Understanding Why Patients Delay Seeking Care for Acute Coronary Syndromes

Abstract

Background-Better insight into the psychosocial factors associated with prehospital delays in seeking care for acute coronary syndromes is needed to inform the design of future interventions. Delay in presenting for care after the onset of symptoms is common, limits the potential benefit of acute reperfusion, and has not been reduced by interventions tested thus far. Methods and Results-Seven hundred ninety-six patients with suspected ischemic heart disease scheduled for clinically indicated imaging stress tests completed questionnaires concerning psychological distress and attachment styles (worthiness to receive care, trustworthiness of others to provide care). The primary dependent variable for this study was response to a question from the rapid early action for coronary treatment trial concerning intention to "wait until very sure" before seeking care for a possible "heart attack." Responses to this question were strongly associated with actual emergency department-reported and self-reported care delay in the rapid early action for coronary treatment trial. In multivariable ordinal regression models, a more negative view of the trustworthiness of others, greater physical limitations from angina, and no previous revascularization were independently associated with increased intention to wait to seek care for a myocardial infarction. Intention to wait was not associated with inducible ischemia or self-perceived risk of myocardial infarction. Conclusions-Intention to delay seeking care for acute coronary syndromes is associated with a patient's view of the trustworthiness of others, previous experience with revascularization, and functional limitations, even after adjustment for objective and perceived acute coronary syndromes risk. These findings provide insight into novel factors contributing to longer delay times and may inform future interventions to reduce delay time.

Use of Emergency Medical Service Transport Among Patients With ST-Segment–Elevation Myocardial Infarction

“…The reasons for the persistence of this finding are not entirely clear, but cost, fear of false alarm, reluctance to bother or burden the medical community, lack of EMS benefit awareness, and other psychosocial factors, such as lack of trust in others have been implicated. 12,13 In contrast to the National Registry of Myocardial Infarction survey 7 and other previous work, 14,15 race was no longer a significant factor implicated in the decision regarding mode of transport in our contemporary population; however, patients of younger age, male sex, and Hispanic ethnicity persistently underuse EMS and therefore should remain targets of community education campaigns. 7 Interestingly, we found that education level was not a major predictor of mode of transport, and in contrast to prior studies, 16 we found that rural residence was also not a major predictor.…”

Delays in Seeking Care

“…Sex was not associated with a greater likelihood of waiting, but those who had lower trust in others, had experienced a previous revascularization, or were more functionally limited by angina were more likely to wait to seek care. 18 Another study did demonstrate a difference between sexes with regard to cardiac symptoms, as more women would wait for a more severe confirmatory event to occur before they would qualify their symptoms as possibly cardiac. 19 Delay to action is not limited to the experience of cardiac symptoms.…”

The Challenge of Reducing Prehospital Delay in Patients With Acute Coronary Syndrome

“…Knowing that older individuals, women, or patients with a history of angina are more likely to delay does not suggest appropriate interventions to reduce delay time, because none of these characteristics are amenable to change. In this issue of Circulation: Cardiovascular Quality and Outcomes, Sullivan et al 11 address an alternate understanding of prehospital ACS care delay. Along with examining delay to treatment in terms of patient sociodemographic and clinical characteristics, they tested a developmental model of attachment theory to characterize patterns of interpersonal functioning.…”