Catherine J. Ryan

Treatment seeking for acute myocardial infarction symptoms: differences in delay across sex and race.

BackgroundPatients experiencing an acute myocardial infarction are known to delay seeking treatment between 2 and 4 hours. This delay is problematic because individuals who receive treatment 2 or more hours after the onset of symptoms are less likely to benefit from emergent reperfusion techniques. Persons most likely to delay seeking treatment for an acute myocardial infarction and their reasons have not been clearly identified. ObjectiveThe purpose of this study was to identify the effect of selected demographic, clinical, cognitive, and environmental variables on the length of the time of delay. In addition, the study was designed to identify whether women delayed longer than men, and whether African Americans delayed longer than non-Hispanic Whites during an acute myocardial infarction. MethodA structured interview was conducted in a convenience sample (N eq> 212) of African American and non-Hispanic White patients hospitalized after acute myocardial infarction. Patients were asked detailed information about the sequence of events prior to the acute myocardial infarction, and the symptoms experienced. Medical records were examined for clinical information. ResultsWomen did not delay significantly longer than men (2.0 vs. 2.5 median hours). African Americans delayed significantly longer than non-Hispanic Whites (3.25 hours vs. 2.0 median hours). Race did not contribute unique variance to delay time in a simultaneous multiple regression analysis; however, race was a significant predictor variable in whether or not participants sought treatment within the first hour after the onset of symptoms. The variance in delay time for African American and Non-Hispanic White men and women that could be explained by the predictor variables ranged from 23–47%. ConclusionsThe reasons for delay differed in part by sex and race.

Transitions of Care in Heart Failure A Scientific Statement From the American Heart Association

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

Symptom Clusters in Acute Myocardial Infarction: A Secondary Data Analysis

Background: Early recognition of acute myocardial infarction (AMI) symptoms and reduced time to treatment may reduce morbidity and mortality. People having AMI experience a constellation of symptoms, but the common constellations or clusters of symptoms have yet to be identified. Objectives: To identify clusters of symptoms that represent AMI. Methods: This was a secondary data analysis of nine descriptive, cross-sectional studies that included data from 1,073 people having AMI in the United States and England. Data were analyzed using latent class cluster analysis, an atheoretical method that uses only information contained in the data. Results: Five distinct clusters of symptoms were identified. Age, race, and sex were statistically significant in predicting cluster membership. None of the symptom clusters described in this analysis included all of the symptoms that are considered typical. In one cluster, subjects had only a moderate to low probability of experiencing any of the symptoms analyzed. Discussion: Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters identified in this study included all of the symptoms that are included typically as symptoms of AMI (chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness). These AMI symptom clusters must be communicated clearly to the public in a way that will assist them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior. Symptom clusters for AMI must also be communicated to the professional community in a way that will facilitate assessment and rapid intervention for AMI.

Is the Medical Record an Accurate Reflection of Patients’ Symptoms During Acute Myocardial Infarction?

Documentation of symptoms in the medical record provides clinicians and researchers with valuable information about the patient’s experience during acute myocardial infarction (AMI). To examine the consistency between the patient’s reported symptoms and the medical record, 215 patients were interviewed and their medical records examined for information about their admission symptoms. Chest pain was the most frequently reported and recorded symptom, and there was good agreement between the patient’s report and the medical record. Although fatigue was the second most frequently reported symptom by patients, it was rarely documented in the medical record. Time of symptom onset was identified by 87.9% of patients but only documented in 60.5% of medical records. Clinicians may be recording those symptoms that support the AMI diagnosis and not those perceived to be less relevant. Findings suggest that the medical record is an inaccurate and inadequate source of information about patients’ actual experience of AMI symptoms.

Knowledge of Symptom Clusters Among Adults at Risk for Acute Myocardial Infarction

Background:Individuals need to recognize acute myocardial infarction symptoms in order to seek treatment promptly. Previous acute myocardial infarction symptom studies asked subjects to identify single symptoms from a list. However, people think about illnesses or respond to symptoms by considering groups or clusters of symptoms. Objective:To use Q methodology to identify the cluster of symptoms that individuals at high risk for acute myocardial infarction and their significant others believe to be associated with acute myocardial infarction. Methods:A Q sort instrument that represented a range of symptoms was developed after analysis of 140 interviews with acute myocardial infarction survivors. Individuals with known coronary artery disease or their significant others (n = 63) sorted the resulting 49 statements describing acute myocardial infarction into “most expected” and “least expected” categories. By-person factor analysis was used. Results:Four factors were identified that described different presentations of acute myocardial infarction symptoms. Respondents loaded on the following factors: Factor 1 (traditional symptoms), Factor 2 (symptoms possibly related to gastrointestinal disorders), Factor 3 (nonspecific symptoms), and Factor 4 (a variation on traditional symptoms). This four-factor solution accounted for 36% of the total variance. Conclusions:The Q methodology showed that people with known coronary artery disease and their significant others had varied expectations of acute myocardial infarction symptoms. New and various strategies need to be developed to help patients accurately identify acute myocardial infarction symptoms.

Critical review of factors predicting health-related quality of life in newly diagnosed coronary artery disease patients.

Background:Newly diagnosed coronary heart disease patients can experience significant negative changes in their health-related quality of life (HRQoL). No existing literature review was found related to factors predicting HRQoL in newly diagnosed coronary heart disease patients. Purpose:The aim of this study was to identify factors predicting HRQoL in newly diagnosed coronary heart disease patients. Review Methods:We searched studies published between 1997 and 2009 with combinations of key words including factors, predictor, health-related quality of life, quality of life, first diagnosed coronary heart disease patients, and coronary heart disease patients. Data sources were ProQuest, ScienceDirect, CINAHL, PsychINFO, PubMed, and Scopus. Seventeen studies were identified that primarily examined HRQoL from 6 weeks to 12 months after diagnosis. Conclusions:Factors predicting HRQoL in newly diagnosed coronary heart disease patients can be divided into 3 groups: sociodemographic, clinical, and psychosocial. Characteristics in each category most strongly predictive of HRQoL in newly diagnosed coronary heart disease patients were: Sociodemographic positive predictors were baseline HRQoL, education level, and marital status; sociodemographic negative predictors included number of cardiovascular risks and female gender. Age was an inverse predictor. Clinical negative predictors included angina, physical functioning, and fatigue. Psychosocial positive predictors included social support and a sense of coherence, whereas depression, anxiety and depression, overall psychosocial characteristics or mood disturbance, anxiety, and hostility were negative predictors. Clinical Implications:This review identifies predictors of HRQoL and shows the importance of assessing factors that predict HRQoL at baseline and throughout the trajectory of this chronic illness because the concept of HRQoL changes over time but the predictors remain constant.

Perceptions of symptoms of myocardial infarction related to health care seeking behaviors in the elderly.

Research on acute myocardial infarction (AMI) suggests that older persons may delay significantly longer than younger persons between the first appearance of symptoms of AMI and seeking treatment and that this delay is associated with increased morbidity and mortality. The factors that potentially influence delay in older persons can be grouped into 4 categories: (a) symptom attribution to aging, (b) symptom severity and duration, (c) symptom attribution to comorbid and chronic conditions, and (d) previous experience with cardiac problems. This article explores the link between symptom interpretation and health care seeking behaviors in elderly patients with AMI as it relates to delay in seeking treatment for AMI. Potential nursing interventions are presented.

Chest pain and associated symptoms of acute coronary syndromes.

Coronary heart disease is the primary health risk for all Americans. Acute coronary syndromes (ACS) is the term used to denote any 1 of 3 clinical manifestations of coronary heart disease: unstable angina, non–ST elevation myocardial infarction, and ST-elevation MI. The major challenge to healthcare providers is the rapid and accurate identification of patients with ACS who would benefit from immediate thrombolysis or percutaneous coronary interventions. The purpose of this article is to describe the incidence, causes, risk factors, assessment, and diagnosis of patients presenting with ACS as well as current recommendations for nurses who treat patients with ACS.

Continuing Education Outcomes Related to Pain Management Practice

BACKGROUND Nursing practice outcomes of continuing education need to be measured and reported as one indicator of the value of nursing continuing education. This article makes the case that knowledge gain, the traditional measure of continuing education effectiveness, is not necessarily sufficient to assess changes in nursing practice. METHOD A pretest/posttest design was used to measure nursing practice outcomes of a continuing education program about pain management. A total of 50 attendees returned both the pretests and posttests and 68 attendees returned the follow-up evaluation. RESULTS Ninety-four percent of the respondents had improved scores on the posttest. Ninety-one percent of the follow-up evaluation respondents stated they had an opportunity to use the new information and 98% stated the use of this information has improved patient care. CONCLUSION This study found that a continuing education program triggered practice changes. The results of this study correlate with previous research that supports the need for practice outcome measurements.

Classifying subgroups of patients with symptoms of acute coronary syndromes: A cluster analysis

The purpose of the study was to identify subgroups of patients presenting with acute coronary syndromes based on symptom clusters. Two hundred fifty-six patients completed a symptom assessment in their hospital rooms. Latent class cluster analysis and analysis of variance were used to classify subgroups of patients according to selected clinical characteristics. Four subgroups were identified and labeled as Heavy Symptom Burden, Chest Pain Only, Sweating and Weak, and Short of Breath and Weak (model fit χ(2) [130,891, n = 256] = 867.5, p = 1.00). The largest group of patients experienced classic symptoms of chest pain and shortness of breath but not sweating. Younger patients were more likely to cluster in the Heavy Symptom Burden group (F = 5.08, p = .002). Interpretation of the clinical significance of these groupings requires further study.