, acute stroke patients present late for care resulting in high mortality and poor functional outcomes. This study determined the prevalence of pre-hospital delay and associated factors among adult acute stroke patients in Uganda.

METHODS

In a hospital based, cross-sectional study, one hundred and forty-three study participants with confirmed acute stroke presenting to the emergency units of Mulago and Kiruddu national referral hospitals were enrolled. Using an interviewer-administered questionnaire, details on sociodemographics, onset of stroke, arrival at the tertiary facility, health system and clinical factors were collected. Descriptive statistics and modified Poisson regression analyses were performed to determine factors associated with prehospital delay.

RESULTS

Among the 143 study participants, nearly two-thirds (79/146) had ischemic stroke while a third (59/143) had haemorrhagic stroke. The mean age was 59 years (SD 16) and 51.7% of acute stroke patients were males. Ninety one percent (130/143) presented to the emergency unit after 3 hours. The majority (124/143) reported visiting lower-level facilities prior to referral to the tertiary facility. Staying outside Kampala district (PR: 1.28 (1.22-1.34), p < 0.001), and using hired or government ambulance for transport to tertiary facility (PR: 1.17 (1.13-1.20), p < 0.001) were associated with pre-hospital delay.

CONCLUSIONS

Prevalence of pre-hospital delay among acute stroke patients presenting to public tertiary hospitals in Uganda is very high. The causes of pre hospital delay should be further explored qualitatively. Efforts to reduce prehospital delay should include improving pre-hospital transport systems for stroke patients.

Perceived performance of activities of daily living by stroke patients: key in decision to call EMS and outcomes

Background

Until recently, public education campaigns aimed at improving help-seeking behavior by acute stroke patients have achieved only limited or even no effects. Better understanding of psychological factors determining help-seeking behavior may be relevant in the design of more effective future campaigns.

Methods

In this prospective, cross-sectional study, we interviewed 669 acute stroke patients within 72 h after hospital admission. The primary endpoint was the effect of psychological factors on the decision to call emergency medical services (EMS). Secondary endpoints were the effects of such factors on treatment rates and clinical improvement (difference between modified Rankin scale (MRS) scores at admission and at discharge).

Results

Only 48.7% of the study population called the EMS. Multivariate logistic and linear regression analyses revealed that perception of unimpaired performance of activities of daily living (ADL) was the only psychological factor that predicted EMS use and outcomes. Thus, patients who perceived only minor impairment in performing ADL were less likely to use EMS (odds ratio, 0.54 [95% confidence interval, 0.38-0.76]; p = 0.001), had lower treatment rates, and had less improvement in MRS scores (b = 0.40, p = 0.004). Additional serial mediation analyses involving ischemic stroke patients showed that perception of low impairment in ADL decreased the likelihood of EMS notification, thereby increasing prehospital delays, leading to reduced thrombolysis rates and, finally, to reduced clinical improvement.

Conclusion

Perception of unimpaired performance of ADL is a crucial barrier to appropriate help-seeking behavior after acute stroke, leading to undertreatment and less improvement in clinical symptoms. Thus, beyond improving the public's knowledge of stroke symptoms, future public education campaigns should focus on the need for calling the EMS in case of stroke symptoms even if daily activities do not seem to be severely impaired.

Hospital admission from the emergency department for selected emergent diagnoses during the first year of the COVID-19 pandemic in Ontario: a retrospective population-based study

BACKGROUND

Avoidance of care during the pandemic may have contributed to delays in care, and as a result, worse patient outcomes. We evaluated markers of illness acuity on presentation to the emergency department among patients with non-COVID-19-related emergent diagnoses and associated outcomes.

METHODS

We conducted a retrospective study using linked administrative data from Ontario. We selected 4 emergent diagnoses, namely appendicitis, ectopic pregnancy, renal failure and diabetic ketoacidosis. We used the nonemergent diagnosis of cellulitis as a control. Our primary outcome of interest was hospital admission. Secondary outcomes were ambulance arrival, surgical intervention, subsequent hospital admission within 30 days of discharge from the emergency department or hospital and 30-day mortality. We compared outcomes during the first year of the COVID-19 pandemic (Mar. 15-Dec. 31, 2020) with a control period (Mar. 15-Dec. 31, 2018, and Mar. 15-Dec. 31, 2019).

RESULTS

Emergency department visits for all conditions initially decreased during the pandemic. During this period, patients across all study diagnoses were more likely to arrive to the emergency department via ambulance. Patients with an ectopic pregnancy had higher odds of surgery in the pandemic period (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.04-1.55) but this was not observed among patients with appendicitis. Patients with renal failure had increased odds of hospital admission (OR 1.14, 95% CI 1.04-1.24) and 30-day mortality (OR 1.17, 95% CI 1.04-1.31) during the pandemic period.

INTERPRETATION

The pandemic period was associated with increased arrival to the emergency department via ambulance across all study diagnoses. Although patients with renal failure had increased hospital admission and death, and patients with ectopic pregnancy had an increased risk of surgery, there were no differences in outcomes for other populations, suggesting the health care system was able to care for these patients effectively.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnostic Performance of a Mnemonic for Warning Symptoms in Predicting Acute Coronary Syndrome Diagnosis: A Retrospective Cross-Sectional Study

Objectives: We aimed to create a mnemonic for acute coronary syndrome (ACS) warning symptoms and determine its diagnostic performance. Methods: This retrospective cross-sectional study included patients visiting the emergency room with symptoms of suspected ACS during 2020-2021. The mnemonic was created using symptoms with an odds ratio (OR) for predicting ACS >1.0. The mnemonic with the highest OR and sensitivity was identified. Sensitivity analysis was performed to test the diagnostic performance of the mnemonic by patient subgroups commonly exhibiting atypical symptoms. Results: ACS prevalence was 12.2% (415/3,400 patients). The mnemonic, "RUSH ChesT" [if you experience referred pain (R), unexplained sweating (U), shortness of breath (S), or heart fluttering (H) together with chest pain (C), visit the hospital in a timely (T) manner] had the best OR [7.81 (5.93-10.44)] and sensitivity [0.81 (0.77-0.85)]. This mnemonic had equal sensitivity in men and women, the elderly and adults, smokers and non-smokers, and those with and without diabetes or hypertension. Conclusion: The "RUSH ChesT" mnemonic shows good diagnostic performance for patient suspected ACS. It may effectively help people memorize ACS warning symptoms.

Detection of Ischemic ST-Segment Changes Using a Novel Handheld ECG Device in a Porcine Model

Background

Portable, smartphone-sized electrocardiography (ECG) has the potential to reduce time to treatment for patients suffering acute cardiac ischemia, thereby lowering the morbidity and mortality. In the UMC Utrecht, a portable, smartphone-sized, multi-lead precordial ECG recording device (miniECG 1.0, UMC Utrecht) was developed.

Objectives

The purpose of this study was to investigate the ability of the miniECG to capture ischemic ECG changes in a porcine coronary occlusion model.

Methods

In 8 animals, antero-septal myocardial infarction was induced by 75-minute occlusion of the left anterior descending artery, after the first or second diagonal. MiniECG and 12-lead ECG recordings were acquired simultaneously before, during and after coronary artery occlusion and ST-segment deviation was evaluated.

Results

During the complete occlusion and reperfusion period, miniECG showed large ST-segment deviation in comparison to 12-lead ECG. MiniECG ST-segment deviation was observed within 1 minute for most animals. The miniECG was positive for ischemia (ie, ST-segment deviation ≥1 mm) for 99.7% (Q1-Q3: 99.6%-99.9%) of the occlusion time, while the 12-lead was only positive for 79.8% (Q1-Q3: 81.1%-98.7%) of the time (P = 0.018). ST-segment deviation reached maxima of 10.5 mm [95% CI: 6.5-14.5 mm] vs 5.0 mm [95% CI: 2.0-8.0 mm] for the miniECG vs 12-lead ECG, respectively.

Conclusions

MiniECG ST-segment deviation was observed early and was of large magnitude during 75 minutes of porcine transmural antero-septal infarction. The miniECG was positive for ischemia for the complete occlusion period. These findings demonstrate the potential of the miniECG in the detection of cardiac ischemia. Although clinical research is required, data suggests that the miniECG is a promising tool for the detection of cardiac ischemia.

Alexithymia for cardiologists: a clinical approach to the patient

Alexithymia literally meaning 'no words for emotions' is a term used in mental health settings to describe people who have difficulties in identifying and verbalizing their emotional states. There is evidence in the literature that this personality trait may influence negatively the illness behavior when an acute coronary event occurs. In fact, people with high alexithymia are more likely to experience wrong appraisal and interpretation of symptoms, and because of their difficulty in describing feelings to others, they can be poor in reporting symptoms at the first consultation with a physician. This behavioral pattern (alexithymic) may put patients with acute myocardial infarction at higher risk for delayed medical care. Here, we aim to present an overview of alexithymia from the perspective of the clinical cardiologist, with a focus on the definition, clinical recognition, and potential impact on cardiovascular health.

Characterization of prehospital time delay in primary percutaneous coronary intervention for acute myocardial infarction: analysis of geographical infrastructure-dependent and -independent components

BACKGROUND

Prehospital delay in reaching a percutaneous coronary intervention (PCI) facility is a major problem preventing early coronary reperfusion in patients with ST-elevation myocardial infarction (STEMI). The aim of this study was to identify modifiable factors that contribute to the interval from symptom onset to arrival at a PCI-capable center with a focus on geographical infrastructure-dependent and -independent factors.

METHODS

We analyzed data from 603 STEMI patients who received primary PCI within 12 h of symptom onset in the Hokkaido Acute Coronary Care Survey. We defined onset-to-door time (ODT) as the interval from the onset of symptoms to arrival at the PCI facility and we defined door-to-balloon time (DBT) as the interval from arrival at the PCI facility to PCI. We analyzed the characteristics and factors of each time interval by type of transportation to PCI facilities. In addition, we used geographical information system software to calculate the minimum prehospital system time (min-PST), which represents the time required to reach a PCI facility based on geographical factors. We then subtracted min-PST from ODT to find the estimated delay-in-arrival-to-door (eDAD), which represents the time required to reach a PCI facility independent of geographical factors. We investigated the factors related to the prolongation of eDAD.

RESULTS

DBT (median [IQR]: 63 [44, 90] min) was shorter than ODT (median [IQR]: 104 [56, 204] min) regardless of the type of transportation. However, ODT was more than 120 min in 44% of the patients. The min-PST (median [IQR]: 3.7 [2.2, 12.0] min) varied widely among patients, with a maximum of 156 min. Prolongation of eDAD (median [IQR]: 89.1 [49, 180] min) was associated with older age, absence of a witness, onset at night, no emergency medical services (EMS) call, and transfer via a non-PCI facility. If eDAD was zero, ODT was projected to be less than 120 min in more than 90% of the patients.

CONCLUSIONS

The contribution of geographical infrastructure-dependent time in prehospital delay was substantially smaller than that of geographical infrastructure-independent time. Intervention to shorten eDAD by focusing on factors such as older age, absence of a witness, onset at night, no EMS call, and transfer via a non-PCI facility appears to be an important strategy for reducing ODT in STEMI patients. Additionally, eDAD may be useful for evaluating the quality of STEMI patient transport in areas with different geographical conditions.

Early Changes in Acute Myocardial Infarction in Pigs: Achieving Early Detection with Wearable Devices

We examined the changes in variables that could be recorded on wearable devices during the early stages of acute myocardial infarction (AMI) in an animal model. Early diagnosis of AMI is important for prognosis; however, delayed diagnosis is common because of patient hesitation and lack of timely evaluations. Wearable devices are becoming increasingly sophisticated in the ability to track indicators. In this study, we retrospectively reviewed the changes in four variables during AMI in a pig model to assess their ability to help predict AMI onset. AMI was created in 33 pigs by 90-min balloon occlusion of the left anterior descending artery. Blood pressure, EKG, and lactate and cardiac troponin I levels were recorded during the occlusion period. Blood pressure declined significantly within 15 min after balloon inflation (mean arterial pressure, from 61 ± 8 to 50 ± 8 mmHg) and remained at this low level. Within 5 min of balloon inflation, the EKG showed ST-elevation in precordial leads V1–V3. Blood lactate levels increased gradually after occlusion and peaked at 60 min (from 1.48 to 2.53 mmol/L). The continuous transdermal troponin sensor demonstrated a gradual increase in troponin levels over time. Our data suggest that significant changes in key indicators (blood pressure, EKG leads V1–V3, and lactate and troponin levels) occurred at the onset of AMI. Monitoring of these variables could be used to develop an algorithm and alert patients early at the onset of AMI with the help of a wearable device.

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not.

OBJECTIVE

To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay.

METHODS

This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters.

RESULTS

Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952).

DISCUSSION

Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

Why do People Avoid Visiting Specialist Doctors? Answers from a Developing Country: Turkey Case

Avoid seeking medical care deemed necessary has severe negative effects on health. Indeed, delayed presentation of patients puts a significant burden on healthcare costs. There is limited literature examining the avoidance behaviour of people. Our study explores the reasons for avoiding considering the Turkey case. TurkStat’s health research survey 2012 data is employed to examine why people avoid visiting the specialist doctor when needed to consult a specialist for healthcare service. Descriptive statistics analysis is conducted. It is seen that among 28,056 respondents 12.6% were avoiders. Compared to non-avoiders, avoiders were more likely to be female, to live in rural area, to make out-of-pocket health payments, to be illiterate and to have low income. Indeed, the avoiders were more likely to have worse perceived health, negative emotions, mental disorders, serious health problems and chronic diseases. It is found that for approximately one-third of avoiders’ the main reason for avoiding was high costs. 22% of the avoiders reported that they could not take time. The other avoiding reasons were organisational factors, fear of medical treatment/surgery, distance/transportation, late appointment dates, having nobody to accompany and non-supportive family/relatives. In Turkey, interventions combating healthcare avoidance behaviours in at-risk populations should be developed.

Declining Public Awareness of Heart Attack Warning Symptoms in the Years Following an Australian Public Awareness Campaign: A Cross-Sectional Study

BACKGROUND

The National Heart Foundation of Australia's (NHFA) Warning Signs campaign ran between 2010 and 2013. This study examines trends in Australian adults' ability to name heart attack symptoms during the campaign and in the years following.

METHODS

Using the NHFA's HeartWatch data (quarterly online surveys) for adults aged 30-59 years, we conducted an adjusted piecewise regression analysis comparing trends in the ability to name symptoms during the campaign period plus one year lag (2010-2014) to the post-campaign period (2015-2020) RESULTS: Over the study period, there were 101,936 Australian adults surveyed. Symptom awareness was high or increased during the campaign period. However, there was a significant downward trend in each year following the campaign period for most symptoms (e.g., chest pain: adjusted odds ratio [AOR] =0.91, 95%CI: 0.56-0.80; arm pain: AOR=0.92, 95%CI: 0.90-0.94). Conversely, the inability to name any heart attack symptom increased in each year following the campaign (3.7% in 2010 to 19.9% in 2020; AOR=1.13, 95%CI: 1.10-1.15); these respondents were more likely to be younger, male, have less than 12 years of education, identify as Aboriginal and/or Torres Strait Islander Peoples, speak a language other than English at home and have no cardiovascular risk factors.

CONCLUSION

Awareness of heart attack symptoms has decreased in the years since the Warning Signs campaign in Australia, with 1 in 5 adults currently unable to name a single heart attack symptom. New approaches are needed to promote and sustain this knowledge, and to ensure people act appropriately and promptly if symptoms occur.

Investigation on Gender Differences in Leadership of Stroke-Related Clinical Trials

BACKGROUND

Gender disparities among principal investigators of clinical trials (CT) can have implications regarding the areas of investigation, methods, conduct, trial enrollment, and interpretation of results. An estimation of the gender gap in the leadership of stroke-related CTs from North America has to date not been undertaken.

METHODS

We extracted information about stroke-related CTs between 2011 and 2020 from www.

CLINICALTRIALS

gov and PubMed. We examined the gender distribution according to the academic credentials and the trial type. The gender of PIs and authors was determined using gender package in R, which identifies gender using historical data from the United States. Additionally, we obtained information from Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education data resource books on the gender composition of full-time neurology faculty, neurology residents and vascular neurology fellows.

RESULTS

In these analyses of 821 CTs registered on Clinicaltrials.gov and 110 trials published on PubMed, we found that gender disparity among the PIs, first and last authors have persisted over the last decade without any significant trend toward parity (P>0.05). On examining the gender distribution according to academic credentials and trial type, we found that men were over-represented in the sub-group of PIs with an MD degree (78.11% versus 21.87%; P<0.01) and those leading acute stroke trials (86.04% versus 13.89%; P<0.01). We also found that a lower proportion of women neurology residents pursued a vascular neurology fellowship during this period (33.5% versus 42.5%; P<0.05).

CONCLUSIONS

Our results show that the favorable trend toward gender parity seen in Neurology faculty over the last decade has not translated to the same in the leadership of CTs. Our findings merit further investigation and a re-examination of efforts toward inclusion of women as leaders of stroke-related CTs.

Receiving or not deemed necessary healthcare services

BACKGROUND

Avoiding deemed necessary healthcare needs may worsen prognosis and treatment options, and damage people's ability to perform their roles in society. Our study investigates why people avoid healthcare services in an upper-middle-income country, Türkiye.

METHODS

We apply TurkStat's 2012 Health Survey Data that includes a comprehensive health and social-demographic information of 28,055 survey participants who were 15 + aged. We use bivariate probit model to analyze the avoidance behavior in inpatient level in accordance with outpatient level because of the observed significant correlation between people's avoidance behavior under tertiary and lower level health care.

RESULTS

The findings show that 2.6% of 15 + aged population avoided deemed necessary hospital services. Furthermore, we found that high cost (31%), organizational factors (21%) and fear (12%) are prominent reasons of avoiding tertiary care. Thereafter, in our bivariate probit model findings, we figure out that being covered by social security schemes decreases the probability of avoiding both outpatient and inpatient health services by 6.9%. Moreover, being female, living in rural area, having lower income increase the chance of being avoider in both stages of healthcare.

CONCLUSION

We conclude that social inequalities are the main underlying determinants of the avoiding behavior.

Effect of a mutual goal-based continuous care program on self-management behaviour and health outcomes in patients after percutaneous coronary intervention: A randomized controlled trial

AIMS

To evaluate the effects of mutual goal-based continuous care program on the outcomes of patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI).

DESIGN

A single-blinded randomized controlled trial.

METHODS

87 patients with CHD after PCI in Hangzhou, Zhejiang, China, were randomly divided into study (n = 42) and control (n = 45) groups. The control group received 12-week cardiac rehabilitation and routine care. The study group received routine care and cardiac rehabilitation and the 12-week intervention program developed according to the goal attainment theory, including the mutual goal-based face-to-face guidance, and every-2-week telephone follow-ups. The self-management behaviour, quality of life, unscheduled readmission rate, and satisfaction of patients were examined.

RESULTS

For the patients subjected to the developed continuous nursing program based on mutual goals, achievement rates of all dimension mutual goals were at high levels (from 80.21% to 98.41%), except for the weight control (60.94%). Moreover, according to the comparable base data, compared with the control group, the self-management behaviour (study group 93.43 vs. control group 76.00), quality of life (QoL), and patients' satisfaction (study group 4.64 vs. control group 4.11) were higher, while the unscheduled readmission rate (study group 4.76% vs. control group 22.22%) was lower, in the study group, with statistically significant differences.

The PRESTO study: awareness of stroke symptoms and time from onset to intervention

Timely access to medical assistance is the first crucial step to improving clinical outcomes of stroke patients. Many educational campaigns have been organized with the purpose of making people aware of what a stroke is and what is necessary to do after its clinical onset. The PRESTO campaign was organized in Genoa (Italy) to spread easy messages regarding the management of the acute phase of stroke. Educational material was disseminated to educate people to call the emergency medical services as soon as symptoms appear. Data collected were analyzed in three different phases of the campaign: before the beginning, during, and after the end. We enrolled 1,132 patients with ischemic stroke admitted to hospital within 24 hours of symptoms onset. Our data showed a mild reduction in onset-to-door time (24 minutes) during the months following the end of the campaign and a slight increase in number of patients who arrived at hospitals, in particular with milder symptoms and transient ischemic attack, as opposed to the same period before the campaign. Interestingly, in the months after the end of the campaign, we observed a slight reduction of the percentage of patients who accessed hospitals after 4.5 hours from symptoms onset. In conclusion, our results may suggest that an informative campaign can be successful in making people rapidly aware of stroke onset, with the consequent rapid access to hospitals. Considering the changing of way of access to information, we think that an extensive multimedia campaign should be evaluated in the next future.

Awareness of stroke signs, symptoms, and risk factors among Jazan University students: An analytic cross-sectional study from Jazan, Saudi Arabia

In the Kingdom of Saudi Arabia, the lifetime risk of stroke is estimated to be between 23% and 28.9%, whereas in Jazan region of the Kingdom there is a high prevalence of sickle cell anemia, which is known to increase the risk of stroke. This study aimed to assess awareness of stroke signs, symptoms, and risk factors among university students in the southern region of Saudi Arabia. In this analytical cross-sectional study, data obtained through an online questionnaire were collected from 897 university students. Data were entered, cleaned, and analyzed using SPSS (IBM, Chicago IL) software version 28. Knowledge was assessed using both open- and closed-ended questions (CEQ). The participants were predominantly female (72%), single (86.8%), a fifth had relatives with cerebrovascular accident (CVA), and a third knew a person with CVA. The open-ended questions showed that 11.8% did not know any symptoms or signs and 25% knew only 1, while in the CEQs, hypertension was selected by 83.0%. Regarding knowledge about symptoms and signs, 33.7% and 21.9% recognized weakness and speech disturbance, respectively, whereas in the CEQs, around 60% selected others. Regarding actions that should be taken if CVA is suspected, >80% preferred going directly to the hospital. The best time to seek professional care was considered to be within 4 hours by 47.5%, 10.3% suggested a later timing, and 42.3% had no knowledge of what to do. Multivariate logistic regression revealed that pursuing a health-related specialty and previous stroke experience in close relatives were significantly associated with good stroke knowledge. The level of knowledge and correct timing and action among participants were better than those reported nationally and internationally. However, there is still room for improvement in awareness, which is recommended to improve the outcomes.

Access to acute stroke care: A retrospective descriptive analysis of stroke patients' journey to a district hospital

Introduction

The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes.

Methods

A descriptive analysis was performed using a retrospective folder and database review. All adult patients with a confirmed ischaemic stroke, on Computed Tomography (CT) scan, presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1^st of January 2019 to 31^st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes.

Results

A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5 h of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24 h (IQR 12-72 h). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16 h.

Conclusion

The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.

Knowledge and Attitude of General People Towards Symptoms of Heart Attack and the Impact of Delay Time in Riyadh, Saudi Arabia

BACKGROUND

Cardiovascular disease is prevalent worldwide. The goal of this research is to evaluate the knowledge of Riyadh, Saudi Arabia, population about heart attack symptoms and risk factors.

METHODOLOGY

A one-year cross-sectional study was carried out. The study was conducted on 385 individuals in Riyadh, Saudi Arabia. We used the Acute Coronary Syndrome Response Index, with additional questions added, such as risk factors of heart attack and physical activity time. An anonymous self-administered online questionnaire was used to collect the data.

RESULTS

We collected data from 440 participants, but only 385 were included in the analysis. Males represented 41.4% of the participants. In terms of participant knowledge of heart attack symptoms, we found that chest pain or pressure was the most common (80.5%), followed by shortness of breath (77%) and weakness and fatigue (72.0%). In addition, 90.2% and 90.7% of the participants knew that smoking and obesity were risk factors for heart attacks. Furthermore, 46% of participants said they "would not be at all certain" of identifying the symptoms and indicators of a heart attack in another person and 45.7% "in themselves." We found that males were more likely than females to have low knowledge (RR: 1.84, 95% CI: 1.24:2.72, P = 0.002).

CONCLUSION

Our findings suggest that there is a lack of awareness of the heart attack warning signs and symptoms. We propose that future local campaigns focus on increasing awareness and recognition of heart attack symptoms.

Comparison of Factors Associated With Direct Versus Transferred-in Admission to Government-Designated Regional Centers Between Acute Ischemic Stroke and Myocardial Infarction in Korea

BACKGROUND

There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI.

METHODS

Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed.

RESULTS

Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI; additionally, age (65-74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI.

CONCLUSIONS

Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

Using the Apple Watch to Record Multiple-Lead Electrocardiograms in Detecting Myocardial Infarction: Where Are We Now?

Although the outcome after myocardial infarction depends on the time to treatment, a delay between symptom onset and treatment is common. Apple Watch, a popular wearable device, provides the ability to perform an electrocardiogram. We review the progress made in using the Apple Watch to record multiple electrocardiogram leads for diagnosing myocardial infarction. Although the data are encouraging, many limitations remain, and more research is needed. Nevertheless, the Apple Watch could eventually serve as a self-check tool for patients who have chest pains or other symptoms of myocardial infarction, thus substantially decreasing the time to treatment and improving the outcome after myocardial infarction.

Clinical presentation in EMS patients with acute chest pain in relation to sex, age and medical history: prospective cohort study

OBJECTIVE

To assess symptom presentation related to age, sex and previous medical history in patients with chest pain.

DESIGN

Prospective observational cohort study.

SETTING

Two-centre study in a Swedish county emergency medical service (EMS) organisation.

PARTICIPANTS

Unselected inclusion of 2917 patients with chest pain cared for by the EMS during 2018.

DATA ANALYSIS

Multivariate analysis on the association between symptom characteristics, patients' sex, age, previous acute coronary syndrome (ACS) or diabetes and the final outcome of acute myocardial infarction (AMI).

RESULTS

Symptomology in patients assessed by the EMS due to acute chest pain varied with sex and age and also with previous ACS or diabetes. Women suffered more often from nausea (OR 1.6) and pain in throat (OR 2.1) or back (OR 2.1). Their pain was more often affected by palpation (1.7) or movement (OR 1.4). Older patients more often described pain onset while sleeping (OR 1.5) and that the onset of symptoms was slow, over hours rather than minutes (OR 1.4). They were less likely to report pain in other parts of their body than their chest (OR 1.4). They were to a lesser extent clammy (OR 0.6) or nauseous (OR 0.6). These differences were present regardless of whether the symptoms were caused by AMI or not.

CONCLUSIONS

A number of aspects of the symptom of chest pain appear to differ in unselected prehospital patients with chest pain in relation to age, sex and medical history, regardless of whether the chest pain was caused by a myocardial infarction or not. This complicates the possibility in prehospital care of using symptoms to predict the underlying aetiology of acute chest pain.

Using Multiple Logistic Regression to Determine Factors Affecting Delaying Hospital Arrival of Patients with Acute Ischemic Stroke

Background

Early treatment of ischemic stroke patients who arrive at the hospital ≤4.5 hours after the onset of symptoms with recombinant tissue plasminogen activator is more beneficial and very important.

Objective

This study is aimed to investigate the factors delaying the hospital arrival of patients with acute ischemic stroke by using multiple logistic regression analysis.

Methods and Materials

This descriptive cross-sectional study was done on patients diagnosed with acute ischemic stroke who were referred to Ardabil city Training and Research hospital at 2018. All patients and/or patient relatives were interviewed and data were collected through a checklist including demographic and clinical data of patients to explore the involved factors delaying hospital arrival of patients and then analyzed using multiple logistic regression analysis.

Results

Of all included patients, only 25.3% arrived at the hospital in ≤ 4.5 hours. By using multivariate logistic regression analysis, living in cities (P = 0.007), cigarette consumption (P = 0.032), having valvular heart disease (P = 0.008), and gender (P = 0.049) were factors associated with an early arrival to the hospital.

Conclusions

Results showed that most of the patients had a considerable delay in arriving at the hospital in ≤ 4.5 hours. Thus, providing health promotion strategies to improve society awareness of early symptoms of stroke, training of local physicians about the importance of early arrival of stroke patients, and more extended ambulance services in all cities and rural areas are necessary for better management of acute stroke patients in this area.

Latent class cluster analysis of knowledge on acute myocardial infarction in community residents: a cross-sectional study in Tianjin, China

OBJECTIVE

Public knowledge of early onset symptoms and risk factors (RF) of acute myocardial infarction (AMI) is very important for prevention, recurrence and guide medical seeking behaviours. This study aimed to identify clusters of knowledge on symptoms and RFs of AMI, compare characteristics and the awareness of the need for prompt treatment.

DESIGN

Multistage stratified sampling was used in this cross-sectional study. Latent GOLD Statistical Package was used to identify and classify the respondent subtypes of the knowledge on AMI symptoms or modifiable RFs. Multivariable logistic regression was performed to identify factors that predicted high knowledge membership.

PARTICIPANTS

A structured questionnaire was used to interview 4200 community residents aged over 35 in China. 4122 valid questionnaires were recovered.

RESULTS

For AMI symptoms and RFs, the knowledge levels were classified into two or three distinct clusters, respectively. 62.7% (Symptom High Knowledge Cluster) and 39.5% (RF High Knowledge Cluster) of the respondents were able to identify most of the symptoms and modifiable RFs. Respondents who were highly educated, had higher monthly household income, were insured, had regular physical examinations, had a disease history of AMI RFs, had AMI history in immediate family member or acquaintance or had received public education on AMI were observed to have higher probability of knowledge on symptoms and RFs. There was significant difference in awareness of the prompt treatment in case of AMI occurs among different clusters. 'Calling an ambulance' was the most popular option in response of seeing others presenting symptoms of AMI.

CONCLUSIONS

A moderate or relatively low knowledge on AMI symptoms and modifiable RFs was observed in our study. Identification of Knowledge Clusters could be a way to detect specific targeted groups with low knowledge of AMI, which may facilitate health education, further reduce the prehospital delay in China and improve patient outcomes.

There is little association between prehospital delay, persistent symptoms, and post-discharge healthcare utilization in patients evaluated for acute coronary syndrome

AIMS

Test for an association between prehospital delay for symptoms suggestive of acute coronary syndrome (ACS), persistent symptoms, and healthcare utilization (HCU) 30-days and 6-months post hospital discharge.

BACKGROUND

Delayed treatment for ACS increases patient morbidity and mortality. Prehospital delay is the largest factor in delayed treatment for ACS.

METHODS

Secondary analysis of data collected from a multi-center prospective study. Included were 722 patients presenting to the Emergency Department (ED) with symptoms that triggered a cardiac evaluation. Symptoms and HCU were measured using the 13-item ACS Symptom Checklist and the Froelicher's Health Services Utilization Questionnaire-Revised instrument. Logistic regression models were used to examine hypothesized associations.

RESULTS

For patients with ACS (n = 325), longer prehospital delay was associated with fewer MD/NP visits (OR, 0.986) at 30 days. Longer prehospital delay was associated with higher odds of calling 911 for any reason (OR, 1.015), and calling 911 for chest related symptoms (OR, 1.016) 6 months following discharge. For non-ACS patients (n = 397), longer prehospital delay was associated with higher odds of experiencing chest pressure (OR, 1.009) and chest discomfort (OR, 1.008) at 30 days. At 6 months, longer prehospital delay was associated with higher odds of upper back pain (OR, 1.013), palpitations (OR 1.014), indigestion (OR, 1.010), and calls to the MD/NP for chest symptoms (OR, 1.014).

CONCLUSIONS

There were few associations between prehospital delay and HCU for patients evaluated for ACS in the ED. Associations between prolonged delay and persistent symptoms may lead to increased HCU for those without ACS.

Barriers and enablers in the implementation of a quality improvement program for acute coronary syndromes in hospitals: a qualitative analysis using the consolidated framework for implementation research

Background

Ischemic heart disease causes a high disease burden globally and numerous challenges in treatment, particularly in developing countries such as China. The National Chest Pain Centers Program (NCPCP) was launched in China as the first nationwide, hospital-based, comprehensive, continuous quality improvement (QI) program to improve early diagnosis and standardized treatment of acute coronary syndromes (ACS) and improve patients’ clinical outcomes. With implementation and scaling up of the NCPCP, we investigated barriers and enablers in the NCPCP implementation process and provided examples and ideas for overcoming such barriers.

Methods

We conducted a nationally representative survey in six cities in China. A total of 165 key informant interviewees, including directors and coordinators of chest pain centers (CPCs) in 90 hospitals, participated in semi-structured interviews. The interviews were transcribed verbatim, translated into English, and analyzed in NVivo 12.0. We used the Consolidated Framework for Implementation Research (CFIR) to guide the codes and themes.

Results

Barriers to NCPCP implementation mainly arose from nine CFIR constructs. Barriers included the complexity of the intervention (complexity), low flexibility of requirements (adaptability), a lack of recognition of chest pain in patients with ACS (patient needs and resources), relatively low government support (external policies and incentives), staff mobility in the emergency department and other related departments (structural characteristics), resistance from related departments (networks and communications), overwhelming tasks for CPC coordinators (compatibility), lack of available resources for regular CPC operations (available resources), and fidelity to and sustainability of intervention implementation (executing). Enablers of intervention implementation were inner motivation for change (intervention sources), evidence strength and quality of intervention, relatively low cost (cost), individual knowledge and beliefs regarding the intervention, pressure from other hospitals (peer pressure), incentives and rewards of the intervention, and involvement of hospital leaders (leadership engagement, engaging).

Conclusion

Simplifying the intervention to adapt routine tasks for medical staff and optimizing operational mechanisms between the prehospital emergency system and in-hospital treatment system with government support, as well as enhancing emergency awareness among patients with chest pain are critically important to NCPCP implementation. Clarifying and addressing these barriers is key to designing a sustainable QI program for acute cardiovascular diseases in China and similar contexts across developing countries worldwide.

Trial registration

This study was registered in the Chinese Clinical Trial Registry (ChiCTR 2100043319), registered 10 February 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01207-6.

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.

Gender Particularities and Prevalence of Atypical Clinical Presentation in Non-ST Elevation Acute Coronary Syndrome

Clinical presentation is one of the factors that can influence how quickly a patient with an acute coronary syndrome is treated, particularly if it is atypical. The purposes of this study are to explore gender-related differences in patients presenting with non-ST elevation acute coronary syndromes (NSTEACS) from the perspective of a series of common risk factors as well as treatment strategies and to evaluate the prevalence of atypical clinical presentation of NSTEACS in the study group. In addition, we explored the differences between the two entities that define NSTEACS: unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI). We conducted a retrospective study by reviewing discharge documents of patients admitted in the cardiology department of the Clinical Rehabilitation Hospital in Cluj-Napoca with NSTEACS between January 2014 and December 2015. We retrieved demographic data, clinical presentation and history, laboratory tests, and coronary angiography records as well as the implemented treatment strategies. Women in the study group were more frequently hypertensive than men (89.5% vs. 75.4%; p = 0.043), had a higher mean serum HDL cholesterol value (43 vs. 38 mg/dL p = 0.022), were more frequently diagnosed with microvascular coronary heart disease (32% vs. 9.8%, p = 0.036), and were more often treated conservatively (49.1% vs. 30.8%, p = 0.038), while men were significantly more prone to smoking than women (30.8% vs. 14%, p = 0.028) and had higher mean serum creatinine (1.2 vs. 0.8 mg/dL; p = 0.022) and uric acid values (6.9 vs. 6.2 mg/dL; p = 0.048). Out of the 122 included patients, 109 had documented information regarding symptoms. The prevalence of atypical presentation was 4.6% (95% CI 0.7–8.5%). In our study group, patients with UA had a more frequent history of cardiovascular ischemic diseases (77.4% vs. 56.7%, p = 0.015), the mean value for BUN was higher in NSTEMI patients compared to patients with UA (47 vs. 39 mg/dL, p = 0.038) and NSTEMI patients more frequently received interventional treatment compared to patients with UA (60% vs. 41.9%; p = 0.046).

Factors associated with late presentation to the emergency department in patients complaining of chest pain

OBJECTIVE

We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).

METHODS

All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).

RESULTS

The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.

CONCLUSION

Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.

PRACTICE IMPLICATIONS

Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

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

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

Factors Affecting Delayed Hospital Arrival of Patients with Acute Myocardial Infarction in Kinmen

This study explores factors related to delayed emergency medical treatment for acute myocardial infarction patients on Kinmen Island. A cross-sectional study was performed in the only hospital in Kinmen Island. The study group consisted of 116 patients diagnosed with acute myocardial infarction (AMI, ICD-10 codes: 121.9) from November 2015 to May 2019. The binary logistic regression analyses were performed for the inferential statistical analysis. The mean age of the study group was 63.0 ± 14.5 years, 39.7% of the patients arrived at the emergency medicine longer than 6 h after the onset of symptoms. The related factors for delayed arrival the hospital emergency medicine department were female sex, age over 65 years, less than nine years’ education, and Killip Class, but only Killip Class reached the significant difference of statistics (OR = 3.616, 95% C.I. = 1.574 to 8.310, p = 0.002), and patients with delayed arrival times (>6 h) were found to have a higher percentage of Killip Class ≥ II. Therefore, it is essential to remind the physicians to proceed with risk stratification for acute coronary syndrome patients. In addition, health authorities should provide effective programs to increase awareness of the symptoms and timely treatment of acute myocardial infraction to the general public, especially the elderly.

From Suspicion to Recognition-Being a Bystander to a Relative Affected by Acute Coronary Syndrome

Within cardiac research, an overwhelming number of studies have explored factors related to pre-hospital delay. However, there is a knowledge gap in studies that explore the bystander's experiences or significance when an individual is affected by acute coronary syndrome (ACS). We conducted an interview study with 17 individuals affected by ACS and the bystander(s) involved and performed a qualitative thematic analysis. In the pre-hospital phase, the bystander moved from suspicion of illness to recognition of illness while trying to convince the individual affected by ACS (p-ACS) to respond to bodily sensations. This led to conflicts and dilemmas which affected the bystander both before and after the p-ACS was hospitalized. Bystanders may influence pre-hospital delay in both positive and negative direction depending on their own knowledge, convictions, and the nature of their interaction with the p-ACSs. The bystander's influence during the pre-hospital delay is more extensive than previously recognized.

Factors Associated With Prehospital Delay Among Patients With Acute Myocardial Infarction in the Era of Percutaneous Coronary Intervention - Insights From the OACIS Registry

BACKGROUND

The Japan Circulation Society launched the STOP-MI campaign in 2014, focusing on immediate hospital arrival for acute myocardial infarction (AMI) treatment. This study aimed to determine the factors influencing longer prehospital time among patients with AMI in Japan.Methods and Results:This study analyzed a total of 4,625 AMI patients enrolled in the Osaka Acute Coronary Insufficiency Study registry from 1998 to 2014. The prehospital time delay was defined as the time interval from the onset of initial symptoms to hospital arrival time ≥2 h. Among eligible patients, 2,927 (63.3%) had a prehospital time ≥2 h. In multivariable analyses, age 65-79 years (adjusted odds ratio [AOR] 1.19, 95% confidence interval [CI] 1.02-1.39), age ≥80 years (AOR 1.42, 95% CI 1.13-1.79), diabetes mellitus (AOR 1.33, 95% CI 1.16-1.52), and onset time of 0:00-5:59 h (AOR 1.63, 95% CI 1.37-1.95) were positively associated with prehospital time ≥2 h, whereas smoking (AOR 0.78, 95% CI 0.68-0.90) and ambulance use (AOR 0.37, 95% CI 0.32-0.43) were negatively associated with prehospital time ≥2 h.

CONCLUSIONS

Older age, diabetes mellitus, and nighttime onset were associated with prehospital time delay for AMI patients, whereas smoking and ambulance use were associated with no prehospital time delay. Healthcare providers and patients could help reduce the time to get to a medical facility by being aware of these findings.

Perceived Heart Attack Likelihood in Adults with a High Diabetes Risk

BACKGROUND

Heart disease is the leading cause of death for women and men in the United States. Yet, little is known about the motivation for care-seeking behavior for heart attack and the perception of self-risk of a heart attack in individuals, especially those at high risk for developing type 2 diabetes.

OBJECTIVES

This study aimed to describe knowledge and awareness of heart attacks and perceived risk for future heart attacks and evaluate factors associated with a low perceived risk of a heart attack in adults with a high risk for type 2 diabetes.

METHODS

In this secondary data, cross-sectional study, the screening/baseline data of 80 adults participating in the mobile phone-based diabetes prevention program trial were analyzed. Validated measures assessed knowledge, self-efficacy, and heart attack risk perception were used. Logistic regressions were performed.

RESULTS

The mean (standard deviation) age of participants was 55.4 (9.0) years. 32.5% of the sample failed to identify any heart attack symptoms. Half of the sample did not perceive their risk of having a heart attack in their lifetime. Older age, lower body mass index, not having a family history of heart attack, and current smokers were significantly associated with a lower perceived risk of heart attack (P < .05).

CONCLUSIONS

Healthcare providers need to assess the discrepancies between the individual's risk perception and the presence of actual risk factors of a heart attack in adults with a high risk for type 2 diabetes.