To improve treatment success of ST-elevation myocardial infarction, a minimal delay from symptom onset to reperfusion therapy is crucial. The patient’s response to initial symptoms (patient delay) substantially affects the delay. We investigated time patterns of patient delay during a seven-year time period, and aimed to identify key predictors that affect the length of the patient delay.
Methods:
Data on 5848 patients hospitalized with ST-elevation myocardial infarction and treated with primary percutaneous intervention during the period 2003–2009 were obtained from Danish registry databases. The dependent variable was patient delay (<120 and ⩾120 min). Data were analysed for a possible time trend during the seven-year study period using Jonckheere-Terpstra analysis and we also performed multiple logistical regression to identify predictors of a prolonged patient delay.
Results:
We observed a decrease in median patient delay from 101 min in 2003 to 85 min in 2009, p=0.018. We identified the age group 55–69 years (odds ratio (OR): 1.27 (95% confidence interval (CI): 1.09–1.47)) and age ⩾70 years (OR: 1.63 (95% CI: 1.40–1.90)), diabetes (OR: 1.26 (95% CI: 1.05–1.50)), female gender (OR: 1.17 (95% CI: 1.03–1.34)) and presentation during the night 22:00–05:59 (OR: 1.92 (95% CI: 1.68–2.20)), as independent risk factors of a patient delay ⩾120 min. Symptom onset between 14:00–21:59 was associated with a shorter patient delay (OR: 0.78 (95% CI 0.68–0.89)).
Conclusion:
A slight decrease in patient delay during the years from 2003–2009 was observed. High age, diabetes, female gender and symptoms presentation during the night were shown to be independent predictors of prolonged patient delay.
KushnerFGHandMSmithSCJr. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol2009; 54: 2205–2241.
2.
TerkelsenCJSorensenJTMaengM. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA2010; 304: 763–771.
3.
TerkelsenCJJensenLOTilstedHH. Primary percutaneous coronary intervention as a national reperfusion strategy in patients with ST-segment elevation myocardial infarction. Circ Cardiovasc Interv2011; 4: 570–576.
4.
PedersenSHGalatiusSHansenPR. Field triage reduces treatment delay and improves long-term clinical outcome in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol2009; 54: 2296–2302.
5.
LonborgJSchoosMMKelbaekH. Impact of system delay on infarct size, myocardial salvage index, and left ventricular function in patients with ST-segment elevation myocardial infarction. Am Heart J2012; 164: 538–546.
6.
TerkelsenCJJensenLOTilstedHH. Health care system delay and heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: Follow-up of population-based medical registry data. Ann Intern Med2011; 155: 361–367.
7.
Perkins-PorrasLWhiteheadDLStrikePC. Pre-hospital delay in patients with acute coronary syndrome: Factors associated with patient decision time and home-to-hospital delay. Eur J Cardiovasc Nurs2009; 8: 26–33.
8.
RasmussenCHMunckAKragstrupJ. Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission. Scand Cardiovasc J2003; 37:183–186.
9.
GoldbergRJYarzebskiJLessardD. Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: The Worcester Heart Attack study. Arch Int Med2000; 160: 3217–3223.
10.
DracupKMcKinleySRiegelB. A randomized clinical trial to reduce patient prehospital delay to treatment in acute coronary syndrome. Circ Cardiovasc Qual Outcomes2009; 2: 524–532.
11.
MackayMHRatnerPANguyenM. Inconsistent measurement of acute coronary syndrome patient’s prehospital delay in research: A review of the literature. Eur J Cardiovasc Nurs2014; 13: 483–493.
12.
KainthAHewittASowdenA. Systematic review of interventions to reduce delay in patients with suspected heart attack. Emerg Med J2004; 21: 506–508.
13.
TingHHBradleyEH. Patient education to reduce prehospital delay time in acute coronary syndrome necessary but not sufficient. Circ Cardiovasc Qual Outcomes2009; 2: 522–523.
14.
SchmidtMMaengMJakobsenCJ. Existing data sources for clinical epidemiology: The Western Denmark Heart Registry. Clin Epidemiol2010; 2: 137–144.
15.
ReynoldsT. Declaration of Helsinki revised. J Natl Cancer Inst2000; 92: 1801–1803.
16.
OttesenMMKoberLJorgensenS. Determinants of delay between symptoms and hospital admission in 5978 patients with acute myocardial infarction. The TRACE Study Group. Trandolapril Cardiac Evaluation. Eur Heart J1996; 17: 429–437.
17.
JägerBFarhanSRohlaM. Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality. Eur Heart J Acute Cardiovasc Care. Epub ahead of print 17February2016. DOI: 10.1177/2048872616633882
18.
DeySFlatherMDDevlinG. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: The Global Registry of Acute Coronary Events. Heart2009; 95: 20–26.
19.
MeischkeHLarsenMPEisenbergMS. Gender differences in reported symptoms for acute myocardial infarction: Impact on prehospital delay time interval. Am J Emerg Med1998; 16: 363–366.
20.
HerningMHansenPRBygbjergB. Women’s experiences and behaviour at onset of symptoms of ST segment elevation acute myocardial infarction. Eur J Cardiovasc Nurs2011; 10: 241–247.
21.
ThylénIEricssonMAngerudKH. First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study. BMJ Open2015; 5; e007059.
22.
LeslieWSUrieAHooperJ. Delay in calling for help during myocardial infarction: Reasons for the delay and subsequent pattern of accessing care. Heart2000; 84: 137–141.
23.
CarneyRFitzsimonsDDempsterM. Why people experiencing acute MI delay seeking medical assistance. Eur J Cardiovasc Nurs2003; 1: 237–242.
24.
McKeeGMooneyMO’DonnellS. Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome. Int J Cardiol2013; 168: 2706–2713.
25.
HarjaiKStoneGWBouraJ. Comparison of outcomes of diabetic and non-diabetic undergoing PCI. Am J Cardiol2003; 91: 1041–1045.
26.
El-MenyarAZubaidMSulaimanK. Atypical presentation of acute coronary syndrome: A significant independent predictor of in-hospital mortality. J Cardiol2011; 57: 165–171.
27.
RegueiroARosasAKaifoszovaZ. Impact of the ‘ACT NOW. SAVE A LIFE’ public awareness campaign on the performance of a European STEMI network. Int J Cardiol2015; 197: 110–112.
28.
KhraimFMCareyMG. Predictors of pre-hospital delay among patients with acute myocardial infarction. Patient Educ Couns2009; 75: 155–161.
29.
SheiferSERathoreSSGershBJ. Time to presentation with acute myocardial infarction in the elderly: Associations with race, sex, and socioeconomic characteristics. Circulation2000; 102: 1651–1656.
30.
HananiaGCambouJ-PGuéretP. Management and in-hospital outcome of patients with acute myocardial infarction admitted to intensive care units at the turn of the century: Results from the French nationwide USIC 2000 registry. Heart2004; 90: 1404–1410.
31.
LaBountyTEagleKAManfrediniR. The impact of time and day on the presentation of acute coronary syndromes. Clin Cardiol2006; 29: 542–546.
32.
PuymiratESimonTStegPG. Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction. JAMA2012; 308: 998–1006.
33.
ThuressonMJarlövMBLindahlB. Thoughts, actions, and factors associated with prehospital delay in patients with acute coronary syndrome. Heart Lung2007; 36: 398–409.
34.
CarneyRFitzsimonsDDempsterM. Why people experiencing acute myocardial infarction delay seeking medical assistance. Eur J Cardiovasc Nurs2002; 1: 237–242.
35.
KirchbergerIHeierMWendeR. The patient’s interpretation of myocardial infarction symptoms and its role in the decision process to seek treatment: The MONICA/KORA Myocardial Infarction Registry. Clin Res Cardiol2012; 101: 909–916.
36.
DeVonHAHoganNOchsAL. Time to treatment for acute coronary syndromes: The cost of indecision. J Cardiovasc Nurs2010; 25: 106–114.
37.
MoserDKKimbleLPAlbertsMJ. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: A scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. Circulation2006; 114: 168–182.
38.
MackayMHRatnerPANguyenM. Inconsistent measurement of acute coronary syndrome patients’ pre-hospital delay in research: A review of the literature. Eur J Cardiovasc Nurs2014; 13: 483–493.
