Abstract
Increased delay in visiting a hospital for patients with ST-segment elevation myocardial infarction (STEMI) is often associated with poor outcomes. The factors associated with the decision time were analyzed by comparing the characteristics of patients with delays longer or shorter than the median of 60 min. Pre-hospital delay tended to be longer for patients living in suburban areas compared to those in urban areas (P=0.015). Shorter decision time was more likely among older patients. Being married, medical insurance coverage, and the level of educational qualification did not affect decision time. More efforts should be paid to educate the patients with high risk in suburban areas in order to effectively reduce pre-hospital delays.
Shortening the time from symptom to reperfusion and choosing the optimal reperfusion strategy are great challenges for patients suffering from STEMI (Zhang and Huo, 2011). The association between pre-hospital delay prior to deciding to go for acute coronary syndrome (ACS) and poor outcomes has been well documented (Ting et al., 2008; 2010; Smolderen et al., 2010). Studies have shown the associations of older age, female gender, and non-white race with longer pre-hospital delays (Goldberg et al., 2002; Nguyen et al., 2010). However, these factors are non-modifiable and likely account for only 10%–25% of pre-hospital delays (Ting et al., 2010). Modifiable characteristics, such as patient education, medical insurance, income, and psychosocial factors are recognized in ACS (Dracup, 2009; Figueredo, 2009; Sullivan et al., 2009).
Further understanding of the factors influencing decision time (from symptom onset to placing a call for medical help) may help target interventions more effectively and reduce pre-hospital delays. While demographic factors associated with these delays have been well described world-wide, scarce data are available for patients in China. Therefore, we assessed the factors that were associated with pre-hospital delay in patients with STEMI being admitted to the Emergency Department of the Second Affiliated Hospital, Wenzhou Medical University, China.
In this study, 74% of patients were male. The mean age was (65.68±12.68) years old. Most patients (77%) had no knowledge of heart infarction. The decision to call for medical help was made primarily by the patients themselves (70%). Most patients (89%) were covered by medical insurance. Patients were all married and predominantly well educated (Table 1). Most patients experienced pain symptoms, including chest pain, breathlessness, sweating, dizziness/fainting as well as chest distress.
Table 1.
Characteristics of patients (n=100)
| Parameter | Value* |
| Sociodemographic factors | |
| Men/women | 74/26 |
| Age (year) | 65.68±12.68 |
| Married | 100 (100%) |
| Socioeconomic factors | |
| Educational status | |
| University qualification | 4 (4%) |
| Middle school qualification | 34 (34%) |
| Elementary school qualification | 22 (22%) |
| No formal educational qualifications | 40 (40%) |
| Source of knowledge | |
| Unawareness | 77 (77%) |
| Medium | 4 (4%) |
| Community education program | 0 (0%) |
| Relatives | 4 (4%) |
| Physicians | 15 (15%) |
| Decision-maker | |
| Patient | 70 (70%) |
| Bystander | 30 (30%) |
| Household income (RMB/month) | |
| 0 | 21 (21%) |
| <1 000 | 36 (36%) |
| 1 000–5 000 | 39 (39%) |
| 5 000–10 000 | 3 (3%) |
| ≥10 000 | 1 (1%) |
| Living partner | |
| Yes | 86 (86%) |
| No | 14 (14%) |
| Medical insurance | |
| Yes | 89 (89%) |
| No | 11 (11%) |
| Residency | |
| Urban | 42 (42%) |
| Suburban | 58 (58%) |
| Cardiac history and risk factors | |
| Previous angina pectoris | 24 (24%) |
| Diabetic | 21 (21%) |
| Symptoms | |
| None | 0 (0%) |
| Chest distress | 11 (11%) |
| Chest pain and breathlessness | 46 (46%) |
| Sweating or dizziness/fainting | 43 (43%) |
Values are expressed as number (percent) or mean±standard deviation (SD)
The median decision time was 1.17 h, ranging from 5 min to 30 d, with a mean delay of 23.58 h (±85.09 h). Patient decision time ≤60 min was observed in 50% of the patients. Most of the patients visited the hospital within 1 d after onset (Fig. 1).
Fig. 1.
Distribution of patients with different decision times
There were no associations between decision time and sociodemographic and socioeconomic factors apart from residency. Pre-hospital delay tended to be longer for patients living in suburban areas compared to those in urban areas (P=0.015) (Table 2). Shorter decision time was more likely among older patients (Fig. 2a). Medical insurance coverage, household income, bystander, knowledge of heart attack, disease history, gender, and level of educational qualification did not affect decision time. However, male patients tended to have longer decision time than female patients ((21.41±89.84) h vs. (21.23±71.39) h, P=0.871; Fig. 2b). Unexpectedly, patients having knowledge about heart attacks, tended to have a longer decision time than those not having any knowledge. This is similar to the tendency that patients with previous angina pectoris have longer decision time ((30.58±79.28) h vs. (21.37±87.23) h, P=0.646; Fig. 2c). Due to the small sample size and great variations of data, these differences did not reach statistical significance. Another important finding was that patients without medical insurance tended to have longer decision time than those with insurance ((68.15±216.22) h vs. (18.08±50.54) h, P=0.065; Fig. 2d). Nevertheless, these phenomena still deserve our further investigation.
Table 2.
Predictors of short patient decision time (DT)
| Parameter | Patient number*
|
P # | |
| DT ≤60 min | DT >60 min | ||
| Sociodemographic factors | |||
| Men/women | 36 (72%)/14 (28%) | 38 (76%)/12 (24%) | 0.648 |
| Age (year) | |||
| <50 | 5 (10%) | 10 (20%) | 0.095 |
| 50–60 | 5 (10%) | 10 (20%) | |
| 60–70 | 17 (34%) | 12 (24%) | |
| 70–80 | 18 (36%) | 14 (28%) | |
| ≥80 | 5 (10%) | 4 (8%) | |
| Married | 50 (100%) | 50 (100%) | |
| Socioeconomic factors | |||
| Educational status | 0.180 | ||
| University | 3 (6%) | 1 (2%) | |
| Middle school | 16 (32%) | 18 (36%) | |
| Elementary school | 10 (20%) | 12 (24%) | |
| No formal educational | 21 (42%) | 19 (38%) | |
| Source of knowledge | 0.239 | ||
| Unawareness | 41 (82%) | 36 (72%) | |
| Medium | 4 (8%) | 0 (0%) | |
| Community education program | 0 (0%) | 0 (0%) | |
| Relatives | 0 (0%) | 4 (8%) | |
| Physicians | 5 (10%) | 10 (20%) | |
| Decision-maker | |||
| Patient | 38 (76%) | 32 (64%) | 0.190 |
| Bystander | 12 (24%) | 18 (36%) | |
| Household income (RMB/month) | |||
| 0 | 12 (24%) | 9 (18%) | 0.657 |
| <1 000 | 17 (34%) | 19 (38%) | |
| 1 000–5 000 | 19 (38%) | 20 (40%) | |
| 5 000–10 000 | 1 (2%) | 2 (4%) | |
| ≥10 000 | 1 (2%) | 0 (0%) | |
| Living partner | |||
| Yes | 42 (84%) | 44 (88%) | 0.564 |
| No | 8 (16%) | 6 (12%) | |
| Medical insurance | |||
| Yes | 45 (90%) | 44 (88%) | 0.749 |
| No | 5 (10%) | 6 (12%) | |
| Residency | |||
| Urban | 27 (54%) | 15 (30%) | 0.015 |
| Suburban | 23 (46%) | 35 (70%) | |
| Cardiac history and risk factors | |||
| Previous angina pectoris | 12 (24%) | 12 (24%) | |
| Diabetic | 9 (18%) | 12 (24%) | 0.461 |
| Symptoms | |||
| None | 0 (0%) | 0 (0%) | 0.973 |
| Chest distress | 8 (16%) | 3 (6%) | |
| Chest pain and breathlessness | 19 (38%) | 27 (54%) | |
| Sweating or dizziness/fainting | 23 (46%) | 20 (40%) | |
Values are expressed as patient number (percent)
Comparison with χ 2 test
Fig. 2.
Factors associated with decision time
(a) Age; (b) Gender; (c) Previous angina pectoris; (d) Medical insurance
The incidence of STEMI is increasing in China as the total elderly population increased during the past decades and the standards of living improves. It is well recognized that primary percutaneous coronary intervention (PCI) plays a central role in the treatment of STEMI (Eagle et al., 2008; Gibson et al., 2008). The American Heart Association/American College of Cardiology (AHA/ACC) guideline for STEMI recommends that PCI be performed within 90 min after onset as a class 1 recommendation and also recommends a total ischaemic time or door-to-balloon time of within 120 min (Antman et al., 2004; 2008). The European Society of Cardiology (ESC) guideline for STEMI recommends PCI within 90 min of the onset of the symptom in patients presenting a low risk of bleeding and better prognosis (Shiomi et al., 2012). Shorter symptom onset to balloon time is associated with better prognosis. In this study we evaluated the factors effecting symptom onset to decision time because the decision to door time is affected mainly by objective factors.
We found that only residency significantly affected onset to decision time in these patients. Surprisingly, a negative correlation was found between onset to decision time and their age. The elder patients arrived at the hospital more timely. This is in contrast to that reported by others, who found that older age was associated with longer pre-hospital delay (Goldberg et al., 2002; Nguyen et al., 2010). The percentage of diabetic patients with angina increased in older patients. Younger people may be too confident of their health status and ignore any chest symptoms. We should pay more attention to popularize STEMI knowledge among younger people.
The fact that most of the patients had no knowledge about heart infarction needs to be paid more attention to. This suggest that we should strengthen the primary prevention of STEMI and popularize the knowledge of STEMI through television, newspapers, internet, and radio stations with regard to precaution, treatment, and prognosis of STEMI.
This study had several limitations. Firstly, the sample size was small and was limited to Wenzhou city. Wenzhou is a coastal city and residents here have higher incomes than most cities in China. As shown in Table 1, most patients were well educated, and thus our results cannot represent the whole population in China. Secondly, we could not exclude the influences of patients’ recall bias for symptom onset; especially with some patients visiting the hospital more than 10 d after the onset.
In conclusion, residency in urban area was associated with shorter decision time. More efforts should be paid to educate the at-risk population in suburban areas to effectively reduce pre-hospital delays.
Materials and methods
Study population
All patients admitted to the emergency department were transferred to the department of cardiology for further care. Inclusion criteria were patients with STEMI, ability to recall the time when symptoms started and time of calling for medical help, absence of comorbid conditions including renal failure, cancer, stroke, and infection, or inflammatory conditions that might influence the symptom presentation.
The diagnosis of STEMI was made if any two of the following were present: a history of characteristic chest pain lasting more than 30 min, development of new Q waves or the elevation of the ST-segment on the electrocardiogram, or an increase in the concentration of cardiac enzymes to the upper limit of normal (Antman et al., 2008).
Of the 283 patients recruited between Feb. 1, 2010 and June 14, 2012, we excluded 183 (65.7%) with incomplete data on symptom onset. After this exclusion, this analysis included 100 patients.
Main outcome measure
Onset-to-decision time was defined as the time between the STEMI symptom onset and making the decision to visit a hospital. Trained research staff used standardized questionnaires at the time of study enrollment.
Socioeconomic position was assessed using educational qualifications which were categorized into four groups: university qualification, middle school qualification, elementary school qualification, or no formal educational qualifications of any kind. The source of knowledge about the heart attack was categorized into four groups: unawareness, having some knowledge from various media (including newspaper, TV broadcasting, radio, and internet), community education programs, relatives or physicians. Decision-makers were categorized into two groups: patients or bystanders. The type of symptoms was categorized into three groups: chest distress, chest pain/breathlessness, and sweating/dizziness/fainting. Other factors included age, marital status, household income, residency, living partner, medical insurance, and diabetes mellitus.
Statistical analysis
The factors associated with decision time were analyzed by comparing the characteristics of patients with delays longer or shorter than 60 min. This criterion was selected because reperfusion therapy is most effective if initiated within the first hour. Groups were compared using χ 2 tests, and the factors were also analyzed by comparing the decision time using χ 2 tests. We also used multiple linear regression and logistic regression to estimate the effect of factors, including age, education, and income, on the decision time.
Footnotes
Project supported by the Zhejiang Provincial Natural Science Foundation (Nos. Y2110550 and LY13H310006) and the Research Project of Wenzhou Science and Technology Bureau (Nos. H20100056 and H20080027), China
Compliance with ethics guidelines: Lu QIAN, Kang-ting JI, Jin-liang NAN, Qin LU, Yong-jin ZHU, Lu-ping WANG, Lian-ming LIAO, and Ji-fei TANG declare that they have no conflict of interest.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000(5). Informed consent was obtained from all patients for being included in the study.
References
- 1.Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Circulation. 2004;110(5):588–636. doi: 10.1161/01.CIR.0000134791.68010.FA. [DOI] [PubMed] [Google Scholar]
- 2.Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians. Circulation. 2008;117(2):296–329. doi: 10.1161/CIRCULATIONAHA.107.188209. [DOI] [PubMed] [Google Scholar]
- 3.Dracup K. The challenge of reducing prehospital delay in patients with acute coronary syndrome. Circ Cardiovasc Qual Outcomes. 2009;2(3):144–145. doi: 10.1161/CIRCOUTCOMES.109.855635. [DOI] [PubMed] [Google Scholar]
- 4.Eagle KA, Nallamothu BK, Mehta RH, Granger CB, Steg PG, van de Werf F, López-Sendón J, Goodman SG, Quill A, Fox KA, et al. Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go. Eur Heart J. 2008;29(5):609–617. doi: 10.1093/eurheartj/ehn069. [DOI] [PubMed] [Google Scholar]
- 5.Figueredo VM. The time has come for physicians to take notice: the impact of psychosocial stressors on the heart. Am J Med. 2009;122(8):704–712. doi: 10.1016/j.amjmed.2009.05.001. [DOI] [PubMed] [Google Scholar]
- 6.Gibson CM, Pride YB, Frederick PD, Pollack CV, Jr, Canto JG, Tiefenbrunn AJ, Weaver WD, Lambrew CT, French WJ, Peterson ED, et al. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the national registry of myocardial infarction from 1990 to 2006. Am Heart J. 2008;156(6):1035–1044. doi: 10.1016/j.ahj.2008.07.029. [DOI] [PubMed] [Google Scholar]
- 7.Goldberg RJ, Steg PG, Sadiq I, Granger CB, Jackson EA, Budaj A, Brieger D, Avezum A, Goodman S. Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (The GRACE Registry) Am J Cardiol. 2002;89(7):791–796. doi: 10.1016/S0002-9149(02)02186-0. [DOI] [PubMed] [Google Scholar]
- 8.Nguyen HL, Saczynski JS, Gore JM, Goldberg RJ. Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction a systematic review. Circ Cardiovasc Qual Outcomes. 2010;3(1):82–92. doi: 10.1161/CIRCOUTCOMES.109.884361. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Shiomi H, Nakagawa Y, Morimoto T, Furukawa Y, Nakano A, Shirai S, Taniguchi R, Yamaji K, Nagao K, Suyama T, et al. Association of onset to balloon and door to balloon time with long term clinical outcome in patients with ST elevation acute myocardial infarction having primary percutaneous coronary intervention: observational study. BMJ. 2012;344:e3257. doi: 10.1136/bmj.e3257. [DOI] [PubMed] [Google Scholar]
- 10.Smolderen KG, Spertus JA, Nallamothu BK, Krumholz HM, Tang F, Ross JS, Ting HH, Alexander KP, Rathore SS, Chan PS. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA. 2010;303(14):1392–1400. doi: 10.1001/jama.2010.409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Sullivan MD, Ciechanowski PS, Russo JE, Soine LA, Jordan-Keith K, Ting HH, Caldwell JH. Understanding why patients delay seeking care for acute coronary syndromes. Circ Cardiovasc Qual Outcomes. 2009;2(3):148–154. doi: 10.1161/CIRCOUTCOMES.108.825471. [DOI] [PubMed] [Google Scholar]
- 12.Ting HH, Bradley EH, Wang Y, Lichtman JH, Nallamothu BK, Sullivan MD, Gersh BJ, Roger VL, Curtis JP, Krumholz HM. Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction. Arch Intern Med. 2008;168(9):959–968. doi: 10.1001/archinte.168.9.959. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ting HH, Chen AY, Roe MT, Chan PS, Spertus JA, Nallamothu BK, Sullivan MD, DeLong ER, Bradley EH, Krumholz HM, et al. Delay from symptom onset to hospital presentation for patients with non-ST-segment elevation myocardial infarction. Arch Intern Med. 2010;170(20):1834–1841. doi: 10.1001/archinternmed.2010.385. [DOI] [PubMed] [Google Scholar]
- 14.Zhang Y, Huo Y. Early reperfusion strategy for acute myocardial infarction: a need for clinical implementation. J Zhejiang Univ-Sci B (Biomed & Biotechnol) 2011;12(8):629–632. doi: 10.1631/jzus.B1101010. [DOI] [PMC free article] [PubMed] [Google Scholar]