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African Americans, acute myocardial infarction, delay, symptoms, women



  1. Zerwic, Julie Johnson
  2. Ryan, Catherine J.
  3. DeVon, Holli A.
  4. Drell, Mary Jo


Background: Patients 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.


Objective: The 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.


Method: A 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.


Results: Women 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%.


Conclusions: The reasons for delay differed in part by sex and race.


Cardiovascular disease (CVD) is the leading cause of death in the United States (American Heart Association, 2001). Every year, more than 1.1 million Americans experience an acute myocardial infarction (AMI) and over 45% die as a result. Morbidity and mortality can be significantly reduced if individuals receive treatment shortly after the onset of symptoms. Emergent percutaneous coronary interventions and thrombolytic medications are both therapies designed to reestablish blood flow through the blocked coronary artery. Numerous clinical trials have clearly established the benefits of these therapies. If implemented within 1 hour after the onset of AMI symptoms, thrombolytics can reduce mortality by 50%, and by 23% when administered within 3 hours of onset of symptoms (Gruppo Italiano per lo Studio della Streptochinasi nell' Infarto Miocardico, 1986;Second International Study of Infarct Survival, 1988). Therefore, the goal is to implement reperfusion therapies within the first 2 hours after the onset of symptoms.


Patient delay prior to seeking treatment during AMI is the major limiting factor in receiving these therapies within the required time frame. A number of studies have documented median patient delay times from the onset of acute symptoms to accessing the emergency medical system (EMS) during AMI to be between 2-4 hours and mean patient delay times that range between 6-29 hours (Dracup & Moser, 1991;Goldberg, Gurwitz, & Gore, 1999;GUSTO Investigators, 1993;Timm, Ross, McKendall, Braunwald, & Williams, 1991). The mean delay times tend to be skewed as a result of individuals who wait days before accessing the healthcare system. Therefore, the median may be a more accurate representation of average delay time.


Investigators have attempted to identify patient characteristics that are associated with longer patient delay times. The assumption is that if individuals at risk for increased delay can be identified, interventions can be directed to these groups and their reasons for delay. Investigators have primarily focused on the relationship between sociodemographic characteristics and delay time. Investigators in a few studies have reported that women delayed longer than men prior to seeking treatment (Gibler et al., 2002;Goldberg et al., 1999;Meischke, Eisenberg, & Larsen, 1993;Turi et al., 1986); however, this has not been validated because possible confounding factors (i.e., older age) have not been controlled. Although there are few studies of delay time among minority groups, three such studies revealed that African Americans delayed substantially longer than non-Hispanic Whites (Clark, Bellam, Shah, & Feldman, 1992;Cooper et al., 1986;Ghali, Cooper, Kowalty, & Liao, 1993), but the reasons for delay was not determined. This delay may be a result from limited access to healthcare, low socioeconomic status, differences in symptom experiences or personal meaning associated with symptoms experienced.


Clinical characteristics and delay time has been examined. A prior history of heart disease has been found in several studies to be associated with longer delay times (Dracup & Moser, 1997;Gurwitz et al., 1997;Horne, James, Petrie, Weinman, & Vincent, 2000;McKinley, Moser, & Dracup, 2000;Scherck, 1997). Comorbidities such as diabetes or hypertension are associated with increased delay (Meischke et al., 1993). On the other hand, participants who experience hemodynamic instability had shorter delay times (Leizorovicz, Haugh, Mercier, & Boissel, 1997;Maynard et al., 1989).


Cognitive variables have received only a small amount of attention in prior research. Investigators have shown that patients who attribute their symptoms to a cardiac origin seek treatment faster than individuals who attribute symptoms to another cause (Leslie, Urie, Hooper, & Morrison, 2000;Meischke, Ho, Eisenberg, Schaeffer, & Larsen, 1995). Several investigators have documented that the general public and AMI patients are knowledgeable about AMI symptoms (Finnegan Jr. et al., 2000;Goff et al., 1998;Goff et al., 1999;Horne et al., 2000). However, this knowledge does not seem to translate to increasing patients' abilities to recognize their symptoms during an actual AMI experience. Clark and colleagues (1992) found in a sample of 200 AMI patients that the majority (95%) knew at least one major AMI symptom, yet only 50% believed their own symptoms were heart-related. Johnson and King (1995) found that patients' prior expectations about AMI symptoms were associated with delay time. Specifically, patients who reported a match between their prior expectations and their actual AMI symptom experience sought treatment significantly faster than patients without a match.


Research has clearly shown that patients' attempts to cope with the symptoms of AMI leads to longer delay time. Whether the individual tries to alleviate the actual symptoms with over-the-counter medications, uses a strategy such as resting, or attempts to consult with a healthcare provider, the overall effect is to increase the time before they access the EMS (Alonzo, 1986;Leitch, Birbara, Freedman, Wilcox, & Harris, 1989;Turi et al., 1986).


The ability to identify the factors contributing to patient delay in seeking treatment during AMI is limited by methodologies used in previous studies. Small samples or small numbers within specific groups (i.e., women, minorities) limited the power of statistical tests to identify differences. Medical record review restricts the type of data that can be collected and raises concerns about the reliability and validity of the data (Aaronson & Burman, 1994).


The purpose of this study was to examine sociodemographic (age, income, education, marital status), clinical (history of heart disease, presence of specific risk factors, symptoms experienced), cognitive (the similarity between the symptoms expected and actually experienced), and contextual factors (presence of a bystander, actions taken in response to symptoms) that contributed to patient delay in seeking treatment during AMI. The study was designed to identify whether women delayed longer than men and African Americans delayed longer than non-Hispanic Whites.