Delayed Presentation of Patients with Acute Myocardial Infarction in Chittagong Medical College Hospital

Abstract

Background: Delay between onset of symptoms and hospital presentation is a critical factor in determining the management strategy and subsequent outcome. Objective of the study was to identify predictors of late presentation in patients with acute myocardial infarction (AMI) and target interventions for those at high risk of late presentation.Methods: In our cross sectional study we prospectively analyzed a cohort of 1032 AMI patients for 1 year (August, 2014 to July, 2015). Demographic factors, clinical characteristics, perception of health and access to health care were compared between early (within 12 hours of symptom onset) and late presenters (>12 hours of symptom onset). Bivariate comparison and multivariate logistic regression were done to identify independent predictors of late presentation .Odds ratio and 95% confidence intervals were calculated directly from the estimated regression coefficient.Results: Of the total 1032 patients 385 (37.3%) were early presenters and 647 (62.7%) were late presenters. Mean time interval between onset of symptom and presentation to hospital were 6.85±8.06 hrs (range 1.5 to 12 hrs) in early and 37.88±25.13 hrs (range 13 to 120 hrs) in late presenters. Bivariate comparison found that in the late presentation group was higher age group patients and employed citizens, had ? one angina episode over past 4 weeks, was unable to use emergency medical transport, had no nearby ECG facilities and misinterpreted chest pain as peptic ulcer disease (PUD). Multivariate analysis showed older age ?65 yrs, traveling long distance ?50 miles from home residence, reporting one or more angina episode over past 4 weeks, attending PHC/clinic and misinterpreting chest pain as PUD were associated with late presentation.Conclusion: A significant majority of patients with AMI were late presenters. Misinterpreting chest pain as PUD was responsible for the delay in the majority. Reporting ?1 angina episodes over past 4 weeks was also independently associated with late presentation. Lack of emergency medical transport and traveling long distance were also significantly associated with the late presenters. Patient education, appropriate utilization of existing resources and use of tele-electrocardiography that allows transmission of ECG signal to a medical control officer may decrease late presentation and improve outcome.Cardiovasc. j. 2016; 9(1): 3-8

Pre-hospital delay in patients with myocardial infarction: an observational study in a tertiary care hospital of northern Bangladesh

“…The conventional belief of people about myocardial infarction to be a disease of old age drives the younger patients to misinterpret the cardiac symptoms as less important ones like heartburn or peptic ulcer disease and this hinders them to take prompt action. Older age is a widely reported risk factor of prolong pre-hospital delay (16,18,21). No significant sex difference were found in case of pre-hospital delay in this study, which is consistent with other studies from both developed and developing countries including the Bangladeshi one (10,16,(22)(23)(24).…”

“…Older age is a widely reported risk factor of prolong pre-hospital delay (16,18,21). No significant sex difference were found in case of pre-hospital delay in this study, which is consistent with other studies from both developed and developing countries including the Bangladeshi one (10,16,(22)(23)(24). However, some other studies identified female sex as significant predictors of prolonged pre-hospital delay (12,25).…”

“…The cause of this difference is clear as most of the patients who have visited government primary health centers were mostly from rural areas whereas the patients admitted directly were mainly from nearby urban areas. The finding is consistent with previous studies of different countries (11,24,34) though it was totally opposite to the other study of Bangladesh (16). They found visiting a primary care center had increased the rate of early presentation, however, they defined early presentation as admission within 12 hours of symptoms onset.…”

“…That study was conducted in private tertiary care hospital, where most of patients were from affluent families, who also showed lower pre-hospital delay in our study. The proportion of early presentation (within 6 hours) was 17.2%, as reported by a study conducted in a government tertiary care hospital situated in Chittagong in Southern part of Bangladesh (16). Situation of government tertiary care hospitals, the main service centers for mass population is quite similar all over the country.…”

“…A recent study conducted in a tertiary care private hospital reported rural residence, longer distance from hospital, self-medication, misinterpretation of symptoms, transportation problem as the predictors of late hospital presentation (15). Another study conducted in Southern part of Bangladesh reported similar findings (16), but these findings cannot be generalized for the entire country, as socio-demographic, geographic and health care system related factors are not homogenous all over the country. Moreover, no previous evidence was found on the effect of pre-hospital delay on in-hospital outcome.…”