Leanne L. Lefler

Women's delay in seeking treatment with myocardial infarction: a meta-synthesis.

Women, especially those older than 65 years, delay longer than do men before seeking medical treatment for symptoms of an acute myocardial infarction (AMI). The majority of delay time results from the patients lengthy decision-making processes after symptoms begin and before seeking medical treatment. Effective treatment is time dependent as mortality and morbidity rise with each hour of delay. Therefore, the purpose of this research was 2-fold: (1) to synthesize reported research findings concerning womens reasons for delay in seeking treatment for symptoms of an AMI and (2) to identify areas for further research. Using Coopers (Synthesizing Research. 3rd ed. London: Sage; 1998) framework for integrative review, this manuscript synthesized the literature from 48 reports published from 1995 to 2003 to describe the primary reason(s) for womens prehospital delay. Three categories emerged to explain why women delay in seeking treatment: (1) clinical, (2) sociodemographic, and (3) psychosocial factors. These factors are found to be multifaceted and complex. The most significant reasons for delay in seeking treatment for symptoms of AMI are the following: atypical presentation of symptoms, severity of presenting symptoms, presence of other chronic illnesses that confused acute symptoms, correct attribution or labeling of symptoms to the heart, perceived seriousness of the symptoms, beliefs of low self-perceived vulnerability to heart attack, and engagement in various other coping mechanisms. This synthesis identified and clarified the current state of science regarding womens prehospital delay in seeking treatment for symptoms of an AMI. Areas for future research are also discussed.

Racial Differences in Women’s Prodromal and Acute Symptoms of Myocardial Infarction

BACKGROUND Minority women, especially black and Hispanic women, have higher rates of coronary heart disease and resulting disability and death than do white women. A lack of knowledge of minority womens symptoms of coronary heart disease may contribute to these disparities. OBJECTIVE To compare black, Hispanic, and white womens prodromal and acute symptoms of myocardial infarction. METHODS In total, 545 black, 539 white, and 186 Hispanic women without cognitive impairment at 15 sites were retrospectively surveyed by telephone after myocardial infarction. With general linear models and controls for cardiovascular risk factors, symptom severity and frequency were compared among racial groups. Logistic regression models were used to examine individual prodromal or acute symptoms by race, with adjustments for cardiovascular risk factors. RESULTS Among the women, 96% reported prodromal symptoms. Unusual fatigue (73%) and sleep disturbance (50%) were the most frequent. Eighteen symptoms differed significantly by race (P<.01); blacks reported higher frequencies of 10 symptoms than did Hispanics or whites. Thirty-six percent reported prodromal chest discomfort; Hispanics reported more pain/discomfort symptoms than did black or white women. Minority women reported more acute symptoms (P < .01). The most frequent symptom, regardless of race, was shortness of breath (63%); 22 symptoms differed by race (P <.01). In total, 28% of Hispanic, 38% of black, and 42% of white women reported no chest pain/discomfort. CONCLUSIONS Prodromal and acute symptoms of myocardial infarction differed significantly according to race. Racial descriptions of womens prodromal and acute symptoms should assist providers in interpreting womens symptoms.

Cluster analysis of women's prodromal and acute myocardial infarction symptoms by race and other characteristics.

Background and Objective:Although research has identified womens prodromal and acute myocardial infarction (MI) symptoms, diagnosing coronary heart disease in women remains challenging. Knowing how individual symptoms cluster by race and other characteristics would provide key diagnostic information. We performed a secondary analysis to: (a) generate naturally occurring symptom clusters based on prodromal and acute MI symptom scores separately, (b) examine the association between womens characteristics and symptom clusters, and (c) describe the percentage of women who reported experiencing the same symptoms in both prodromal and acute MI phases. Subject and Methods:The database contained retrospective self-reported data obtained by telephone survey from 1270 women (43% black, 42% white, 15% Hispanic) with a confirmed MI recruited from 15 geographically diverse sites. Data included frequency and severity of 33 prodromal symptoms, intensity of 37 acute MI symptoms, and comorbidities/risk factors. We used both bivariate and multivariate analyses to examine associations between cluster assignment and characteristics/risk factors. Because of the possibility of complex interactions, we explored nonlinear interactions with recursive partitioning. Results:Cluster analysis yielded 3 naturally occurring clusters for each of the prodromal and acute symptom sets. Each cluster contained women who reported increasing frequency and severity of symptoms. Six characteristics (age, race, body mass index, personal history of heart disease, diabetes, smoking status) were strongly associated with the clusters. Body mass index was the most important factor in classifying prodromal symptoms, whereas age was for acute symptoms. Conclusions:Black women younger than 50 years were more likely to report frequent and intense prodromal symptoms, whereas older white women reported the least. Younger, obese, diabetic black women reported the most acute symptoms, whereas older nonobese, nondiabetic white women reported the fewest. Symptom clusters and characteristics of women in these clusters provide valuable diagnostic information. Further research with a control group is needed.

Women's prehospital delay associated with myocardial infarction: does race really matter?

Background/Research Objective: Well-documented disparities in cardiovascular health account for approximately one third of the difference in life expectancy between blacks and whites. Mortality from cardiovascular disease is greater among black women than among white women, and black women report longer delays in treatment seeking following onset of symptoms of acute myocardial infarction (AMI). Despite this disparate burden, there is little race-specific data on correlates of delay for black or white women. This secondary data analysis compares duration and correlates of delay in treatment seeking by race following onset of AMI symptoms. Subjects/Methods: We analyzed self-report data from 509 black and 500 white women, interviewed 4 to 6 months after AMI, using multivariable logistic and linear regression. Results/Conclusions: Median delay time was nonsignificantly shorter for black than for white women (1.0 vs 1.5 hours). Equal proportions of black and white women (57% vs 54%) sought treatment within 2 hours of symptom onset. In multivariable analyses, correct attribution of symptoms to AMI was a significant predictor of treatment seeking within 2 hours of symptom onset for black and white women (odds ratios = 2.79 and 3.86, respectively); eligibility for public insurance was a significant predictor for black women only (odds ratio = 2.3). Common comorbidities, AMI risk factors, and other demographics were not significantly associated with delay time. Insurance coverage and the correct attribution of symptoms to cardiac causes are substantial and modifiable predictors of delay in seeking treatment of AMI.

The advanced practice nurse's role regarding women's delay in seeking treatment with myocardial infarction.

Purpose To synthesize nursing literature on reasons women delay in seeking treatment for signs and symptoms of an acute myocardial infarction (AMI), to hypothesize upon the primary reason(s) for this delay, and to propose advanced practice nurse (APN) interventions to reduce this delay. Data Sources Utilizing Stetlers Model of Research Utilization, all reports published in nursing journals within the last 10 years specifically examining prehospital delay related to gender factors were analyzed. Conclusions Women, especially those in advanced age, delay longer before seeking treatment for signs and symptoms of AMI. Effective treatment is time dependent; mortality and morbidity rise with increased prehospital delay. The reasons identified in the literature for this delay included severity, specificity, atypical presentation of symptoms, differences in event perception according to gender roles, and the interpretation and attribution of symptoms. Implications for Practice Identifying and teaching women at highest risk for delay, dispelling internal and external gender bias, increasing ones perception of patient vulnerability to AMI, and developing ones awareness of atypical presentations are the major factors that are likely to impact APN practice and consequently reduce prehospital delays for women at risk.

Examining Medication Adherence in Older Women with Coronary Heart Disease

The purposes of this study were to examine medication adherence in older women with coronary heart disease and to identify barriers and facilitators of medication adherence. Methods: The study used a semistructured interview guide and established measures to examine medication taking 3 months after hospital discharge. Results: Thirty-two women completed the study: 65.6% were adherent to medications, but others were less adherent and self-modified their therapy. Over half (52.1%) suffered side effects, 71.9% had experienced psychological barriers, and all had economic barriers. Facilitators included a pillbox system (85%) and discharge medication counseling (90%). Conclusion: Tailored interventions to improve adherence in older women are needed.

Temporal discounting rates and their relation to exercise behavior in older adults.

UNLABELLED As our nations population ages, the rates of chronic illness and disability are expected to increase significantly. Despite the knowledge that exercise may prevent chronic disease and promote health among older adults, many still are inactive. Factors related to exercise behaviors have been explored in recent years. However, temporal discounting is a motivational concept that has not been explored in regard to exercise in older adults. Temporal discounting is a decision making process by which an individual chooses a smaller more immediate reward over a larger delayed reward. The aim of this study was to determine if temporal discounting rates vary between exercising and non-exercising older adults. DESIGN This study used cross-sectional survey of 137 older adults living in the community. Older adults were recruited from 11 rural Arkansas churches. The Kirby delay-discounting Monetary Choice Questionnaire was used to collect discounting rates and then bivariate analysis was performed to compare temporal discounting rate between the exercisers and non-exercisers. Finally, multivariate analysis was used to compare discounting rate controlling for other covariates. RESULTS The results indicated that exercising older adults display lower temporal discounting rates than non-exercising older adults. After controlling for education, exercisers still have lower temporal discounting rates than non-exercisers (p<0.001). CONCLUSIONS AND IMPLICATIONS These findings are important as several chronic health conditions relate to lack of exercise especially in older adults. This research suggests that if we can find appropriate incentives for discounting individuals, some type of immediate reward, then potentially we can design programs to engage and retain older adults in exercise.

“Missing Pieces”: Exploring Cardiac Risk Perceptions in Older Women

Approximately 95% of older women have factors that put them at risk for developing cardiovascular disease, but research indicates many do not perceive themselves to be at risk. We examined older womens perceived risk for coronary heart disease (CHD) and the factors influencing their perceptions. We conducted a descriptive, qualitative study using in-depth, individual interviews and quantitative measures to assess perceived risk and risk factors. Twenty-four older African American and Caucasian women had a mean 4.46 cardiac risk factors but perceived their own CHD risk as unrealistically low at 1.95 cm (SD = 1.57, on 0-to-8 cm visual analogue scale). Narrative data clustered in themes that represented a lack of fact-based information and multiple misconceptions about CHD and prevention. Major improvements in CHD health are only achievable if risk factors are prevented. This research suggests older women have substantial needs for consistent CHD information and prevention guidance.

New cardiovascular guidelines: Clinical practice evidence for the nurse practitioner

Purpose:Guidelines for the prevention and treatment of cardiovascular disease (CVD) have recently changed. Goals of these guidelines have shifted to the promotion of health and control of risk rather than solely on treatment of CVD. This article summarizes the six new cardiovascular screening, prevention, and treatment guidelines for use in practice. Data sources:Published and peer‐reviewed guidelines published jointly and in collaboration with the National Heart Lung and Blood Institute by the American Heart Association and the American College of Cardiology constitute the evidence base for this article. Conclusions:The potential for making lifestyle changes a way of life instead of a diet or program is an important point to make in clinical visits. If nurse practitioners (NPs) could promote a way‐of‐life lifestyle change to individuals in America, even change at a modest level, we could improve the health of the nation. Implications for practice:NPs need to be aware of new guidelines and best practices to improve the cardiovascular health of their patients. We summarized these new guidelines into an easy‐to‐interpret format for use in practice.Purpose Guidelines for the prevention and treatment of cardiovascular disease (CVD) have recently changed. Goals of these guidelines have shifted to the promotion of health and control of risk rather than solely on treatment of CVD. This article summarizes the six new cardiovascular screening, prevention, and treatment guidelines for use in practice. Data sources Published and peer-reviewed guidelines published jointly and in collaboration with the National Heart Lung and Blood Institute by the American Heart Association and the American College of Cardiology constitute the evidence base for this article. Conclusions The potential for making lifestyle changes a way of life instead of a diet or program is an important point to make in clinical visits. If nurse practitioners (NPs) could promote a way-of-life lifestyle change to individuals in America, even change at a modest level, we could improve the health of the nation. Implications for practice NPs need to be aware of new guidelines and best practices to improve the cardiovascular health of their patients. We summarized these new guidelines into an easy-to-interpret format for use in practice.

Hospital Executives’ Perceptions of End-of-Life Care

Hospital executives are key stakeholders in the hospital setting. However, despite extensive medical and nursing literature on the importance of end-of-life (EOL) care in hospitals, little is known about hospital executives’ perceptions of the provision of EOL care in their facilities. The objective of this study was to capture hospital executives’ perceptions of the provision of EOL care in the hospital setting. This descriptive, naturalistic phenomenological, qualitative study utilized in-person interviews to explore executives’ opinions and beliefs. The sample consisted of 14 individuals in the roles of medical center directors, chiefs of staff, chief medical officers, hospital administrators, hospital risk managers, and regional counsel in Arkansas, Louisiana and Texas. An interview guide was developed and conducted utilizing a global question followed by probes concerning perceptions of EOL care provision. Hospital executives acknowledged that EOL care was a very important issue, and more attention should be paid to it in the hospital setting. Their comments and suggestions for improvement focused on (a) current EOL care, (b) barriers to changing EOL care, and (c) enhancing provision of EOL care in the hospital setting. The findings of this study suggest that hospital executives although key change agents, may have insufficient EOL information to implement steps toward cultural and infrastructural change and should therefore be included in any EOL discussions and education.