Linda L. Coventry

Sex differences in symptom presentation in acute myocardial infarction: A systematic review and meta-analysis

BACKGROUND Recognition of sex differences in symptom presentation of acute myocardial infarction (AMI) is important for timely clinical diagnosis. This review examined whether women are equally as likely as men to present with chest pain. METHODS We conducted a systematic review and meta-analysis of English language research articles published between 1990 and 2009. RESULTS Meta-analysis showed women with AMI had lower odds and a lower rate of presenting with chest pain than men (odds ratio .63; 95% confidence interval, .59-.68; risk ratio .93; 95% confidence interval, .91-.95). Women were significantly more likely than men to present with fatigue, neck pain, syncope, nausea, right arm pain, dizziness, and jaw pain. CONCLUSION Health campaigns on symptom presentation of AMI should continue to promote chest pain as the cardinal symptom of AMI, but also reflect a wider spectrum of possible symptoms and highlight potential differences in symptom presentation between men and women.

Myocardial infarction: Sex differences in symptoms reported to emergency dispatch

Abstract Background. Emergency management of myocardial infarction (MI) is time-critical, because improved patient outcomes are associated with reduced time from symptom onset to definitive care. Previous studies have identified that women are less likely to present with chest pain. Objective. We sought to measure the effect of sex on symptoms reported to the ambulance dispatch and ambulance times for MI patients. Methods. The Western Australia Emergency Department Information System (EDIS) was used to identify patients with emergency department (ED) diagnoses of MI (ST-segment elevation MI and non–ST-segment elevation MI) who arrived by ambulance between January 1, 2008, and October 31, 2009. Their emergency telephone calls to the ambulance service were transcribed to identify presenting symptoms. Ambulance data were used to examine ambulance times. Sex differences were analyzed using descriptive and age-adjusted regression analysis. Results. Of 3,329 MI patients who presented to Perth EDs, 2,100 (63.1%) arrived by ambulance. After predefined exclusions, 1,681 emergency calls were analyzed. The women (n = 621; 36.9%) were older than the men (p < 0.001) and, even after age adjustment, were less likely to report chest pain (odds ratio [OR] = 0.70; 95% confidence interval [CI] 0.57, 0.88). After age adjustment, ambulance times did not differ between the male and female patients with chest pain. The women with chest pain were less likely than the men with chest pain to be allocated a “priority 1” (lights and sirens) ambulance response (men 98.3% vs. women 95.5%; OR = 0.39; 95% CI 0.18, 0.87). Conclusion. Ambulance dispatch officers (and paramedics) need to be aware of potential sex differences in MI presentation in order to ensure appropriate ambulance response.

Symptoms of Myocardial Infarction: Concordance between Paramedic and Hospital Records

Abstract Introduction. To further reduce time to definitive therapy for acute myocardial infarction (MI) patients, the focus of research needs to be on better understanding prehospital delay in recognition and response to symptoms. Paramedic clinical records can serve as a convenient source of data for such studies, but their accuracy needs to be established. Objectives. This study aimed to determine the concordance of the symptoms and symptom-onset time recorded in the paramedic patient care record (PCR) with those recorded in the hospital medical record for MI patients. Methods. A retrospective review of paramedic and hospital medical records was undertaken between January 1, 2008 and October 31, 2009 for all patients with an emergency department (ED) discharge diagnosis of MI at a single teaching hospital in Perth, Western Australia. The symptoms of MI and onset times documented in the paramedic PCR were compared with those recorded in the hospital medical record, which was considered the “gold standard.” The study assessed differences in documentation using McNemars tests, and concordance was described by kappa and adjusted kappa statistics, sensitivity, specificity, and positive and negative predictive value (PPV, NPV). Results. Of 810 patients with an ED discharge diagnosis of MI, 584 (71%) patients arrived by ambulance and 509 patients had a paramedic PCR. After exclusions, 400 patients had both paramedic PCR and hospital medical records available for review. Of 21 documented MI symptoms, the majority (71.4%) had adjusted kappa statistics greater than 0.75, and observed agreement greater than 90%. For the symptom of chest pain, sensitivity, specificity, PPV, and NPV were all over 85%. Where recorded in both records (n = 196, 49%) the symptom-onset time agreed exactly for 118 (60.2%) records, differed by 1–15 minutes for 24 (12.2%) records, and differed by 16–30 minutes for 22 (11.2%) records. Conclusion. Our study demonstrated that documentation of the common symptoms of MI and symptom-onset time was similar between the paramedic and hospital records, justifying the use of paramedic PCRs as a source of data for research in prehospital MI patient delay. Further research is required to investigate why symptom-onset time was not routinely documented for all patients with chest pain.

Myocardial infarction, patient decision delay and help-seeking behaviour: A thematic analysis

AIMS AND OBJECTIVES To explore patient decision delay, the symptom experience and factors that motivated the patient experiencing myocardial infarction to go to the emergency department. BACKGROUND Reperfusion for myocardial infarction is more effective if performed as soon as possible after the onset of symptoms. Multiple studies show that prehospital delay is long and can average several hours. DESIGN A qualitative descriptive design using semi-structured interviews. METHODS All consecutive myocardial infarction patients who between July 2013-January 2014 at a single-centre metropolitan tertiary hospital in Western Australia were included. Patient responses to an open-ended question were recorded and transcribed verbatim. Data were analysed using Braun & Clarke (Qual Res Psychol, 3, 2006, 77-101) thematic analysis method. RESULTS Of the 367 eligible, 255 provided consent. Three themes emerged from the qualitative analyses: (1) onset and response to symptoms, and this included three subthemes: context of the event, diversity of symptom interpretation and response to symptoms; (2) help-seeking behaviour, and this included the patient seeking help from various lay and professional sources; and (3) help-seeking outcomes, which include calling the emergency ambulance, going to emergency department, seeing a general practitioner, seeing a general practitioner who advised them to go home. CONCLUSION The context of the event, their symptomatology and the layperson who was the first point of contact influenced the decision for the patient to go to the emergency department. Many patients used private transport or contacted their general practitioner. New knowledge from this study emphasises the importance of the layperson understanding the appropriate response is to seek prompt care through immediate emergency transport by ambulance to emergency department. RELEVANCE TO CLINICAL PRACTICE This study highlights the need to educate both the patient and the wider public, not only to seek prompt care but to also to call the emergency ambulance to arrange transport to the emergency department.

The Effect of Presenting Symptoms and Patient Characteristics on Prehospital Delay in MI Patients Presenting to Emergency Department by Ambulance: A Cohort Study

INTRODUCTION There is little recent information about prehospital delay time for Australian patients with myocardial infarction (MI). OBJECTIVES This study: (1) describes prehospital delay time for patients with MI; (2) identifies variables and presenting symptoms which contribute to the delay. METHODS This retrospective cohort study identified patients with an Emergency Department (ED) discharge diagnosis of MI, transported by ambulance to one of the seven Perth metropolitan EDs, between January 2008 and October 2009. Prehospital delay times were analysed using linear regression models. Non-numeric (word descriptions) of delay time were categorised. RESULTS Of 1,633 patients, symptom onset-time was available for 1,003. For 829 patients with a numeric onset-time, median delay was 2.2hours; decreased delay was associated with age <70 years, presenting with chest pain, and diaphoresis. Increased delay was associated with being with a primary health care provider, and if the patient was at home and if the person who called the ambulance was anyone other than the spouse. For 174 patients with non-numeric onset-times, 37% patients delayed one to three days and 110 (64.0%) patients described their symptoms as intermittent and/or of gradual onset. CONCLUSION Given that prehospital delay times remain longer than is optimal, public awareness of MI symptoms should be enhanced in order to decrease prehospital delay.

Characteristics and outcomes of MI patients with and without chest pain: a cohort study

INTRODUCTION There are conflicting data on patient characteristics and outcomes of myocardial infarction (MI) patients presenting with and without the symptom of chest pain. OBJECTIVES Compare the characteristics and survival of patients stratified by the symptom chest pain. METHODS This retrospective cohort study identified patients with an emergency department discharge diagnosis of MI, who arrived by ambulance at a teaching hospital in Perth, Western Australia, between January 2008 to October 2009. The cohort was linked to hospital data and the state-based death register; clinical data were extracted by medical record review. Patient characteristics were compared using logistic regression models and survival analysis using Kaplan-Meier curves and Cox regression models. RESULTS Of 382 patients, 26% presented without chest pain. The odds of presenting without chest pain were increased if aged 80+ (OR 7.54; 95%CI 2.81-20.3) and aged 70-79 years (OR 4.33; 95% CI 1.50-12.5), and female (OR 1.67; 95%CI 0.99-2.82). The adjusted hazard (median follow-up time 2.2 years) of presenting without chest pain was not significantly associated with survival (HR 1.03; 95%CI 0.71-1.48). CONCLUSION Characteristics differed between patients with and without chest pain. However, the symptom of chest pain was not associated with survival.

The Effect of Media Campaigns, Patient Characteristics, and Presenting Symptoms on Prehospital Delay in Myocardial Infarction Patients: A Prospective Cohort Study

BACKGROUND Delays in reperfusion therapy for myocardial infarction (MI) are associated with increased mortality and morbidity, and most of this delay is due to delay in patients initiating contact with emergency services. This study assesses the impact of the Australian National Heart Foundation media campaign and identifies patient characteristics and presenting symptoms that may contribute to delay. METHODS This prospective cohort study identified patients with a diagnosis of MI admitted to a single tertiary metropolitan hospital in Perth, Western Australia from July 2013 to January 2014. Patients were interviewed and responses were categorised to determine their reasons for delaying treatment and the impact of mass media campaigns. Delay times were analysed using multivariable linear regression models for the Whole Cohort (all patients admitted to the tertiary hospital, including patients from rural and peripheral hospitals) and the Direct Admission Cohort (patients admitted directly to the tertiary hospital). RESULTS Of 376 patients, 255 patients provided consent, and symptom onset-time was available for 175 patients. While almost two thirds of the cohort was aware of media campaigns, awareness was not associated with decreased prehospital delay. Median delay was 3.9hours for the Whole Cohort and 3.5hours for the Direct Admission Cohort. Delay was associated with being widowed, symptom onset on a weekday compared with weekend, past medical history of MI and coronary artery bypass graft, private compared with ambulance transport to hospital, and lack of symptoms of sweating and weakness. In addition, for the Direct Admission Cohort, age and income were also associated with delay. CONCLUSIONS This study did not find an association between awareness of media campaigns and delay. This study identified important characteristics and presenting symptoms that are associated with delay, and possibly relevant to future media campaigns.