1. Pelter, Michele M. PhD, RN

Article Content

It is well understood that a critical factor for reducing morbidity and mortality due to acute coronary syndrome (ACS) is timely treatment aimed at restoring blood flow to the heart. Recommendations from the National Heart Attack Alert Program state that reperfusion therapy should occur within 1 hour of symptom onset.1 Although treatment delay for ACS includes both prehospital (ie, patient and emergency medical transport) and hospital (ie, emergency department) factors, the one that contributes the most to treatment delay is patient factors related to symptom recognition and action by the patient.2,3 Unfortunately, studies show that most patients delay for hours before seeking life-saving treatments, with median prehospital delay times of 2 to 6 hours.4-7


We have learned from descriptive studies that sociodemographic, cognitive, emotional, clinical, and social variables contribute to patient delay. The one clinical trial published to date, which used a community-based mass media intervention aimed at educating the public about signs/symptoms of myocardial infarction (MI) and calling 911, did not shorten delay time.7 Therefore, our work in this area is far from finished.


In this issue of the Journal of Cardiovascular Nursing, DeVon and coworkers8 explore patient-stated factors associated with a decision to seek care for symptoms of ACS. Using 2 open-ended questions and a structured quantitative questionnaire, the investigators interviewed 256 patients during hospitalization for ACS about their symptoms and what made them decide to seek care. Key findings of this study and other important considerations will be discussed.


One strength of the De Von et al study design was that the patients were interviewed about symptoms and their decision to seek care by members of the research team while still hospitalized for ACS. In many previous studies, symptom data have been collected well after hospital discharge, which is problematic because patient recall after ACS is likely to be imprecise. A second strength was that open-ended questions were used so that the patients were given the opportunity to state, using their own words, symptoms and what made them decide to seek care. These 2 prospective design features add to the overall credibility of this study. As pointed out by the authors, factors such as insurance status and income that may have affected seeking medical attention were not assessed.


Using an innovative statistical approach, the investigators identified 5 decision-making categories that patients used when seeking treatment for ACS. These categories offer interesting teaching points for clinicians to consider when educating patients and their families about ACS symptom recognition. In addition, as pointed out by the authors, the patients in their study used symptom language that differed significantly from descriptors that we as clinicians use, another important point for teaching. I was particularly intrigued by 2 of the motivating factors mentioned by DeVon et al, the first being externally motivating factors (contacting a family friend or healthcare professional) and the second being internally motivating factors (patient driven). Although it is known that delay time is increased when advice from others is sought, innovative interventions that could be designed to target external motivation, such as a direct telephone line to a healthcare professional or a "buddy," might be what patients need to prompt them into calling 911.


In the Devon et al study, only 3% of the sample presented within 1 hour of symptom onset; rather, most of the patients (43%) delayed by 6 to 96 hours. Although not statistically significant, median delay times were longer for women than for men (9.5 vs 6 hours, respectively). Prehospital delay was significantly shorter among patients who had an ST-segment elevation MI and constant pain. The issue of intermittent pain in ACS is an important point of discussion. When continuous 12-lead electrocardiographic monitoring is used in patients admitted to the hospital for suspected ACS, intermittent ST-segment changes indicative of acute myocardial ischemia can occur (Figure 1). The dynamic and unpredictable nature of ACS is easy to appreciate in this illustration and adds to our understanding of why patients may have intermittent symptoms that can lead to a delay in seeking medical care. Who of us has not said, "I'll wait to see if I feel worse and then I'll call my caregiver?" Importantly, the patient in the example did not complain of symptoms during any of the 3 episodes. This finding is common with transient episodes of ischemia, occurring in as many as 70% of patients, and might happen during transient ischemia lasting only minutes.9 DeVon et al found that patients with ST-segment elevation MI acted quicker when seeking treatment, which might have occurred because unrelenting ischemia and infarction were well underway. What is unanswered is how we can intervene at the onset of ischemia (preinfarction).

Figure 1 - Click to enlarge in new windowFIGURE 1. This 3-dimensional image illustrates ST-segment deviation (y-axis) in 12 ECG leads (x-axis) for a 15-hour period (z-axis) in a 78-year-old patient admitted to the telemetry unit with chest pain "rule out MI." The figure shows 3 separate ischemic events, characterized by ST-segment elevation (indicating total coronary occlusion), in leads V

Although the DeVon et al article adds to our understanding of symptom recognition and the decisions that people make when seeking care, we are still left with the question on how to address the biggest issue of this clinical problem-how to get patients to act on their symptoms immediately? The use of objective measures of ischemia, such as electrocardiographic monitoring, should be explored. However, many technical issues and how to teach patients and families to use this equipment would need to be overcome. Regardless, this line of inquiry must move forward so that timely treatment for ACS is met, with the ultimate goal of improving morbidity and mortality in patients.




1. Dracup K, Alonzo AA, Atkins JM, et al. The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Ann Intern Med. 1997;126(8):645-651. [Context Link]


2. Dracup K, Moser DK, Eisenberg M, Meischke H, Alonzo AA, Braslow A. Causes of delay in seeking treatment for heart attack symptoms. Soc Sci Med. 1995;40(3):379-392. [Context Link]


3. Rasmussen CH, Munck A, Kragstrup J, Haghfelt T. Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission. Scand Cardiovasc J. 2003;37(4):183-186. [Context Link]


4. Dracup K, Moser DK, McKinley S, et al. An international perspective on the time to treatment for acute myocardial infarction. J Nurs Scholarsh. 2003;35(4):317-323. [Context Link]


5. Goldberg RJ, Gurwitz JH, Gore JM. Duration of, and temporal trends (1994-1997) in, prehospital delay in patients with acute myocardial infarction: the second National Registry of Myocardial Infarction. Arch Intern Med. 1999;159(18):2141-2147. [Context Link]


6. Goldberg RJ, Yarzebski J, Lessard D, Gore JM. Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: the Worcester Heart Attack study. Arch Intern Med. 2000;160(21):3217-3223. [Context Link]


7. Luepker RV, Raczynski JM, Osganian S, et al. Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: the Rapid Early Action for Coronary Treatment (REACT) Trial. JAMA. 2000;284(1):60-67. [Context Link]


8. DeVon HA, Hogan N, Ochs AL, Shapiro M. Time to treatment for acute coronary syndromes: the cost of indecision. J Cardiovasc Nurs. 2009;25(2):106-114. [Context Link]


9. Pelter MM, Adams MG, Drew BJ. Transient myocardial ischemia is an independent predictor of adverse in-hospital outcomes in patients with acute coronary syndromes treated in the telemetry unit. Heart Lung. 2003;32(2):71-78. [Context Link]