Patient Denial of Myocardial Infarction in the Prehospital Phase: Prevalence and Correlates

BACKGROUND

Limited knowledge exists regarding patients' denial of myocardial infarction (MI) before hospitalization for an MI.

OBJECTIVE

The aim of this study was to determine the prevalence and correlates of denial of MI in the prehospital phase of a confirmed MI.

METHODS

This secondary analysis included 166 hospitalized patients (mean [SD] age, 54.1 [10.5] years) who developed MI outside a healthcare facility and had high congruence between their experienced and expected symptoms. Measurements included the Denial subscale of the Brief COPE Inventory, the modified Response to Symptoms Questionnaire, and a Likert scale measuring perceived risk for MI. Patients who arrived at a hospital at least 1 hour after the onset of their symptoms were considered to have prolonged prehospital delay.

RESULTS

Despite their high symptom congruence, 77% of patients denied the possibility of having an MI before hospitalization. The lower denial group was characterized by cardiac history, whereas the higher denial group was distinguished by nonsmoking, a lower perceived risk of MI, less anxiety at symptom onset, and more concerns about seeking medical help. Compared with the lower denial group, patients in the higher denial group were more likely to underestimate the seriousness of their symptoms and delay seeking medical help. The higher denial group responded to symptoms in a more passive manner (eg, waiting), whereas the lower denial group showed a more problem-solving approach (eg, contacting emergency services).

CONCLUSIONS

Denial of MI is highly prevalent in the prehospital phase and is negatively linked with cognitive, emotional, and behavioral responses to MI symptoms.

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

AIMS

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

BACKGROUND

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

DESIGN

Meta-synthesis.

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

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

IMPACT

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

REPORTING METHOD

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

PATIENT OR PUBLIC CONTRIBUTION

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

Women's Prodromal Myocardial Infarction Symptom Perception, Attribution, and Care Seeking: A Qualitative Multiple Case Study

BACKGROUND

Most women experience prodromal myocardial infarction (MI) symptoms, but more information is needed about the perception, attribution, and care-seeking behaviors related to these prodromal symptoms.

OBJECTIVES

We aimed to describe women's perceptions, attributions, and care-seeking behaviors related to prodromal MI symptoms.

METHOD

We used a qualitative, multiple case study approach, recruiting participants during summer 2019 from a large hospital in the Midwestern United States. Data were collected from interviews with the women who experienced MI and some of their family members, journals, and electronic health records. An inductive, comparative analysis procedure was applied.

RESULTS

Ten women, ages 42 to 84, participated in the study. The women experienced a mixture of certainty and uncertainty related to their symptoms and engaged in several cognitive processes to conceptualize and act upon their symptoms. Although all the women retrospectively reported at least 4 prodromal symptoms, they lacked knowledge of prodromal MI symptoms and often responded to prodromal sensations that they experienced using emotion- and avoidance-based strategies. It was difficult for the women to establish a symptom pattern that was attributable to heart disease.

DISCUSSION

The findings of this study may be used as evidence to support interventions that would facilitate women's care seeking for and health care providers' recognition of prodromal MI symptoms. Additional research is necessary to more fully characterize the cognitive processes at play for women of many different sociocultural backgrounds who experience prodromal MI symptoms.

Contextualising lifestyles: how socially contrasting places in Fife, Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease

Coronary heart disease (CHD) is a significant public health issue showing persistent geographical health inequalities. However, little attention has focussed on lay perspectives of how contrasting social contexts influence lifestyles and health behaviour in relation to CHD. The aim of this qualitative study is to explore lay perspectives of lifestyle and behaviour in socioeconomically contrasting places, with women and men who had survived a heart attack in Fife, Scotland. This study contributes to knowledge on CHD health inequalities and health promotion, particularly cardiac rehabilitation, emphasising the importance of situating experiences and understandings of health, geographically.

Symptoms and delay times during myocardial infarction in 694 patients with and without diabetes; an explorative cross-sectional study

BACKGROUND

In myocardial infarction (MI) a short pre-hospital delay, prompt diagnosis and timely reperfusion treatment can improve the prognosis. Despite the importance of timely care seeking, many patients with MI symptoms delay seeking medical care. Previous research is inconclusive about differences in symptom presentation and pre-hospital delay between patients with and without diabetes during MI. The aim of this study was to describe symptoms and patient delay during MI in patients with and without diabetes.

METHODS

Swedish cross-sectional multicentre survey study enrolling MI patients in 5 centres within 24 h from admittance.

RESULTS

Chest pain was common in patients both with and without diabetes and did not differ after adjustment for age and sex. Patients with diabetes had higher risk for shoulder pain/discomfort, shortness of breath, and tiredness, but lower risk for cold sweat. The three most common symptoms reported by patients with diabetes were chest pain, pain in arms/hands and tiredness. In patients without diabetes the most common symptoms were chest pain, cold sweat and pain in arms/hands. Median patient delay time was 2 h, 24 min for patients with diabetes and 1 h, 15 min for patients without diabetes (p = 0.024).

CONCLUSION

Chest pain was common both in patients with and without diabetes. There were more similarities than differences in MI symptoms between patients with and without diabetes but patients with diabetes had considerably longer delay. This knowledge is important not only for health care personnel meeting patients with suspected MI, but also for the education of people with diabetes.

Women's help-seeking behaviour during a first acute myocardial infarction

Studies indicate that the time from onset of symptoms to medical treatment has decreased in acute myocardial infarction (AMI). However, there are still variations indicating that women wait longer than men before making the decision to seek medical care. Multidimensional factors hindering and facilitating the decision have been identified in previous studies, though few have fully explored how social context affects women's expectations, interpretations and actions and so influences the decision-making process. The aim of this study was therefore to identify how women's experiences interacted and influenced the decision to seek medical care at their first AMI. Seventeen women, aged 38-75 years, were interviewed, at home or in the hospital, between June 2011 and May 2012. Grounded theory was used as a method, and data collection and analysis were carried out simultaneously. The results showed that before deciding to seek medical care, these women went through three defined but interrelated processes that together hindered their normal activities and made them act according to existential needs. The women's experiences of the progression of the disease, in terms of both symptoms and time, were very different, so they sought medical care at different times, sometimes life-threateningly late and sometimes before developing an AMI. Three mechanisms had to coincide if the women were to receive medical care. First, the women had to acknowledge their symptoms as something more than common bodily changes. Second, the healthcare system had to be accessible when the women made their decision to seek care. Third, the women must have come into contact with healthcare providers when the heart muscle had taken enough damage to measure.

The Process of Care-seeking for Myocardial Infarction Among Patients With Diabetes

BACKGROUND

People with diabetes have a higher risk for myocardial infarction (MI) than do people without diabetes. It is extremely important that patients with MI seek medical care as soon as possible after symptom onset because the shorter the time from symptom onset to treatment, the better the prognosis.

OBJECTIVE

The aim of this study was to explore how people with diabetes experience the onset of MI and how they decide to seek care.

METHODS

We interviewed 15 patients with diabetes, 7 men and 8 women, seeking care for MI. They were interviewed 1 to 5 days after their admission to hospital. Five of the participants had had a previous MI; 5 were being treated with insulin; 5, with a combination of insulin and oral antidiabetic agents; and 5, with oral agents only. Data were analyzed according to grounded theory.

RESULTS

The core category that emerged, "becoming ready to act," incorporated the related categories of perceiving symptoms, becoming aware of illness, feeling endangered, and acting on illness experience. Our results suggest that responses in each of the categories affect the care-seeking process and could be barriers or facilitators in timely care-seeking. Many participants did not see themselves as susceptible to MI and MI was not expressed as a complication of diabetes.

CONCLUSIONS

Patients with diabetes engaged in a complex care-seeking process, including several delaying barriers, when they experienced symptoms of an MI. Education for patients with diabetes should include discussions about their increased risk of MI, the range of individual variation in symptoms and onset of MI, and the best course of action when possible symptoms of MI occur.

“Manifestos do Coração”: Significados Atribuídos à Doença por Pacientes Cardíacos Pré-cirúrgicos

RESUMO Este estudo objetivou explorar os significados atribuídos à doença cardíaca por pacientes cardíacos pré-cirúrgicos em tratamento ambulatorial no sul do Brasil. É um estudo clínico-qualitativo, de caráter exploratório e descritivo, cuja coleta de dados aconteceu por meio de entrevistas semiestruturadas e da autofotografia, propostas a 15 indivíduos. Foi realizada análise de conteúdo temática, emergindo as categorias: Confrontação com a doença: os saberes em questão, Negação da doença, Doença e trabalho e Sexualidade rompida. Os resultados destacaram as dificuldades dos participantes relacionadas à apropriação do quadro da doença e à aceitação dessa condição. Salienta-se a premência de ações de saúde, que possam ser coadjuvantes na reestruturação das possibilidades de vida para os pacientes cardíacos pré-cirúrgicos.

Perception of illness symptoms in patients with acute coronary syndrome: a need to improve

BACKGROUND

Interpretation of the symptoms of acute coronary syndrome (ACS) can influence the time of hospital admission and negatively affect patients' prognosis. We decided to explore illness perception and its predictors among patients with ACS.

METHODS

We conducted a retrospective analysis of all consecutive patients with ACS admitted to the cardiology department of a tertiary hospital between January and September 2011. Data were obtained from patients' medical records and telephone interviews.

RESULTS

One hundred and eighty-six patients with ACS (mean age 64 ± 12 years; 70% male) were included. The majority (62.6%) had no perception of ACS until informed by their doctor. Only 26% of patients with ST-segment elevation myocardial infarction had perception of cardiac disease. Among those who had perception, 82.6% were men and 58% had a previous diagnosis of ischemic heart disease (IHD). Gender and previous diagnosis of IHD were independent predictors of ACS perception, with male gender and patients with previous IHD having greater illness perception. No association was found between ACS perception and age or residence area (rural vs. urban).

CONCLUSIONS

The illness perception of ACS patients needs to be improved, independently of sociodemographic factors. An educational program for the general population, but particularly for women and individuals without a past history of IHD, focusing on the alert signs for ACS, may help to improve illness perception in this setting.

Experiences and actions during the decision making process among men with a first acute myocardial infarction

BACKGROUND

Previous studies have shown that people hesitate to seek medical attention when experiencing the initial symptoms of acute myocardial infarction (AMI), but the reasons why and the events underpinning the decision-making process are unclear. The aim of this study was to describe the actions and experiences involved in the process of seeking medical attention in men with a first AMI.

METHODS

We studied 21 men, aged 39-73 years, hospitalized with a first AMI between May 2011 and March 2013. All were interviewed in the coronary unit before discharge, with one exception. Data collection and analysis were carried out simultaneously in accordance with grounded theory methodology.

RESULTS

Men diagnosed with a first AMI experienced a spectrum of insidious and vague symptoms, which they did not associate with an AMI. This caused uncertainty in how to interpret symptom severity and contributed to a reluctance to seek medical care. Participants also had difficulty interpreting online information when seeking to explain their symptoms. Weighing up and comparing the various experiences during the early stages of AMI proved to be the trigger that changed the men's perspectives and made them aware of the abnormality, the severity of their illness, and the need for action.

CONCLUSION

Healthcare professionals should be aware that men experience a range of insidious and vague symptoms during their first AMI and must give greater emphasis to their narratives, particularly when objective clinical signs are limited or absent. Consideration should be given to the ways laypeople interpret online information when designing healthcare resources for the Internet.

Turkish patients' decision-making process in seeking treatment for myocardial infarction

AIM

The purpose of this study was to reveal how Turkish patients experiencing acute myocardial infarction (AMI) for the first time decide to seek medical treatment following the initiation of the symptoms.

METHODS

This qualitative study was carried out by using the grounded theory. Data were collected in a university hospital cardiology clinic in Turkey between March 2009 and March 2010. The sample comprised 30 patients having experienced AMI for the first time. The data were collected by an in-depth interview technique via a semistructured interview form. All of the interviews were recorded using a tape-recorder.

RESULTS

The median decision-making time was 90 min. Two main themes emerged at the end of the study: "feeling of abnormality" and "thinking the situation is critical". Deciding to seek medical help was found to be a process which emerges with the severity of symptoms, an inability to manage symptoms, fear, and extrinsic factors.

CONCLUSION

The results of this study show the importance of being aware of the symptoms when deciding to seek treatment. It is recommended to develop training programs about AMI symptoms and the importance of receiving early medical help by targeting society in general and the individuals with a diagnosis of coronary artery disease and their relatives in particular, and to organize awareness-raising campaigns supported by the media.

Approach and avoidance coping and regulatory focus in patients having coronary artery bypass graft surgery

Coronary artery bypass graft (CABG) surgery is stressful, and the patient's coping affects recovery and outcome. The aim of the study was to identify patients' thoughts and concerns, and explore the relevance of approach/avoidant coping and Regulatory Focus Theory (RFT). Nine patients were interviewed, using an interpretative phenomenological approach. The patients made use of various avoidant (e.g. neglecting symptoms, delaying help-seeking, avoiding thoughts) and approach strategies (e.g. persistent search for the diagnosis, mental preparation for surgery). RFT versus approach/avoidant coping is discussed. RFT may contribute to our understanding of motivational cognitions in patients' coping with illness and treatment.

Factors associated with posttraumatic growth among the spouses of myocardial infarction patients

To clarify the rationale behind Posttraumatic Growth (PTG), a model by Schaefer and Moos describes the relative contribution of environmental resources, individual resources, event related factors, cognitive processing and coping (CPC) on PTG. In the present study, this model was tested with the spouses of myocardial infarction patients with data from various hospitals in Turkey. A structural equation model revealed that neither individual nor environmental resources had indirect effects on PTG through the effect of event-related factors and CPC, while they showed direct effects on PTG. The findings were discussed in the context of the theoretical model.

Predictors of pre-hospital delay among patients with acute myocardial infarction

OBJECTIVE

To evaluate current literature on predictors of pre-hospital delay among patients with acute myocardial infarction (AMI).

METHODS

Medline, CINHAL, and Psych Info databases were searched using keywords: attitude to illness/health, health beliefs, help/health seeking behavior, health behavior, psychosocial factors, treatment delay, socioeconomic factors, time factors, pre-hospital delay, and symptoms. These keywords were combined with AMI to identify literature published during 1995-2008.

RESULTS

Twenty-six data-based research articles were identified. Delay varied across literature and median pre-hospital delay was often reported due to distribution skewness resulting from extremely prolonged values (1.5-15.2h). Six categories of predictors influenced pre-hospital delay; socio-demographic, symptom onset context, cognitive, affective/psychological, behavioral, and clinical factors. Pre-hospital delay was shortest when the decision to seek healthcare was facilitated by family members or coworkers and when symptoms suggestive of heart attack were continuous and severe.

CONCLUSION AND PRACTICE IMPLICATIONS

Developing interventions programs to reduce pre-hospital delay for high-risk patients is warranted. Because decision delay is the only modifiable part by intervention, it is recommended that future investigations and interventions attend to decision time as the primary variable of interest instead of combining it with transportation time. Moreover, content of patient education need to emphasize on symptom awareness and recognition, and prompt and proper patient actions for optimum results. Also, in order to eliminate sampling bias resulting from investigating surviving AMI patients, it is recommended that future studies incorporate data from both surviving and surrogates of non-surviving AMI patients.

'It was not chest pain really, I can't explain it!' An exploratory study on the nature of symptoms experienced by women during their myocardial infarction

AIMS AND OBJECTIVES

This study sought to explore the presenting nature of cardiac symptoms as experienced by women diagnosed with a myocardial infarction. The objectives were to use the participants' own words to gain a detailed understanding of how they perceived their evolving symptoms.

BACKGROUND

Women with coronary heart disease tend to delay seeking help despite experiencing symptoms. The classic hallmarks used to diagnose a myocardial infarction have been based on research primarily involving white middle-aged men with a focus on specific descriptions of chest pain. Whether these hallmarks apply to women in the same way as they apply to men is an area of increasing contention.

DESIGN

Using a purposive sample, a qualitative design was used to investigate the nature of cardiac symptoms experienced by women prior to and at the time of their myocardial infarction.

METHOD

Twelve women participated in semi-structured in-depth tape-recorded interviews conducted while they were in hospital.

RESULTS

Three interlinking themes emerged, which reflect a changing dynamic status in health, mediated by the perceived threat of individual symptoms. These included gradual awareness, not having pain in the chest and reactions to symptoms.

CONCLUSIONS

It would appear that symptom presentation and distribution amongst women may not follow the pattern traditionally associated with current understanding of a 'typical' myocardial infarction. These differences together with perceptions about their cardiac symptoms may influence their health-seeking behaviours.

RELEVANCE TO CLINICAL PRACTICE

Women with a myocardial infarction may present with non-specific chest symptoms, which are difficult to interpret or recognize by patients and health professionals alike. Skill in recording history and in performing a comprehensive assessment of initial and current symptoms will enable nurses to identify women with a differential diagnosis of chest pain readily. Additionally, to increase awareness of coronary heart disease, nurses must use any opportunity to educate women of all age groups.

Women, men and coronary heart disease: a review of the qualitative literature

AIM

This paper presents a review of the qualitative literature which examines the experiences of patients with coronary heart disease. The paper also assesses whether the experiences of both female and male patients are reflected in the literature and summarizes key themes.

BACKGROUND

Understanding patients' experiences of their illness is important for coronary heart disease prevention and education. Qualitative methods are particularly suited to eliciting patients' detailed understandings and perceptions of illness. As much previous research has been 'gender neutral', this review pays particular attention to gender.

METHODS

Published papers from 60 qualitative studies were identified for the review through searches in MEDLINE, EMBASE, CINAHL, PREMEDLINE, PsychINFO, Social Sciences Citation Index and Web of Science using keywords related to coronary heart disease.

FINDINGS

Early qualitative studies of patients with coronary heart disease were conducted almost exclusively with men, and tended to generalize from 'male' experience to 'human' experience. By the late 1990s this pattern had changed, with the majority of studies including women and many being conducted with solely female samples. However, many studies that include both male and female coronary heart disease patients still do not have a specific gender focus. Key themes in the literature include interpreting symptoms and seeking help, belief about coronary 'candidates' and relationships with health professionals. The influence of social roles is important: many female patients have difficulties reconciling family responsibilities and medical advice, while male patients worry about being absent from work.

CONCLUSIONS

There is a need for studies that compare the experiences of men and women. There is also an urgent need for work that takes masculinity and gender roles into account when exploring the experiences of men with coronary heart disease.

Perceived health status and perceived diabetes control: psychological indicators and accuracy

OBJECTIVE

The aim of this study is to assess the association of psychological, as well as physical and sociodemographic, indicators with patients' ratings of personal health status and diabetes control and to investigate the association of mental health and depression with errors in the perception of diabetes control.

METHOD

A sociodemographically diverse sample of 623 diabetes patients was recruited from the general medicine clinics of a county health care system and a Veterans Affairs health care system. We examined three types of determinants of patients' health perceptions: physical health indicators (symptoms, comorbid diagnoses, and glycosylated hemoglobin or HbA1c levels), psychological health indicators (general mental health and diabetes-related worry), and sociodemographic factors (age, race, gender, income, and education).

RESULTS

After controlling for patient' sociodemographic characteristics, perceived general health was associated with patients' symptom burden and emotional distress (but not with patients' HbA1c levels). Perceived diabetes control additionally was associated with HbA1c and diabetes-related worries. Further analyses showed that both mental health and diagnosed depression were associated with errors in personal appraisals of diabetes control, with depressed patients more often inaccurately assessing their glycemic control as poor (false-positive error) and nondepressed patients more often missing poor HbA1c levels (false-negative error).

CONCLUSIONS

Findings indicate that patients use a comprehensive model for assessing their general health and that depression may lead to more accurate assessments of poor glucose control.