Factors associated with decision time for patients with ST-segment elevation acute myocardial infarction

Factors associated with decision time for patients with ST-segment elevation acute myocardial infarction 1 first-author 1 1 1 1 1 2 corresp ‡Corresponding Author ‡Corresponding Author †E-mail:llm@fjtcm.edu.cnjefftang@medmail.com.cn †E-mail:llm@fjtcm.edu.cnjefftang@medmail.com.cn llm@fjtcm.edu.cn 1 corresp ‡Corresponding Author ‡Corresponding Author †E-mail:llm@fjtcm.edu.cnjefftang@medmail.com.cn †E-mail:llm@fjtcm.edu.cnjefftang@medmail.com.cn llm@fjtcm.edu.cn Department of Cardiology, the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China Department of Cardiology, the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou 350112, China Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou 350112, China 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. 1 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 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 2008 ; 2010 2010 ; Smolderen et al., 2010 2010 ). Studies have shown the associations of older age, female gender, and non-white race with longer pre-hospital delays (Goldberg et al., 2002 2002 ; Nguyen et al., 2010 2010 ). However, these factors are non-modifiable and likely account for only 10%–25% of pre-hospital delays (Ting et al., 2010 2010 ). Modifiable characteristics, such as patient education, medical insurance, income, and psychosocial factors are recognized in ACS (Dracup, 2009 2009 ; Figueredo, 2009 2009 ; Sullivan et al., 2009 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 1 ). Most patients experienced pain symptoms, including chest pain, breathlessness, sweating, dizziness/fainting as well as chest distress. Values are expressed as number (percent) or mean±standard deviation (SD) Parameter Value * * 2 Sociodemographic factors  Men/women 74/26  Age (year) 65.68±12.68  Married 100 (100%) 2 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%) 2 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%) 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 1 ). 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 2 ). Shorter decision time was more likely among older patients (Fig. 2a 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 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 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 2d ). Nevertheless, these phenomena still deserve our further investigation. Values are expressed as patient number (percent) Comparison with χ 2 test 2 Parameter 2 Patient number * * 2 P # # DT ≤60 min DT >60 min 4 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%) 4 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%) 4 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%) (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 2008 ; Gibson et al., 2008 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 2004 ; 2008 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 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 2002 ; Nguyen et al., 2010 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 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 1 Study population 2 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 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 2 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 2 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. References EM Antman , DT Anbe , PW Armstrong , ER Bates , LA Green , M Hand , JS Hochman , HM Krumholz , FG Kushner , GA Lamas , 等 . 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 . 15289388 DOI: 10.1161/01.CIR.0000134791.68010.FA http://doi.org/10.1161/01.CIR.0000134791.68010.FA . 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) EM Antman , M Hand , PW Armstrong , ER Bates , LA Green , LK Halasyamani , JS Hochman , HM Krumholz , GA Lamas , CJ Mullany , 等 . 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 . 18071078 DOI: 10.1161/CIRCULATIONAHA.107.188209 http://doi.org/10.1161/CIRCULATIONAHA.107.188209 . 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 K Dracup . The challenge of reducing prehospital delay in patients with acute coronary syndrome . Circ Cardiovasc Qual Outcomes , 2009 . 2 ( 3 ): 144 - 145 . 20031829 DOI: 10.1161/CIRCOUTCOMES.109.855635 http://doi.org/10.1161/CIRCOUTCOMES.109.855635 . The challenge of reducing prehospital delay in patients with acute coronary syndrome KA Eagle , BK Nallamothu , RH Mehta , CB Granger , PG Steg , F van de Werf , J López-Sendón , SG Goodman , A Quill , KA Fox , 等 . 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 . 18310671 DOI: 10.1093/eurheartj/ehn069 http://doi.org/10.1093/eurheartj/ehn069 . 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 VM Figueredo . 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 . 19635269 DOI: 10.1016/j.amjmed.2009.05.001 http://doi.org/10.1016/j.amjmed.2009.05.001 . The time has come for physicians to take notice: the impact of psychosocial stressors on the heart CM Gibson , YB Pride , PD Frederick , Jr CV Pollack , JG Canto , AJ Tiefenbrunn , WD Weaver , CT Lambrew , WJ French , ED Peterson , 等 . 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 . 19032997 DOI: 10.1016/j.ahj.2008.07.029 http://doi.org/10.1016/j.ahj.2008.07.029 . 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 RJ Goldberg , PG Steg , I Sadiq , CB Granger , EA Jackson , A Budaj , D Brieger , A Avezum , S Goodman . 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 . 11909560 DOI: 10.1016/S0002-9149(02)02186-0 http://doi.org/10.1016/S0002-9149(02)02186-0 . Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (The GRACE Registry) HL Nguyen , JS Saczynski , JM Gore , RJ Goldberg . 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 . 20123674 DOI: 10.1161/CIRCOUTCOMES.109.884361 http://doi.org/10.1161/CIRCOUTCOMES.109.884361 . Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction a systematic review H Shiomi , Y Nakagawa , T Morimoto , Y Furukawa , A Nakano , S Shirai , R Taniguchi , K Yamaji , K Nagao , T Suyama , 等 . 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 22623632 DOI: 10.1136/bmj.e3257 http://doi.org/10.1136/bmj.e3257 . 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 KG Smolderen , JA Spertus , BK Nallamothu , HM Krumholz , F Tang , JS Ross , HH Ting , KP Alexander , SS Rathore , PS Chan . Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction . JAMA , 2010 . 303 ( 14 ): 1392 - 1400 . 20388895 DOI: 10.1001/jama.2010.409 http://doi.org/10.1001/jama.2010.409 . Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction MD Sullivan , PS Ciechanowski , JE Russo , LA Soine , K Jordan-Keith , HH Ting , JH Caldwell . Understanding why patients delay seeking care for acute coronary syndromes . Circ Cardiovasc Qual Outcomes , 2009 . 2 ( 3 ): 148 - 154 . 20031831 DOI: 10.1161/CIRCOUTCOMES.108.825471 http://doi.org/10.1161/CIRCOUTCOMES.108.825471 . Understanding why patients delay seeking care for acute coronary syndromes HH Ting , EH Bradley , Y Wang , JH Lichtman , BK Nallamothu , MD Sullivan , BJ Gersh , VL Roger , JP Curtis , HM Krumholz . 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 . 18474760 DOI: 10.1001/archinte.168.9.959 http://doi.org/10.1001/archinte.168.9.959 . Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction HH Ting , AY Chen , MT Roe , PS Chan , JA Spertus , BK Nallamothu , MD Sullivan , ER DeLong , EH Bradley , HM Krumholz , 等 . Delay from symptom onset to hospital presentation for patients with non-ST-segment elevation myocardial infarction . Arch Intern Med , 2010 . 170 ( 20 ): 1834 - 1841 . 21059977 DOI: 10.1001/archinternmed.2010.385 http://doi.org/10.1001/archinternmed.2010.385 . Delay from symptom onset to hospital presentation for patients with non-ST-segment elevation myocardial infarction Y Zhang , Y Huo . 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 http://doi.org/10.1631/jzus.B1101010 . Early reperfusion strategy for acute myocardial infarction: a need for clinical implementation 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. 10.1631/jzus.BQICC709 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 2013-07-01 2013-07-01 2013-07-19 2022-01-05 Copyright © Zhejiang University and Springer-Verlag Berlin Heidelberg 2013 2013 Journal of Zhejiang University-SCIENCE B (Biomedicine and Biotechnology) 08 14