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

  1. Kathleen Dracup, RN, DNSc;
  2. Angelo A. Alonzo, PhD;
  3. James M. Atkins, MD;
  4. Nancy M. Bennett, MD, MS;
  5. Allan Braslow, PhD;
  6. Luther T. Clark, MD;
  7. Mickey Eisenberg, MD, PhD;
  8. Keith Copelin Ferdinand, MD;
  9. Robert Frye, MD;
  10. Lee Green, MD, MPH;
  11. Martha N. Hill, PhD, RN;
  12. J. Ward Kennedy, MD;
  13. Eva Kline-Rogers, MS, RN;
  14. Debra K. Moser, RN, DNSc;
  15. Joseph P. Ornato, MD;
  16. Bertram Pitt, MD;
  17. Jane D. Scott, ScD, MSN;
  18. Harry P. Selker, MD, MSPH;
  19. Sharron J. Silva, PhD;
  20. William Thies, PhD;
  21. W. Douglas Weaver, MD;
  22. Nanette K. Wenger, MD; and
  23. Suzanne K. White, RN, MN, CNAA
  1. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. From the National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Note: Patients and health care professionals who need more information about the National Heart Attack Alert Program can contact the National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; telephone, 301-251-1222; fax, 301-251-1223; e-mail, nhlbiic@dgsys.com; World Wide Web, http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm; gopher, gopher.nhlbi.nih.gov. Acknowledgments: The authors thank Mary Pat Larsen, MS (King County Department of Emergency Medical Services, Seattle, Washington) for statistical support; Jane Lynn (Severna Park, Maryland) and Alan Jung, DDS (Baltimore, Maryland) for serving as patient representatives; and Patrice Desvigne-Nickens, MD, Denise Simons-Morton, MD, PhD, and George Sopko, MD (National Institutes of Health, Bethesda, Maryland) for scientific review and input. Requests for Reprints: Kathleen Dracup, RN, DNSc, University of California, Los Angeles, School of Nursing, PO Box 951702, Los Angeles, CA 90024. Current Author Addresses: Dr. Dracup: University of California, Los Angeles, School of Nursing, PO Box 951702, Los Angeles, CA 90024.
     
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    Abstract

    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.

    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.

    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, β-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.

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    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].

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    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.

    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.

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    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.

    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).

    View this table:
    Table 1. Symptoms of Patients with Confirmed Myocardial Infarction and History of Coronary Heart Disease*

    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.

    Figure 1.
    View larger version:
      Figure 1. Office telephone triage algorithm.
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      Summary

      Early medical therapy can reduce the rates of morbidity and mortality associated with acute myocardial infarction. Physicians and other health care providers play an important role in reducing the delay to treatment. Patients who are known to have cardiovascular disease are at high risk for acute myocardial infarction. Providers must educate high-risk patients about the symptoms that they might have during a coronary occlusion, what steps to take if symptoms occur, and the importance of contacting emergency medical services immediately. Patients should be aware of the treatment options that are available when they present early and the rewards of early treatment. These instructions need to be reviewed frequently and reinforced with appropriate written material and wallet cards.

      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.

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      Appendix

      The following are members of the Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction: Kathleen Dracup, RN, DNSc (Chair), University of California, Los Angeles, Los Angeles, California; Angelo A. Alonzo, PhD, Ohio State University, Columbus, Ohio; James M. Atkins, MD, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; Nancy M. Bennett, MD, MS, University of Rochester School of Medicine and Dentistry, Rochester, New York; Allan Braslow, PhD, Braslow and Associates, Alexandria, Virginia; Luther T. Clark, MD, State University Hospital at Brooklyn, Health Science Center, Brooklyn, New York; Mickey Eisenberg, MD, PhD, University of Washington Medical Center, Seattle, Washington; Keith Copelin Ferdinand, MD, Xavier University of New Orleans, New Orleans, Louisiana; Robert Frye, MD, Mayo Clinic, Rochester, Minnesota; Lee Green, MD, MPH, University of Michigan Medical School, Ann Arbor, Michigan; Martha Hill, PhD, RN, Johns Hopkins University, Baltimore, Maryland; J. Ward Kennedy, MD, University of Washington, Seattle, Washington; Eva Kline-Rogers, MS, RN, University of Michigan Medical Center, Ann Arbor, Michigan; Debra K. Moser, DNSc, RN, Ohio State University, Columbus, Ohio; Joseph P. Ornato, MD, Medical College of Virginia, Richmond, Virginia; Bertram Pitt, MD, University of Michigan Hospital, Ann Arbor, Michigan; Jane D. Scott, ScD, MSN, formerly with the Agency for Health Care Policy and Research, Rockville, Maryland; Harry P. Selker, MD, MSPH, New England Medical Center, Boston, Massachusetts; Sharron Silva, PhD, American Red Cross National Headquarters, Washington, D.C.; William Thies, PhD, American Heart Association, Dallas, Texas; W. Douglas Weaver, MD, University of Washington, Seattle, Washington; Nanette K. Wenger, MD, Emory University School of Medicine, Atlanta, Georgia; Suzanne K. White, RN, MN, CNAA, formerly with St. Joseph's Health Systems, Atlanta, Georgia; Alan Jung, DDS (Patient Representative), Baltimore, Maryland; and Jane Lynn (Patient Representative), Severna Park, Maryland.

      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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      References

      1. 1.↵
        Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Lancet. 1986; 1:397-402.
      2. 2.↵
        Long-term effects of intravenous thrombolysis in acute myocardial infarction: final report of the GISSI study. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Lancet. 1987; 2:871-4.
      3. 3.↵
        Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. J Am Coll Cardiol. 1988; 12(6 Suppl A):3A-13A.
      4. 4.↵
        Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet. 1994; 343:311-22.
      5. 5.↵
        Cannon CP, Antman EM, Walls R, Braunwald E. Times as an adjunctive agent to thrombolytic therapy. Journal of Thrombosis and Thrombolysis. 1994; 1:27-34.
      6. 6.↵
        Timm TC, Ross R, McKendall GR, Braunwald E, Williams DO. Left ventricular function and early cardiac events as a function of time to treatment with t-PA: a report from TIMI II [Abstract]. Circulation. 1991; 84 (4 Suppl II):II-230.
      7. 7.↵
        Berger PB, Bell MR, Holmes DR Jr, Gersh BJ, Hopfenspirger M, Gibbons R. Time to reperfusion with direct coronary angioplasty and thrombolytic therapy in acute myocardial infarction. Am J Cardiol. 1994; 73:231-6.
      8. 8.↵
        Herlitz J, Hartford M, Aune S, Karlsson T, Hjalmarson A. Delay time between onset of myocardial infarction and start of thrombolysis in relation to prognosis. Cardiology. 1993; 82:347-53.
      9. 9.↵
        Weaver WD, Cerqueira M, Hallstrom AP, Litwin PE, Martin JS, Kudenchuk PJ, et al. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA. 1993; 270:1211-6.
      10. 10.↵
        Emergency department: rapid identification and treatment of patients with acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee, 60 Minutes to Treatment Working Group. Ann Emerg Med. 1994; 23:311-29.
      11. 11.↵
        O'Keefe JH Jr, Rutherford BD, McConahay DR, Ligon RW, Johnson WL Jr, Giorgi LV, et al. Early and late results of coronary angioplasty without antecedent thrombolytic therapy for acute myocardial infarction. Am J Cardiol. 1989; 64:1221-30.
      12. 12.↵
        Rogers WJ, Bowlby LJ, Chandra NC, French WJ, Gore JM, Lambrew CT, et al. Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction. Circulation. 1994; 90:2103-14.
      13. 13.↵
        Cannon CP, Henry TD, Schweiger MJ, Haugland JM, McKendall GR, Shah PK, et al. Current management of ST elevation myocardial infarction and outcome of thrombolytic ineligible patients: results of the multicenter TIMI 9 Registry [Abstract]. J Am Coll Cardiol. 1995; (Special Issue):231A-2A.
      14. 14.↵
        Lee TH, Weisberg MC, Brand DA, Rouan GW, Goldman L. Candidates for thrombolysis among emergency room patients with acute chest pain. Potential true- and false-positive rates. Ann Intern Med. 1989; 110:957-62.
      15. 15.↵
        Muller DW, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy. Ann Intern Med. 1990; 113:949-60.
      16. 16.↵
        Goldberg RJ, Gurwitz J, Yarzebski J, Landon J, Gore JM, Alpert JS, et al. Patient delay and receipt of thrombolytic therapy among patients with acute myocardial infarction from a community-wide perspective. Am J Cardiol. 1992; 70:421-5.
      17. 17.↵
        Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal trends and factors associated with extent of delay to hospital arrival in patients with acute myocardial infarction: the Worcester Heart Attack Study. Am Heart J. 1994; 128:255-63.
      18. 18.↵
        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; 40:379-92.
      19. 19.↵
        Dracup K, Moser DK. Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction. Heart Lung. 1991; 20(5 Pt 2):570-5.
      20. 20.↵
        An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med. 1993; 329:673-82.
      21. 21.↵
        Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) phase II trial. The TIMI Study Group. N Engl J Med. 1989; 320:618-27.
      22. 22.↵
        Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat Series 10193. 1995:1-520.
      23. 23.↵
        Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, McCann TJ, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992; 326:381-6.
      24. 24.↵
        Pekkanen J, Linn S, Heiss G, Suchindran CM, Leon A, Rifkind BM, et al. Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med. 1990; 322:1700-7.
      25. 25.↵
        Salonen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb. 1991; 11:1245-9.
      26. 26.↵
        Kannel WB, Schatzkin A. Sudden death: lessons from subsets in population studies. J Am Coll Cardiol. 1985; 5(6 Suppl):141B-149B.
      27. 27.↵
        Kuller L, Perper J, Cooper M. Demographic characteristics and trends in arteriosclerotic heart disease mortality: sudden death and myocardial infarction. Circulation. 1975; 52(6 Suppl):III 1-15.
      28. 28.↵
        Maynard C, Althouse R, Olsufka M, Ritchie JL, Davis KB, Kennedy JW. Early versus late hospital arrival for acute myocardial infarction in the western Washington thrombolytic therapy trials. Am J Cardiol. 1989; 63:1296-300.
      29. 29.↵
        Meischke H, Eisenberg MS, Larsen MP. Prehospital delay interval for patients who use emergency medical services: the effect of heart-related medical conditions and demographic variables. Ann Emerg Med. 1993; 22:1597-601.
      30. 30.↵
        Moss AJ, Wynar B, Goldstein S. Delay in hospitalization during the acute coronary period. Am J Cardiol. 1969; 24:659-65.
      31. 31.↵
        Rawles JM, Haites NE. Patient and general practitioner delays in acute myocardial infarction. Br Med J (Clin Res Ed). 1988; 296:882-4.
      32. 32.↵
        Turi ZG, Stone PH, Muller JE, Parker C, Rude RE, Raabe DE, et al. Implications for acute intervention related to time of hospital arrival in acute myocardial infarction. Am J Cardiol. 1986; 58:203-9.
      33. 33.↵
        Weaver WD, Litwin PE, Martin JS, Kudenchuk PJ, Maynard C, Eisenberg MS, et al. Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. The MITI Project Group. J Am Coll Cardiol. 1991; 18:657-62.
      34. 34.↵
        Alonzo AA. The impact of the family and lay others on care-seeking during life-threatening episodes of suspected coronary artery disease. Soc Sci Med. 1986; 22:1297-311.
      35. 35.↵
        Clark LT, Bellam SV, Shah AH, Feldman JG. Analysis of prehospital delay among inner-city patients with symptoms of myocardial infarction: implications for therapeutic intervention. J Natl Med Assoc. 1992; 84:931-7.
      36. 36.↵
        Cunningham MA, Lee TH, Cooke EF, Brand DA, Rouan GW, Weisberg MC, et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group. J Gen Intern Med. 1989; 4:392-8.
      37. 37.↵
        Schmidt SB, Borsch MA. The prehospital phase of acute myocardial infarction in the era of thrombolysis. Am J Cardiol. 1990; 65:1411-5.
      38. 38.↵
        Ghali JK, Cooper RS, Kowatly I, Liao Y. Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients. J Natl Med Assoc. 1993; 85:180-4.
      39. 39.↵
        Ell K, Haywood LJ, Sobel E, deGuzman M, Blumfield D, Ning JP. Acute chest pain in African Americans: factors in the delay in seeking emergency care. Am J Public Health. 1994; 84:965-70.
      40. 40.↵
        Crawford SL, McGraw SA, Smith KW, McKinlay JB, Pierson JE. Do blacks and whites differ in their use of health care for symptoms of coronary heart disease? Am J Public Health. 1994; 84:957-64.
      41. 41.↵
        Hofgren K, Bondestam E, Johansson FG, Jem S, Herlitz J, Holmberg S. Initial pain course and delay to hospital admission in relation to myocardial infarct size. Heart Lung. 1988; 17:274-80.
      42. 42.↵
        Moss AJ, Goldstein S. The pre-hospital phase of acute myocardial infarction. Circulation. 1970; 41:737-42.
      43. 43.↵
        Schroeder JS, Lamb IH, Hu M. The prehospital course of patients with chest pain. Analysis of the prodromal, symptomatic, decision-making, transportation and emergency room periods. Am J Med. 1978; 64:742-8.
      44. 44.↵
        Simon AB, Feinleib M, Thompson HK Jr. Components of delay in the prehospital phase of acute myocardial infarction. Am J Cardiol. 1972; 30:476-82.
      45. 45.↵
        Reilly A, Dracup K, Dattolo J. Factors influencing prehospital delay in patients experiencing chest pain. Am J Crit Care. 1994; 3:300-6.
      46. 46.↵
        Leitch JW, Birbara T, Freedman B, Wilcox I, Harris PJ. Factors influencing the time from onset of chest pain to arrival at hospital. Med J Aust. 1989; 150:6-10.
      47. 47.↵
        Gray D, Keating NA, Murdock J, Skene AM, Hampton JR. Impact of hospital thrombolysis policy on out-of-hospital response to suspected myocardial infarction. Lancet. 1993; 341:654-7.
      48. 48.↵
        Hackett TP, Cassem NH. Factors contributing to delay in responding to the signs and symptoms of acute myocardial infarction. Am J Cardiol. 1969; 24:651-8.
      49. 49.↵
        Lee TH, Ting HH, Shammash JB, Soukup JR, Goldman L. Long-term survival of emergency department patients with acute chest pain. Am J Cardiol. 1992; 69:145-51.
      50. 50.↵
        Margolis JR, Kannel WS, Feinleib M, Dawber TR, McNamara PM. Clinical features of unrecognized myocardial infarction-silent and symptomatic. Eighteen year follow-up: the Framingham study. Am J Cardiol. 1973; 32:1-7.
      51. 51.↵
        Uretsky BF, Farquhar DS, Berezin AF, Hood WB Jr. Symptomatic myocardial infarction without chest pain: prevalence and clinical course. Am J Cardiol. 1977; 40:498-503.
      52. 52.↵
        Gillum RF, Fortmann SP, Prineas RJ, Kottke TE. International diagnostic criteria for acute myocardial infarction and acute stroke. Am Heart J. 1984; 108:150-8.
      53. 53.↵
        Johnson JA, King KB. The influence of expectations about symptoms on delay in seeking treatment during myocardial infarction. Am J Crit Care. 1995; 4:29-35.
      54. 54.↵
        Braunwald E, Mark DB, Jones RH, Cheitlin MD, Fuster V, McCauley KM, et al. Unstable Angina: Diagnosis and Management. Rockville, MD: U.S. Department of Health and Human Services; 1994: AHCPR publication no. 94-0602. (Clinical Practice Guideline; no. 10).
      55. 55.↵
        Weaver WD, Kennedy JW. Myocardial infarction-thrombolytic therapy in the prehospital setting. In: Fuster V, Varstraete M, eds. Thrombosis in Cardiovascular Disorders. Philadelphia: WB Saunders; 1992:275-87.
      56. 56.↵
        Dracup K, McKinley S, Moser DK. Australian patients' delay in response to heart attack symptoms. Med J Aust. [In press].
      57. 57.↵
        Ho MT, Eisenberg MS, Litwin P, Schaeffer S, Damon S, Weaver WD, et al. Reasons chest pain patients delay or do not call 911 [Abstract]. Circulation. 1988; 78:II-187.
      58. 58.↵
        Raczynski JM, Taylor H, Cutter G, Hardin M, Rappaport N, Oberman A. Diagnoses, symptoms, and attribution of symptoms among black and white inpatients admitted for coronary heart disease. Am J Public Health. 1994; 84:951-6.
      59. 59.↵
        Fetro JV. Personal and Social Skills: Understanding and Integrating Competence across Health Content. Santa Cruz, CA: ETR Associates; 1992.
      60. 60.↵
        Bandura A. A Social Learning Theory. Morristown, NJ: General Learning Pr; 1971.
      61. 61.↵
        Bandura A. Influence of model's reinforcement contingencies on the acquisition of imitative responses. J Pers Soc Psychol. 1965; 36:589-95.
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      1. Ann Intern Med April 15, 1997 vol. 126 no. 8 645-651
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