Postgrad Med J 1999 Mumford 90 4

8/11/2019 Postgrad Med J 1999 Mumford 90 4

1/7

Delays by patients in seeking treatment for acutechest pain: implications for achieving earlierthrombolysis

Andrew D Mumford, Kim V Warr, Sandra J Owen, Alan G Fraser

SummaryA study was set up to identify why patientsdelay seeking medical assistance aftermyocardial infarction. The study wasperformed in 100 consecutive patientswith suspected acute myocardial infarc-tion admitted to either the UniversityHospital of Wales, CardiV, UK, or theRoyal Jubilee Hospital, Victoria, BritishColumbia, Canada (50 patients from eachcentre). The main outcome measure wasthe delay from the onset of symptoms toadmission to hospital. The mean totaldelay before admission was 385 minutes(SEM 45). The mean delay incurred bythe patient in seeking assistance was 172minutes (SEM 27), representing 45% ofthe total. Delay was longer in patientswith crescendo angina and shorter inthose later confirmed to have myocardialinfarction. Patients with prior ischaemicheart disease (74% of patients) presentedlater than those with no such history.No other demographic or clinicalfactors predicted early or late presenta-tion.

Delays in seeking medical assistanceafter the onset of severe chest paincontribute significantly to total delays inpatients hospital admission and throm-

bolysis. The unexpected observation thatpatients with known ischaemic heart dis-ease delay longer before seeking help inspite of their frequent contact with doc-tors, suggests that opportunities for edu-cating patients are being wasted. MajoreVorts are needed to understand andmodify behaviour of patients with chestpain to further reduce delays in treat-ment.

Keywords: chest pain; myocardial infarction; throm-

bolysis

Patients with acute myocardial infarction needearly medical supervision so that life-threatening arrhythmias can be detected andtreated and a thrombolytic agent adminis-tered.1 2 Urgent admission of patients withchest pain to a cardiac care unit requires a pre-determined sequence of events to occur inrapid succession starting with the patientsdecision to seek medical assistance from theprimary healthcare services. There may thenfollow the steps of assessment in the commu-

nity, transport to hospital, assessment in hospi-tal, and transfer within hospital to the cardiaccare unit. Each step increases the total delaybefore treatment can be given.

Delays in this process have been reduced byinitiatives such as rapid-response paramedicambulances and fast-track admittingsystems,3 4 although these measures only re-duce delays in medical response after patientswith chest pain have decided to seek help.The single largest component of delay totreatment occurs before the patient contactsthe medical services.514 Strategies for reducingtotal treatment delays must encompass thesedelays in patient decision time yet little isknown about patient behaviour in this criticalperiod.

We therefore undertook a prospective studyto identify factors related to variability inpatients decision time. This was performed intwo geographically distinct centres, to comparediVerent populations and to test the generalapplicability of our findings. By recordingdemographic variables and obtaining detailedaccounts of patients clinical histories, includ-ing previous experience of chest pain, we

attempted to characterise patients who pre-sented early and late, and thereby to designpossible strategies for reducing delay.

Patients and methods

The study was performed simultaneously intwo centres. At the University Hospital ofWales in CardiV, patients with suspected myo-cardial infarction arrived for assessment in anEmergency Admissions Unit either after con-tacting the emergency ambulance servicedirectly or by first presenting to a general prac-titioner or to the Accident and Emergencydepartment in a nearby hospital. At the Royal

Jubilee Hospital, Victoria, British Columbia,Canada, patients presented directly to theEmergency Admissions unit or were referredby a cardiologist or family doctor. In both hos-pitals, after assessment in the EmergencyAdmissions ward, those with suspected acutemyocardial infarction were transferred directlyto a dedicated cardiac care unit.

The study was continued for about 8 weeksuntil 50 consecutive patients from each centrehad been included. Eligible patients hadpresented with a history compatible with acutemyocardial infarction and were admitted tothe cardiac care unit. Chest pain was not a

Postgrad Med J1999;75:9095 The Fellowship of Postgraduate Medicine, 1999

Department of

Cardiology, Universityof Wales College ofMedicine, Heath Park,CardiVCF4 4XN, UKA D MumfordK V WarrS J OwenA G Fraser

Correspondence toDr Alan G Fraser

Accepted 23 June 1998

group.bmj.comon April 30, 2013 - Published bypmj.bmj.comDownloaded from
http://group.bmj.com/http://group.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://pmj.bmj.com/http://group.bmj.com/http://pmj.bmj.com/


2/7

prerequisite for inclusion, but only patientswho developed symptoms outside hospitalwere eligible. Five Canadian and seven Britishpatients were excluded because of unwilling-ness or inability to participate.

On admission, a record sheet for each patientwas completed by the cardiac care unit nurses.With information obtained from the patients ortheir relatives and from nursing and ambulancerecords, we established the timings of events

leading to admission. The following intervalswere calculated:v patient decision time: from the onset of acute

symptoms to the decision to seek medicalassistance

v first consultation time: the time awaiting ini-tial contact and assessment by the primaryhealthcare services

v transport time: from leaving the place of firstconsultation to arrival at hospital

v hospital assessment time: from arrival in hos-pital to admission to the cardiac care unit

v total delay time: from the onset of symptomsto the patients arrival on the cardiac careunit.

When British patients presented directly to theAccident and Emergency department, timespent awaiting and undergoing assessment bycasualty staVwas recorded as the first consul-tation time. When patients at either hospitalpresented as a self-referral to the EmergencyAdmissions unit, the first consultation time wasnot recorded.

Within 48 hours of admission, patients wereasked to complete a standard questionnaire toassess further details of the circumstances sur-rounding their admission. This was reviewedwith each patient prior to their discharge toensure correct completion. The questionswere of open-ended format and assessed

factors thought to influence delay by patientsin reporting their symptoms. In addition to thepatients demographic details, the circum-stances of the onset of symptoms, their nature,and patients interpretations were recorded.The perceived severity of pain was assessedwith a visual analogue scale (graded 010, with10 representing the most severe pain ever).The questionnaire examined the patientsbehaviour and that of attending relatives andfriends, from the onset of symptoms up to thedecision to seek medical assistance.Pre-existing diagnoses of ischaemic heart dis-ease were recorded, and history of previousangina was assessed using the Rosequestionnaire.15

Statistical analysis was performed usingminitab, on the whole group and on a modifiedgroup excluding patients who presented longerthan 24 hours after the onset of symptoms.This excluded patients whose hospital admis-sion was prompted by complications arisingfrom recent myocardial infarction, rather thanthe infarction itself. Data are quoted either asmean values with standard errors or medianvalues with quartile ranges. Statistical signifi-cance was set at 0.05 for two-tailed tests. Datawere compared using chi-squared and Stu-dents t-tests as appropriate.

Results

STUDY POPULATIONS

A total of 100 patients were studied, 50 fromeach centre. Their mean age was 64 years(range 3787 years), and 65 were men. Thetwo cohorts are compared in table 1. Therewere no significant diVerences between thedemographic characteristics of the studygroups.

PREVIOUS EXPERIENCE OF ISCHAEMIC HEART

DISEASE

The subjects had considerable previous experi-ence of ischaemic heart disease, both person-ally and through friends or relatives (table 2).In total, 73 had a prior history compatible withangina, although in 12 patients from each cen-tre this had not been diagnosed by a doctor,while 35 patients had had chest pain for thefirst time in the year before admission, includ-ing 11 with symptoms only in the previousmonth. There was an increase in the frequencyof chest pain immediately prior to admission,with 24 British and 27 Canadian patients

describing crescendo angina in the 48 hoursbefore presentation.

Twenty-six British and 30 Canadian pa-tients were confident that they knew thesymptoms of a heart attack although whenasked to indicate as many symptoms as theyknew or to guess if they were unsure, 45British and 47 Canadian patients correctlystated at least one symptom (table 3).

Table 1 Demographic features of study groupsshowing mean ages and age ranges in years, andnumbers of patients according to sex, socioeconomicgroup, marital status, educational attainment anddistance of residence from hospital

UniversityHospital ofWales(n=50)

RoyalJubileeHospital(n=50)

Age (years) 63 (3787) 65 (4287)Sex (male) 33 32Socio-economic g roup (13n)* 25 31Married 40 29Higher education 6 16Living withi n 5 miles of h ospita l 34 34

*Reference 16

Table 2 Numbers of patients with previousexperience of ischaemic heart disease

UniversityHospital ofWales(n=50)

RoyalJubileeHospital(n=50)

Previous myocardial infarction 22 18Previous diagnosis of angina 21 28History compatible with prior

angina* 33 40Previous chest pain longer than

20 mins 16 14Previous rest pain 16 21Previo us prescr ipti on for nitrate 17 23P re vi ous m edi ca l a dv ic e a bo ut I HD 2 5 2 4Family member has IHD 33 31F ri en d o r c ol le ag ue a t wo rk h as I HD 3 3 2 8

*Positive reply to the Rose Questionnaire.15

IHD = ischaemic heart disease

Patient delays in seeking treatment for acute chest pain 91



3/7

Canadian patients cited breathlessness as asymptom of a heart attack more often thanBritish patients (p8 onvisual analogue scale) by 26 British and 20Canadian patients. Additional symptoms listedby patients were sweating (52 patients), breath-lessness (45), weakness or collapse (25) andnausea (21). When their symptoms started, 34British and 38 Canadian patients correctlyattributed their presenting complaint to theheart. Otherwise patients blamed the gastro-intestinal tract (10 patients), the musculo-skeletal system (three), the lungs (four), orwere unsure (11).

DIAGNOSIS

The ultimate diagnoses in the British patientswere myocardial infarction in 35 cases andangina pectoris in 15. In the Canadianpatients, myocardial infarction was diagnosedin 12, angina pectoris in 31 and non-cardiac

chest pain in seven (p


4/7


5/7

associations between delay and demographiccharacteristics or symptoms. Prolonged delayhas been reported in the elderly and inwomen6 12 and in patients of lower socio-economic status.11 The perception of symp-toms as severe5 and conviction by the patientthat symptoms derived from the heart, havebeen associated with reduced delay.5 11 Thesefindings are inconsistent, and are not sup-ported by our data. A common problem

encountered in our own, and previous studiesis that very subtle variations in patientbehaviour may be diYcult to diVerentiate withcomparatively small study sizes. It is reasonableto conclude, however, that simple demographiccharacteristics do not allow the prior identifica-tion of patients on an individual basis who areat particular risk of late presentation.

THE PROCESS OF SEEKING ASSISTANCE

The observation that delays in admission arenot associated with demographic characteris-tics or the nature of symptoms, indicates thatdelay may relate to more complex patient char-acteristics such as personality and individual

interpretation of symptoms. The processesinvolved in decisions to seek help involve mul-tiple perceptive and cognitive steps,6 each ofwhich may be influenced by many interactingpersonal and external factors.

Patients must recognise their symptoms asrepresenting an important deviation from nor-mal, and therefore they must have an accurateknowledge of the symptoms of myocardial in-farction. In our study most patients were ableto cite chest pain as the predominant symptombut many still had misconceptions about itsinterpretation. For example, some patientsknew the symptoms yet presented late withchest pain themselves, because they believedthat myocardial infarction only occurred dur-

ing physical exertion or was always accompa-nied by dyspnoea.

Impaired recognition of the significance ofsymptoms may also result from denial. Thisphenomenon is a normal psychological defencemechanism whereby patients allay anxiety byrepudiating the whole or part of their symp-toms. It is common in patients with ischaemicheart disease17 and frequently takes the form ofdisplacement of the perceived origin of acutesymptoms onto an alternative source, particu-larly one from which symptoms have previouslybeen overcome with ease. This leads to delay inseeking assistance until denial is overwhelmedby the persistence or progression of symptoms.

There is evidence for this phenomenon in ourstudy since, although our patients had a goodgeneral knowledge of the features of myocar-dial infarction, they frequently attributed thesame symptoms in themselves to a non-cardiacsource. It is diYcult to explain their initial mis-conceptions without invoking denial.

After patients successfully recognise theseverity of their symptoms, they must also real-ise that they warrant urgent medical assistance.Patients may prolong this step by engaging inunnecessary non-therapeutic activity.7 In ourstudy patients were often reluctant to abandontheir social obligations and some made elabo-

rate preparations for an anticipated stay in hos-pital. Activities included changing clothes andpacking an overnight bag or contacting rela-tives before calling an emergency ambulance.Patients may also delay or refuse admissionbecause they cannot tolerate abandoning theirusual activities or adopting the sick role.6

The behaviour of those patients who hadprevious heart disease highlights the complex-ity of the process of calling for medical

assistance. The perception of symptoms in thisgroup may have been masked by pre-existinganti-anginal treatment, and impending myo-cardial infarction often diVers from chronicstable angina only in the severity of chest pain.Patients already accustomed to this may nothave identified severe pain as unusual, particu-larly when symptoms developed slowly as increscendo presentations. Patients with chronicangina frequently prevaricated by making pro-longed attempts to relieve their symptoms withsublingual nitrate. Anxiety generated by thepossibility of repeating previous unpleasantadmissions may have provoked denial phenom-ena. We need constantly to reinforce the

message to patients with angina that admissionis never inappropriate if they have severe symp-toms.

PUBLIC EDUCATION

EVorts to incorporate psychological factors inpatients perception of symptoms has beenassessed in Swedish and Canadian trials utilis-ing mass-media education campaigns to em-phasise the importance of early presentationafter chest pain.18 19 This strategy significantlyreduced delays in presentation, at the expenseof a greatly increased rate of presentation ofpatients with non-cardiac diagnoses. The ben-efits of public education are clear in those

patients who delay admission due to miscon-ceptions about the significance of their symp-toms or the need to seek medical assistance.The advantages are less clear in patients whodelay admission through the processes ofdenial. This aspect of patients behaviour isresistant to education and may even be exacer-bated by giving more information.8 Moreunderstanding of these phenomena is needed,and it is likely that the diYcult task of modify-ing behaviour cannot be accomplished bymass-media campaigns alone.

CLINICAL IMPLICATIONS

The logical way to reduce overall delays in

admitting patients to the cardiac care unitwould be to reduce its largest single compo-nent: the time taken by the patient to seekmedical assistance after developing symptoms.Many patients still incur unacceptable delaysbecause they are slow to present, but behaviourat this time is highly variable. The unexpectedfinding that patients with previous ischaemicheart disease, who were the majority of patientswith myocardial infarction, actually presentedlater, is an indictment of our present services.The reasons for this apparently paradoxicalresult are complex and multifactorial, but morespecific education of patients and development

94 Mumford,Warr,Owen, et al



6/7

of methods to modify behaviour are urgentlyneeded.

Doctors and nurses should give simple andunambiguous advice to all patients with anyevidence of ischaemic heart disease, and totheir relatives: emergency medical assistanceshould be sought in the event of any severecentral chest pain which lasts longer than 15minutes, or any pain that does not respond to

sublingual nitrates. Existing patients are themost important target group for this advice,but opportunities for education aVorded bytheir frequent contact with the medical servicesare currently being wasted.

We would like to thank Dr Richard Mildenberger, Royal JubileeHospital, Victoria, British Columbia for his assistance with therecruitment of the Canadian cohort of patients.

1 Gruppo Italiano per lo Studio della Streptochinasinelllnfarto Miocardico (GISSI). EVectiveness of intra-venous thrombolytic treatment in acute myocardial infarc-tion.Lancet1986;1:397401.

2 ISIS-2 Collaborative Group. Randomised trial of intra-venous streptokinase, oral aspirin, both, or neither among17 187 cases of suspected acute myocardial infarction. Lan-cet1988;2:34860.

3 Kereiakes DJ, Gibler WB,Martin LH, Pieper KS,AndersonLC. Relative importance of emergency medical systemtransport and the prehospital electrocardiogram on reduc-ing hospital time delay to therapy for acute myocardialinfarction: a preliminary report from the Cincinnati HeartProject.Am Heart J1992;123:8359.

4 Pell ACH, Miller HC, Robertson CE, Fox KAA. EVect offast track admission for acute myocardial infarction ondelay to thrombolysis.BMJ1992;304:837.

5 Hackett TP, Cassem NH. Factors contributing to delay inresponding to the signs and symptoms of acute myocardialinfarction.Am J Cardiol1969;24:6518.

6 Moss AJ, Wynar B, Goldstein S. Delay in hospitalizationduring the acute coronary period. Am J Cardiol 1969;24:

65965.7 Simon AB, Feinleib M, Thompson HK. Components of

delay in the pre-hospital phase of acute myocardialinfarction.Am J Cardiol1972;30:47682.

8 Erhardt LR, Sjogren A, Sawe U, Theorell T. Prehospitalphase of patients admitted to a coronary care unit.Acta MedScand1974;195:416.

9 Gillum RF, Feinleib M, Margolis JR, Fabsitz RR, BraschRC. Delay in the prehospital phase of acute myocardial inf-arction.Arch Intern Med1976;136:64954.

10 Schroeder JS, Lamb IH, Hu M. The prehospital course ofpatients with chest pain. Am J Med1978;64:7428.

11 Sjogren A, Erhart LR, Theorell T. Circumstances aroundthe onset of myocardial infarction. A study of factorsrelevant to the perception of symptoms and to the delay inarriving at a coronary care unit. Acta Med Scand1979;205:28792.

12 Turi ZG, Stone PH, Muller JE,et al. Implications for acuteintervention related to time of hospital arrival in acute myo-cardial infarction.Am J Cardiol1986;58:2039.

13 Rawles JM, Haites N. Patient delay in acute myocardial inf-arction.Br Heart J1987;59:112.

14 Leitch JW, Birbara T. Freedman B,Wilcox l, Harris PJ. Fac-tors influencing the time from onset of chest pain to arrivalat hospital.Med J Aust1989;150:610.

15 Rose GA, Blackbum H, Gillum RF, Prineas RJ.Cardiovas-cular survey methods. WHO monograph series, no 56.Geneva: World Health Organisation, 1982.

16 OYce of Population Censuses and Surveys.Classification ofoccupation and coding index. London: Her Majestys Station-

ary OY

ce, 198017 Olin HS, Hackett TP. The denial of chest pain in 32patients with acute myocardial infarction.JAMA1964;190:97781.

18 Herlitz J, Hartford M, Blohm M, et al. EVect of a mediacampaign on delay times and ambulance use in suspectedacute myocardial infarction.Am J Cardiol1989;64:903.

19 Mitic VM, Perkins RRT. The eVect of a media campaign onheart attack delay and decision times. Can J Public Health1984;75:4148.

Medical Anniversary

Charles Herbert Best, 27 February 1899

Charles Herbert Best (18891978) was born of Canadian parents in Maine, USA, where hisfather was a physician. He was educated at Toronto University, where he qualified MD(1925) and where he met Frederick Grant Banting, his co-discoverer of insulin. On 11January 1922, the first insulin was given successfully to a 14-year-old diabetic at the TorontoGeneral Hospital. In 1923, the Charles H Best Institute, Toronto, built in his honour, wasopened by Sir Henry Dale. Charley, as he was universally known, died on 30 March 1978

in Toronto. DG James

Patient delays in seeking treatment for acute chest pain 95



7/7

doi: 10.1136/pgmj.75.880.901999 75: 90-94Postgrad Med J

Andrew D Mumford, Kim V Warr, Sandra J Owen, et al.earlier thrombolysisacute chest pain: implications for achievingDelays by patients in seeking treatment for

http://pmj.bmj.com/content/75/880/90.full.htmlUpdated information and services can be found at:

These include:

References

http://pmj.bmj.com/content/75/880/90.full.html#related-urlsArticle cited in:

http://pmj.bmj.com/content/75/880/90.full.html#ref-list-1

This article cites 14 articles

serviceEmail alerting

box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in the

CollectionsTopic

(117 articles)Ischaemic heart disease(291 articles)Drugs: cardiovascular system

(177 articles)Pain (neurology)

Articles on similar topics can be found in the following collections

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

http://pmj.bmj.com/content/75/880/90.full.htmlhttp://pmj.bmj.com/content/75/880/90.full.htmlhttp://pmj.bmj.com/content/75/880/90.full.html#related-urlshttp://pmj.bmj.com/content/75/880/90.full.html#related-urlshttp://pmj.bmj.com/content/75/880/90.full.html#ref-list-1http://pmj.bmj.com/cgi/collection/ischaemic_heart_diseasehttp://pmj.bmj.com/cgi/collection/ischaemic_heart_diseasehttp://pmj.bmj.com/cgi/collection/drugs_cardiovascular_systemhttp://pmj.bmj.com/cgi/collection/drugs_cardiovascular_systemhttp://pmj.bmj.com/cgi/collection/drugs_cardiovascular_systemhttp://group.bmj.com/group/rights-licensing/permissionshttp://group.bmj.com/group/rights-licensing/permissionshttp://journals.bmj.com/cgi/reprintformhttp://journals.bmj.com/cgi/reprintformhttp://group.bmj.com/subscribe/http://group.bmj.com/http://group.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://pmj.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://group.bmj.com/subscribe/http://journals.bmj.com/cgi/reprintformhttp://group.bmj.com/group/rights-licensing/permissionshttp://pmj.bmj.com/cgi/collection/ischaemic_heart_diseasehttp://pmj.bmj.com/cgi/collection/drugs_cardiovascular_systemhttp://pmj.bmj.com/cgi/collection/pain2http://pmj.bmj.com/content/75/880/90.full.html#related-urlshttp://pmj.bmj.com/content/75/880/90.full.html#ref-list-1http://pmj.bmj.com/content/75/880/90.full.html

Documents

Postgrad Med J 1999 Mumford 90 4