Hendrika Meischke

Causes of delay in seeking treatment for heart attack symptoms

With the advent of thrombolytic therapy and other coronary reperfusion strategies, rapid identification and treatment of acute myocardial infarction greatly reduces mortality. Unfortunately, many patients delay seeking medical care and miss the benefits afforded by recent advances in treatment. Studies have shown that the median time from onset of symptoms to seeking care ranges from 2 to 61/2 hours, while optimal benefit is derived during the first hour from symptom onset. The phenomenon of delay by AMI patients and those around them needs to be understood prior to the design of education and counseling strategies to reduce delay. In this article the literature is reviewed and variables that increase patient delay are identified. A theoretical model based on the health belief model, a self regulation model of illness cognition, and interactionist role theory is proposed to explain the response of an individual to the signs and symptoms of acute myocardial infarction. Finally, recommendations are made for future research.

REASONS PATIENTS WITH CHEST PAIN DELAY OR DO NOT CALL 911

STUDY OBJECTIVE To determine the reasons patients with suspected acute myocardial infarction (AMI) delay seeking medical care or do not call 911. DESIGN Telephone interview of patients hospitalized with suspected AMI. SETTING Nine hospitals in King County, Washington. PARTICIPANTS Patients admitted to a CCU or ICU between October 1, 1986, and December 31, 1987, with suspected AMI occurring out-of-hospital. Spouses of patients who met criteria but died during the hospitalization also participated. INTERVENTIONS Hospital records were reviewed, and a 20-minute telephone interview was conducted of patients who reside in King County but do not live in an extended care facility. MEASUREMENTS Patient demographics, cardiac history, symptoms, time of acute symptom onset, time of emergency department arrival, method of transportation, discharge diagnosis, and hospital outcome were abstracted from hospital records. Circumstances leading to the hospitalization, reasons for delay in seeking care, and reasons for not calling 911 were determined in the telephone interview. RESULTS In a 15-month period, 5,207 patients were hospitalized for suspected AMI in King County, Washington. Twenty-seven percent had AMI. Median patient delay between symptom onset and hospital arrival was 2 hours. Paramedics transported 45% of all patients. A representative subset of patients (2,316) were interviewed. The main reasons for delay were because the patient thought that the symptoms would go away, because the symptoms were not severe enough, and because the patient thought that the symptoms were caused by another illness. The main reasons for not calling 911 were because the symptoms were not severe enough, because the patient did not think of calling 911, and because the patient thought that self-transport would be faster because of his or her close location to the hospital. CONCLUSION Maximal benefit from thrombolytic therapy is not realized in a substantial proportion of patients with AMI because of delays in seeking medical care. Knowledge of the reasons patients delay or do not call 911 can help focus efforts on achieving more rapid treatment of patients with AMI.

Demographic, Belief, and Situational Factors Influencing the Decision to Utilize Emergency Medical Services Among Chest Pain Patients

BACKGROUND Empirical evidence suggests that people value emergency medical services (EMS) but that they may not use the service when experiencing chest pain. This study evaluates this phenomenon and the factors associated with the failure to use EMS during a potential cardiac event. METHODS AND RESULTS Baseline data were gathered from a randomized, controlled community trial (REACT) that was conducted in 20 US communities. A random-digit-dial survey documented bystander intentions to use EMS for cardiac symptoms in each community. An emergency department surveillance system documented the mode of transport among chest pain patients in each community and collected ancillary data, including situational factors surrounding the chest pain event. Logistic regression identified factors associated with failure to use EMS. A total of 962 community members responded to the phone survey, and data were collected on 875 chest pain emergency department arrivals. The mean proportion of community members intending to use EMS during a witnessed cardiac event was 89%; the mean proportion of patients observed using the service was 23%, with significant geographic differences (range, 10% to 48% use). After controlling for covariates, non-EMS users were more likely to try antacids/aspirin and call a doctor and were less likely to subscribe to (or participate in) an EMS prepayment plan. CONCLUSIONS The results of this study indicate that indecision, self-treatment, physician contact, and financial concerns may undermine a chest pain patients intention to use EMS.

A Randomized Clinical Trial to Reduce Patient Prehospital Delay to Treatment in Acute Coronary Syndrome

Background—Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time. Methods and Results—Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67±11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%). Conclusions—The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge. Clinical Trial Registration—clinicaltrials.gov. Identifier NCT00734760.

Increasing Cardiopulmonary Resuscitation Provision in Communities With Low Bystander Cardiopulmonary Resuscitation Rates A Science Advisory From the American Heart Association for Healthcare Providers, Policymakers, Public Health Departments, and Community Leaders

There are approximately 360 000 out-of-hospital cardiac arrests (OHCAs) in the United States each year, accounting for 15% of all deaths.1 Striking geographic variation in OHCA outcomes has been observed, with survival rates varying from 0.2% in Detroit, MI,2 to 16% in Seattle, WA.3 Survival variation can be explained in part by differing rates of bystander cardiopulmonary resuscitation (CPR), a vital link in improving survival for victims of OHCA. For every 30 people who receive bystander CPR, 1 additional life is saved.4 Communities that have increased rates of bystander CPR have experienced improvements in OHCA survival5,6; therefore, a promising approach to increasing OHCA survival is to increase the provision of bystander CPR. Yet provision of bystander CPR varies dramatically by locale, with rates ranging from 10% to 65% in the United States.7,8 On average, however, bystander CPR is provided in only approximately one fourth of all OHCA events in the United States despite public education campaigns and promotion of CPR as a best practice by organizations such as the American Heart Association and American Red Cross.9–11 Internationally, similar variation exists, with rates of bystander CPR reported to be as low as 1%12 and as high as 44%.13 Therefore, it is important to understand why certain communities have low bystander CPR rates and to provide recommendations for how to increase bystander CPR provision in these communities. Four critical steps are involved in providing bystander CPR as part of a coordinated community emergency response (Figure 1). First, the potential rescuer must recognize that the victim needs assistance. Early recognition may include the bystander recognizing that the victim has had a cardiac arrest, or simply that the victim needs assistance from emergency medical services (EMS). Second, the …

911 and Emergency Department Use for Chest Pain: Results of a Media Campaign

STUDY OBJECTIVE We evaluated the effects of a community public education campaign that encouraged patients to quickly call 911 after the onset of acute myocardial infarction (AMI) symptoms. SETTING AND PARTICIPANTS The media campaign focused on residents 50 years of age or older in King County, Washington, which has a population of 1.5 million (1990 census). DESIGN We determined 911 responses for chest pain, emergency department visits for AMI symptoms, the number of patients admitted to a CCU with an admitting diagnosis of rule-out MI, and the number of confirmed AMIs before and after the campaign. RESULTS The number of emergency medical services (EMS) responses (911 runs) for patients 50 years of age or older experiencing AMI symptoms increased significantly during the media campaign. ED visits for chest pain also increased significantly during the campaign, as did the number of patients 50 years of age or older admitted to a King County CCU with an admitting diagnosis of rule-out MI. Each of the above increases tapered--with time after the media campaign but remained above baseline. CONCLUSION An intense public education campaign can significantly increase EMS use, ED visits, and CCU admissions for AMI symptoms. However, these effects taper off with time after the campaign.

'Call fast, Call 911': a direct mail campaign to reduce patient delay in acute myocardial infarction.

OBJECTIVES A 10-month direct mail campaign was implemented to increase use of emergency medical services via 911 calls and to reduce prehospital delay for individuals experiencing acute myocardial infarction symptoms. METHODS This prospective, randomized, controlled trial involved three intervention groups (receiving brochures with informational, emotional, or social messages) and a control group. RESULTS Intervention effects were not observed except for individuals who had a history of acute myocardial infarction and who were discharged with a diagnosis of acute myocardial infarction; their 911 use was meaningfully higher in each intervention group than in the control group. CONCLUSIONS The mailings affected only the individuals at greatest risk.

CPR instruction by videotape: results of a community project.

STUDY OBJECTIVE To increase the rate of bystander CPR in a community by use of a free, mailed, 10-minute videotape of CPR instruction. DESIGN Prospective, randomized intervention trial. One half of the households (8,659) received the free videotape (video-tape group) and were considered the intervention group, and one half (8,659) served as the control (no-videotape group). All households were followed from December 1991 to March 1993 to determine whether a cardiac arrest occurred and who initiated CPR. A telephone interview obtained additional information about circumstances of the arrest and whether members of the household viewed the videotape. SETTING City of Everett and South Snohomish County, Washington. A commercial mailing list was used to identify 17,318 households with a head of the household who was more than 50 years old. PARTICIPANTS A case was defined as a cardiac arrest in which CPR was initiated or continued by emergency medical services personnel. Only cardiac arrests due to presumed underlying heart disease were included. Arrests occurring after arrival of emergency medical services personnel were not included. INTERVENTIONS The intervention was a free 10-minute videotape with CPR instructions mailed to the 8,659 intervention households. Paramedic run reports were reviewed and interviews were conducted with cardiac arrest bystanders to determine who initiated CPR and whether they had received and viewed the videotape. RESULTS Sixty-five cardiac arrests occurred in the study households: 31 in households that received the videotape and 34 in households that did not review the videotape. The overall rate of bystander CPR was 47% in the videotape group and 53% in the no-videotape group (P = NS). In nine cardiac arrests, an individual was present who had watched the videotape; six of these nine cases (66%) had bystander CPR. CONCLUSION Mass mailings of CPR instructional videos are likely to be ineffective in increasing the rate of bystander CPR in a community.

Factors That Influence Personal Perceptions of the Risk of an Acute Myocardial Infarction

Abstract Personal risk perceptions of acute myocardial infarction (AMI) affect peoples preventive health behaviors as well as their beliefs during a heart attack episode. The authors investigated factors that are associated with personal risk perceptions of having an AMI. A random-digit-dial survey was conducted among 1294 respondents, aged 18 years or older, in 20 communities across the nation as part of the Rapid Early Action for Coronary Treatment (REACT) trial. Results of two mixed-model linear regression analyses suggested that worse perceived general health, more risk factors, and greater knowledge were associated with greater perception of AMI risk. The results also showed that women who answered, incorrectly, that heart disease is not the most common cause of death for women in the United States reported significantly lower risk perceptions than women who answered this question correctly. The findings in this study suggest that interventions need to target specific misconceptions regarding AMI risk.

Persistent Comorbid Symptoms of Depression and Anxiety Predict Mortality in Heart Disease

BACKGROUND Incident anxiety and depression are associated separately with cardiac events and mortality in patients after acute coronary syndromes, but the influence of persistent comorbid depression and anxiety on mortality remains unknown. The purpose of this study was to determine the prevalence of comorbid persistent depressive and anxious symptoms in individuals with ischemic heart disease and to evaluate effects on mortality. METHODS Prospective, longitudinal cohort design in the context of a randomized trial to decrease patient delay in seeking treatment for ischemic heart symptoms (PROMOTION trial) was used, with twelve-month follow-up of 2325 individuals with stable ischemic heart disease. Participants were assessed on enrollment and at 3 months using the Multiple Adjective Affect Checklist and the Brief Symptom Inventory for depressive and anxious symptoms, respectively. RESULTS At 3 months, 608 individuals (61.7%) reported persistent symptoms of depression, anxiety, or both. Three hundred seventy-nine (42.5%) and 1056 (45.4%) had persistent anxious and depressive symptoms, respectively. Those with persistent, comorbid symptoms had higher mortality compared to others (p=.029). The combined presence of anxious and depressive symptoms contributed significantly to mortality when compared to symptom-free participants (OR 2.35, 95% CI 1.23-4.47, p=.010). The presence of persistent depressive symptoms only and persistent anxious symptoms only were not associated with death, when other demographic and clinical variables were considered. CONCLUSIONS Persistent symptoms of anxiety and depression increased substantially the risk of death in patients with ischemic heart disease. Future research into shared and unique pathways and treatments is needed.