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15 April 1997 | Volume 126 Issue 8 | Pages 645-651
Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.
Not all patients with acute myocardial infarction receive the benefits of these dramatic advances in treatment. Data from a national registry of more than 240 000 patients with acute myocardial infarction showed that only 35% of patients who had a diagnosis of acute myocardial infarction at discharge received thrombolytic therapy [12]. Data from the National Registry of Myocardial Infarction [12] and the TIMI (Thrombolysis in Myocardial Infarction) 9 Registry [13] indicate that patients who did not receive a thrombolytic agent were also not treated aggressively with such drugs as aspirin, ß-blockers, and heparin, all of which have been shown to effectively reduce morbidity and mortality rates. Arrival at the hospital more than 6 hours after symptom onset and lack of ST-segment elevation are frequently cited as reasons for not administering a thrombolytic drug [13-17].
Studies have documented that treatment is most often delayed because patients do not seek care promptly [18]. The median delay in seeking care after the onset of symptoms of acute myocardial infarction ranges from 2 to 6.4 hours [19]. The median delay to treatment recorded by the National Registry of Myocardial Infarction was 2.2 hours [12]. Although early treatment is potentially beneficial, few patients are treated within the first 60 to 90 minutes. For example, only 3% of patients in the GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial [20], 3% of patients in the TIMI phase II trial [21], and 10.9% of patients in the GISSI (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico) I trial [1] were treated within the first hour after symptom onset.
The National Heart Attack Alert Program is a national education program that was launched in 1991 to educate health care providers, health care systems administrators, patients, and the general public about the importance of rapid and appropriate response to symptoms and signs of acute myocardial infarction. The ultimate goal of the program is to reduce morbidity and mortality rates through the early treatment of patients with acute myocardial infarction. The program has directed its initial efforts toward reducing delays to assessment, diagnosis, and treatment in the emergency department. A current objective is to encourage physicians and other health care providers to instruct their high-risk patients to seek immediate and appropriate medical care if they have symptoms that suggest acute myocardial infarction or ischemia. The program plans to begin other public education efforts after further educating health care providers and evaluating the results of community-based research being done by the National Heart, Lung, and Blood Institute.
In this paper, which is based on a report of a National Heart Attack Alert Program working group, we describe 1) the rationale for targeting a high-risk group, 2) predictors of patient delay, and 3) recommendations for the education of patients who are at high risk for acute myocardial infarction.
Sociodemographic characteristics, including older age [17, 28-33], female sex [29, 32, 34-37], and being in certain minority groups [18, 35], are associated with a longer delay before care is sought for acute myocardial infarction. Delays also seem to be associated with low socioeconomic status [38, 39], but this finding is not consistent [40].
Several clinical characteristics also affect delay. Severe chest pain is associated with a shorter delay but only if the pain is sudden in onset [34, 37] or is accompanied by hemodynamic instability [28, 32]. Patients who have severe chest pain of gradual onset do not respond more quickly than patients who have pain that is less severe, possibly because these patients adjust to gradually increasing pain [28, 41]. Patients with a history of angina or diabetes are more likely to delay than patients without these conditions [29, 32, 42-44]. A striking finding of all studies is that delays among patients who have already received a diagnosis of coronary heart disease, heart failure, or myocardial infarction are the same as or greater than those among patients who have not previously had a myocardial infarction or diagnosis of coronary heart disease.
Physicians, other health care providers, family members, significant others, and friends, in helping patients make decisions about seeking emergency care, can influence the time to therapy. Most patients consult someone, either a layperson or a physician, before calling an ambulance or taking other transportation to the hospital [34, 45]. If a patient telephones a physician or other health care provider who may not be available at the time of the call, delay is substantially increased [34, 44-47]. Patients report to the emergency department more quickly if they consult a friend, coworker, or stranger than if they consult a family member or significant other [34, 48].
In managed care settings, requiring patients to contact their primary care physician or an authorization service before proceeding to the emergency department may contribute to delay. However, delays associated with managed care have not been systematically compared with those associated with fee-for-service. The National Heart Attack Alert Program is working with managed care organizations to develop standards of care that minimize any potential negative effects of preauthorization regulations.
Whom To Educate
Providers should focus their educational efforts on patients who are known to have cardiovascular disease; they should give special attention to women, elderly patients, and patients of low socioeconomic status. Patients with a known history of coronary heart disease who present to the emergency department with chest pain and are discharged from the emergency department have a subsequent rate of death from cardiovascular disease similar to that of patients who are discharged after hospitalization for angina or myocardial infarction [49]. Therefore, providers of emergency care should recommend that such patients see their personal physician soon after the episode.
What To Tell High-Risk Patients
The message that providers must convey to their patients includes three essential components: provision of information, discussion of emotional issues, and discussion of social factors. Patients should be informed about the typical symptoms of acute myocardial infarction and the actions that should be taken if the symptoms occur.
Although the presentation of acute myocardial infarction can be atypical [50, 51], most patients present with chest pain or discomfort, pain or heaviness in the left arm, shortness of breath, or a sense of dread [52]. Analyses of 1027 patients who presented with a myocardial infarction and a history of angina or previous myocardial infarction showed that most patients had chest pain that may have radiated to the arm, neck, or jaw (Table 1). More women than men presented with symptoms of congestive heart failure; nausea; and, to a lesser extent, dyspnea (King County, Washington. Unpublished data). PERSPECTIVE
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
A dramatically decreased mortality rate has been seen with early administration of thrombolytic therapy in acute myocardial infarction in several large, randomized clinical trials [1-6]. The administration of thrombolytic drugs within 1 hour of symptom onset results in little or no evidence of myocardial damage in many patients [7-10]. An effect of time to treatment has also been seen in patients with primary angioplasty [11], but more data are needed. If patients and their families seek and receive expeditious care, many effective interventions are available for the early management of acute myocardial infarction, acute cardiac ischemia, potentially fatal arrhythmia, and cardiogenic shock.
Rationale for Targeting a High-Risk Group
Education about the symptoms and signs of acute myocardial infarction and the need to seek treatment promptly should ideally be directed to all patients; educating all patients is a long-term goal of the National Heart Attack Alert Program. However, education and counseling should aim to reduce delay for persons who are at high risk for an acute myocardial infarction so that resources can be focused on persons who might benefit most. According to results of health interviews done in 1994, about 8 million persons in the United States have coronary heart disease, about 3 million have cerebrovascular disease, and about 2 million have peripheral vascular disease [22]. Patients with coronary heart disease, clinical atherosclerotic disease of the aorta or peripheral arteries, or clinical cerebrovascular disease are at high risk for subsequent myocardial infarction or death from coronary heart disease [23-25]. About 50% of all myocardial infarctions and at least 70% of deaths from coronary heart disease occur in persons who have had previous manifestations of cardiovascular disease [26, 27]. The risk for subsequent myocardial infarction and death is five- to seven-fold higher in patients who have coronary heart disease or other atherosclerotic disease than in the general population [23].
Predictors of Patient Delay
Researchers have identified sociodemographic factors, clinical characteristics, and patient and bystander behaviors that are associated with a long delay in seeking care for acute myocardial infarction. These findings can help clinicians 1) identify patients who are likely to delay seeking treatment and 2) guide strategies for reducing delay.
Recommendations for the Education of Patients at High Risk for Acute Myocardial Infarction
Physicians and other health care providers who are preparing to educate their high-risk patients will need to decide whom to educate, what to tell them, and how to present the message in the most effective manner. All instructions should be entered in patient records so that other members of the health care team can reinforce these instructions during subsequent visits.
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Health care providers should take into consideration that the symptoms of acute myocardial infarction in elderly persons may be vague. Older patients are more likely than younger patients to have a history of hypertension, congestive heart failure, and myocardial infarction and are more likely to delay presentation. In the MITI (Myocardial Infarction, Triage, and Intervention) trial, 1848 patients who were older than 65 years of age had acute myocardial infarction. A greater proportion of these patients had no chest pain when they were first evaluated in the hospital, and a smaller proportion had ST-segment elevation on the initial electrocardiogram.
Because they often believe that an acute myocardial infarction is characterized by sudden, crushing chest pain and unconsciousness [53], patients should be informed that symptoms may occur gradually or intermittently. The educational message should be adapted to an individual patient's history of symptoms. However, the more common symptoms of myocardial infarction should be discussed because a second episode may not manifest in exactly the same way as the first.
Patients must clearly understand the actions they should take if symptoms of acute myocardial infarction occur. Such actions include taking nitroglycerin (if prescribed), taking aspirin, and contacting emergency medical services. Although advice about medication should be tailored for individual patients, the general guideline for the use of nitrates for angina that was published by the Agency for Health Care Policy and Research Guideline Panel seems to be sound [54]. According to this guideline, patients should take one nitroglycerin tablet as soon as they feel discomfort, a second tablet if the discomfort is not alleviated in 5 minutes, and a third tablet after 5 more minutes if symptoms persist. If the medication does not relieve the discomfort in 15 minutes, patients are instructed to report to the hospital immediately. Because of the benefit that aspirin has shown for an acute ischemic event [3], patients should also be advised to chew an adult-strength (325-mg), uncoated aspirin tablet when symptoms occur.
Contacting emergency medical services shortens the delay for almost all patients suspected of having acute myocardial infarction [55]. Therefore, high-risk patients and their families should be told to telephone for emergency services when symptoms that suggest acute myocardial infarction occur. If a patient lives in a rural area or is far from a hospital, the health care provider should discuss the merits of alternative plans. Having a family member or friend drive is not recommended because the person driving cannot render care to the patient and usually cannot communicate with the hospital while on the way. Moreover, arrival at the emergency department by private vehicle has been shown to delay triage and assessment of patients who have acute myocardial infarction [56].
Another component of the message relates to the emotional issues that surround acute myocardial infarction and may contribute to delay of presentation. Recent research suggests that a significant delay is related to the patient's belief that the symptoms are not serious or cardiac related [45, 56-58]. Patients and their families need assistance in anticipating this defense and recognizing that denial of the serious nature of symptoms contributes to delay.
To balance the aversive nature of the educational message, patients should be told about the rewards of acting quickly and receiving definitive treatment before irreversible myocardial damage occurs. Positive messages about the salvage of cardiac muscle and survival that occur when treatment is started soon after symptom onset are potentially more effective than negative messages about delay and the possibility of sudden death.
The final component of the message involves social factors that surround the decision to seek treatment. Most patients consult a family member or significant other about their symptoms [34, 45]. These persons should be included in all education and counseling, and they should understand the nature of symptoms of acute myocardial infarction and the importance of quickly contacting emergency medical services.
Educational Techniques for Conveying the Message
Because symptoms can increase anxiety, patients should be encouraged to rehearse their response to a possible acute myocardial infarction during less stressful times so that their reaction becomes automatic [59-61]. Just as practicing fire drills in the workplace can improve outcome, reviewing feelings and optimal behavior in response to symptoms of acute myocardial infarction increases the probability that appropriate steps will be taken despite intense emotional reaction. The National Heart Attack Alert Program has developed a sample patient advisory form that contains the essential information that providers should review with patients at high risk for myocardial infarction. (This form is available from the address at the end of the text.)
Office Triage System
Finally, all staff members of the health care office (particularly receptionists or others with whom the patient is likely to have initial contact) should understand and support this educational program. Practitioners should provide clear instructions and training for staff members about the actions that should be taken when a patient who has symptoms suggestive of an acute cardiac event telephones or walks into the office and seeks advice. Staff members must not waste time trying to contact a physician. The physician (or policymaking committee in a managed care setting) must devise a system to quickly identify such patients and refer them for emergency medical services if appropriate. An algorithm for triage may help staff members identify which patients need emergency referral (Figure 1). A continuous approach for improving quality should also be part of any office- or clinic-based triage system whereby information is collected about triage and referral processes (for example, using a log sheet for telephone calls about chest pain). The physician and staff can review these data and modify procedures when the data indicate potential problems.
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No single intervention, however carefully designed and implemented, will alter the patient's propensity to delay. However, a consistent, regularly delivered message may help. Impediments to early treatment should be identified and modified with an appropriate plan of action when possible. Family members and significant others should participate in all instruction because they play an important role in increasing or decreasing the delay to treatment.
Dr. Alonzo: Ohio State University, 300 Bricker Hall, 190 North Ovall Mall, Columbus, OH 43210.
Dr. Atkins: Division of Cardiology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-8890.
Dr. Bennett: Monroe County Health Department, Room 946, 111 Westfall Road, Rochester, NY 14692.
Dr. Braslow: Braslow and Associates, Suite E-420, 80 South Van Dorn Street, Alexandria, VA 22304.
Dr. Clark: Division of Cardiovascular Medicine, State University Hospital at Brooklyn, Health Science Center, 450 Clarkson Avenue, Box 1199, Brooklyn, NY 11203.
Dr. Eisenberg: University of Washington Medical Center, Box 356123, 1959 Northeast Pacific Street NE207, Seattle, WA 98195.
Dr. Ferdinand: Heartbeats Life Center of New Orleans, 1201 Poland Avenue, New Orleans, LA 70117.
Dr. Frye: Department of Internal Medicine, Mayo Clinic, 200 First Street, S.W., Rochester, MN 55905.
Dr. Green: Department of Family Practice, University of Michigan Medican School, 1018 Fuller Street, Ann Arbor, MI 48109.
Dr. Hill: Center for Nursing Research, Johns Hopkins University, School of Nursing, Room 233, 1830 East Monument Street, Baltimore, MD 21205-2100.
Dr. Kennedy: Division of Cardiology, University of Washington, Box 356422, University Hospital, Seattle, WA 98195-6422.
Ms. Kline-Rogers: Cardiology Department B1F245, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0022.
Dr. Moser: Ohio State University, College of Nursing, 1585 Neil Avenue, Columbus, OH 43210.
Dr. Ornato: Medical College of Virginia, PO Box 525, MCV Station, 401 North 12th Street, Richmond, VA 23298-0525.
Dr. Pitt: Division of Cardiology, University of Michigan Hospital, Room 3910, Taubman Building, 1500 East Medical Drive, Ann Arbor, MI 48109-0366.
Dr. Scott: National Study Center for Trauma and EMS, University of Maryland School of Medicine, 701 West Pratt Street-001, Baltimore, MD 21201-1023.
Dr. Selker: Division of Clinical Care Research, New England Medical Center, 750 Washington Street, Box 63, Boston, MA 02111.
Dr. Silva: Public Policy and Planning, American Red Cross, 430 17th Street, Washington, DC 20006.
Dr. Thies: Emergency Cardiac Care Programs, American Heart Association, 7272 Greenville Avenue, Dallas, TX 75075.
Dr. Weaver: Henry Ford Hospital, Cardiovascular Medicine K-14, 2799 West Grand Boulevard, Detroit, MI 48202.
Dr. Wenger: Grady Memorial Hospital, Thomas K. Glenn Memorial Building, 69 Butler Street, S.E., Atlanta, GA 30303.
Ms. White: Ernst and Young, LLP, Suite 2800, 600 Peachtree Street, N.E., Atlanta, GA 30308-2215.
Appendix
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Staff, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland: Mary M. Hand, MSPH, RN (Coordinator, National Heart Attack Alert Program) and Michael Horan, MD, ScM (Director, Division of Heart and Vascular Diseases).
The Support Contract staff for the National Heart Attack Alert Program Coordinating Committee who worked on this publication are John C. Bradley, MS, Pamela A. Christian, RN, MPA, and Susan Shero, RN, MS, ROW Sciences, Inc., Rockville, Maryland.
National Heart Attack Alert Program Coordinating Committee
The following are member organizations of the National Heart Attack Alert Program Coordinating Committee: Agency for Health Care Policy and Research; American Academy of Family Physicians; American Academy of Insurance Medicine; American Association for Clinical Chemistry, Inc.; American Association of Critical Care Nurses; American Association of Occupational Health Nurses; American College of Cardiology; American College of Chest Physicians; American College of Emergency Physicians; American College of Occupational and Environmental Medicine; American College of Physicians; American College of Preventive Medicine; American Heart Association; American Hospital Association; American Medical Association; American Nurses' Association, Inc.; American Pharmaceutical Association; American Public Health Association; American Red Cross; Association of Black Cardiologists; Centers for Disease Control and Prevention; Department of Defense, Health Affairs; Department of Veterans Affairs; Emergency Nurses Association; Federal Emergency Management Agency; Food and Drug Administration; Health Care Financing Administration; Health Resources and Services Administration; International Association of Fire Chiefs; National Association of Emergency Medical Technicians; National Association of EMS Physicians; National Association of State Emergency Medical Services Directors; National Black Nurses' Association, Inc.; National Center for Health Statistics; National Heart, Lung, and Blood Institute; National Highway Traffic Safety Administration; National Medical Association; National Heart, Lung, and Blood Institute Ad Hoc Committee on Minority Populations; Society for Academic Emergency Medicine; and Society of General Internal Medicine.
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