Time-to-Treatment for Myocardial Infarction: Barriers and Facilitators Perceived by American Indians in Three Regions

Early recognition of acute myocardial infarction (MI), followed by prompt emergency care, improves patient outcomes. Among rural American Indian (AI) populations there are disparities in access to care for MI and processes of care, resulting in poor MI-related health outcomes compared to the general population. We sought to gain an understanding of barriers related to MI time-to-treatment delays using a qualitative approach. We conducted semi-structured interviews and focus groups with AI key informants and community members in three Indian Health Service regions. Major barriers to care included long travel distance to care and lack of supporting infrastructure; distrust of the health care system; low overall literacy and basic health literacy; priority of family care-giving; and lack of specialized medical facilities and specialists. Findings suggest that improved time-to-treatment facilitators include educating the local community about the causes and consequences of MI and culturally-sensitive health communication, as well as addressing the quality of local systems of care and the community's perception of these systems. Pursuing these strategies may improve quality of care and reduce MI-related morbidity and mortality in rural AI populations.

The increasing incidence of coronary artery disease and cardiovascular risk factors among a Southwest Native American tribe: the White Mountain Apache Heart Study

BACKGROUND

Rates of cardiovascular disease and its risk factors seem to be increasing in American Indian populations, yet these changes have received little documentation.

OBJECTIVES

To evaluate incidence rates of coronary artery disease, acute myocardial infarction, and cardiac events during a 10-year period (1987-1996); to assess cardiac risk factors for an American Indian tribe in Arizona.

METHODS

A retrospective medical chart review was performed for tribal members from January 1, 1987-December 31, 1996. Patient records with even minor indications of coronary disease were reviewed independently by 2 cardiologists of the Native American Cardiology Program. Multiple databases were reviewed in an effort to find all diagnoses, and incidence rates were calculated and analyzed for increasing trends. Cardiac risk factors were assessed in a population convenience sample.

RESULTS

From 1987 through 1996, the number of incident cases increased from 3 to 18 for coronary artery disease, 1 to 10 for acute myocardial infarction, and 3 to 26 for cardiac events. Statistically significant increasing trends were calculated for each. Of our youthful convenience sample, 49% had 2 or more cardiac risk factors.

CONCLUSIONS

This study confirms increasing rates of coronary artery disease and its comorbidities in this American Indian population and demonstrates high prevalence of cardiovascular risk factors among tribal members without extant coronary disease. This suggests that coronary disease will likely continue to increase as this population ages. To prevent such increases, culturally appropriate, aggressive preventive interventions are needed.

Procainamide-induced psychosis: a case report and review of the literature

OBJECTIVE

To describe a case of procainamide-induced psychosis in an adult treated for atrial fibrillation.

CASE SUMMARY

A 45-year-old Native American woman developed acute psychosis within 72 hours of initiating procainamide for atrial fibrillation. Symptoms abated within 24 hours of discontinuing procainamide. Serum procainamide/N-acetylprocainamide concentrations were therapeutic throughout treatment. Sotalol was started without recurrence of symptoms.

DISCUSSION

Psychosis is a rare complication of treatment with procainamide, but the exact mechanism for this adverse event is not fully understood. Seven cases implicating procainamide as the cause of acute psychosis are reported in the literature. Cases of psychosis involving other antiarrhythmic agents have also been reported.

CONCLUSIONS

Healthcare personnel should be aware of this adverse event related to procainamide and other antiarrhythmic agents.

Prognostic significance of ST-segment depression during adenosine perfusion imaging

To determine the significance of ST-segment depression during adenosine perfusion imaging for predicting future cardiac events, 188 patients with interpretable electrocardiograms were assessed 1 to 3 years (mean 21.5 +/- 6.6 months) after adenosine testing. At least 1 mm of ST-segment depression was observed in 32 (17%) patients, with > or = 2 mm of ST-segment depression in 10 (5.3%). Thirty-seven cardiac events occurred during the study period: 2 cardiac deaths, 5 nonfatal myocardial infarctions, 6 admissions for unstable angina, and 24 revascularizations. Univariate predictors of events were a history of congestive heart failure, previous non-Q-wave myocardial infarction, previous coronary angioplasty, use of antianginal medication, ST-segment depression during adenosine infusion (particularly > or = 2 mm), any reversible perfusion defect, transient left ventricular cavity dilation, and the severity of perfusion defects. Multivariate analysis identified > or = 2 mm ST-segment depression as the most significant predictor of cardiac events (relative risk [RR] = 6.5; p = 0.0001). Other independent predictors of events were left ventricular dilation (RR = 3.8; p = 0.002), previous coronary angioplasty (RR = 3.3; p = 0.001), a history of non-Q-wave myocardial infarction (RR = 2.3; p = 0.01), and the presence of any reversible defect (RR = 2.0; p = 0.05). We conclude that ST-segment depression occurs uncommonly during adenosine infusion, but the presence of > or = 2 mm of ST-segment depression is an independent predictor of future cardiac events and provides information in addition to that obtained from clinical variables and the results of adenosine perfusion imaging.