In this study, from 200 patients, two thirds were men. Women had more delay comparing to men and also most of them had long delay (45.1%). According to Dracup, between 1/4–1/2 patients with MI had delay more than 6 hours from the beginning of the symptoms.
32 For every 30 minutes delay in sending the patients to hospital, the probability of decrease in human life span increases by 7.5% for one year; and 30–40% of the patients who had delay were looking for help for more than 6 hours, and doing nursing actions reduced the delay time from the average of 5.7 hours to 5.5 hours.
18 Gilber has mentioned 110 minutes as the average time of the onset of symptoms till arriving to the hospital. African women had the most delay.
20 In a study in Scotland in 2000, Robert showed that women had the most delay in referring to hospital. Perhaps the reason for these results is the high threshold of pain tolerance in women or more common rate of MI in men, and that women don't attribute chest pain to heart and its related diseases and so they don't act to reduce it. On the other hand, the women are influenced with heart attacks in older ages, so their sense of pain may decrease with age; and this pain may become more tolerable.
33The findings of the show that with advancing age, the rate of delay has generally increased. The people older than 60 years old often came with slight and long delay in proportion to the previous groups. In a study by Cramlish in 2000 on patients with acute MI it was showed that as age increases, the rate of delay also increases.
4 Boresma mentioned that the most common cause of delay in patients with infarction was increasing age (more than 45 years).
34 The results of these findings may be due to high pain threshold in older people; or the increase in personal knowledge and experience has caused the delay for referring to hospital.
34 The rate of in-time referal in patients has a reverse relation with their situation of revenue; namely the patients whose income is lower have more delay and have less in-time referal in comparison with others. In a study by Robert in 2000 patients who had low income had also the longest delay.
8 Also Lisa described that one of the reasons for delay was low life income.
35 The above findings have been coincident. Perhaps high treatment expense and patients' low income have been the reasons for the delay in patients with MI. Illiterate patients had more delay compared to those with educated ones and the abundance of long delay in this group was more; and this finding is in accordance with Lisa's study in 2000,
35 but Rosenfeld (2001) did not introduce low education as the reason for delay but remarks the low knowledge and information from cardiac disease and the complications due to lack of in-time treatment as the most important cause. The longest delay has been in patients who had a positive history of underlying diseases (HTN, DM)
1 and the reason for in-time refer in patients with infarction along with diabetes is probably because of physician's education based on the possibility of lack of pain and taking every chest pain into consideration and the necessity of in-time referral which needs more survey. Also 84 people who had a hospitalization history because of heart problems did not have such differences with the ones who never had the former history. The reasons for delay are divided into two parts: the background causes (female sex or the older ages) and clinical (DM and Angina history) and the environmental factors (physician's consult with one of the members in the family at the time of the event) and the emotional reactions (anxiety and bothering others, fear from outcomes)
18 and in a study by Novis (1998) on the patients with MI, the ones with a positive history of HTN and previous MI, had more delay.
16 This point is of high importance because some attributed these symptoms to their previous disorders with respect to not having previous experiences, but the patients with cardiac disease often have personal experience and this is a factor that remarks the in-time refer and the necessity of attention to the ones who have risk factors like DM and HTN so that they can have enough education. On the other hand, some diseases such as diabetes increase the pain threshold.
36 The findings show that the longest delay was among the patients who had come directly to the general practitioner and those who had come to the city emergency or public health service. In a study in Scotland in 2000, one of the most common causes of pre-hospital delay was the general practitioners because of insufficient experience and wrong diagnosis which confirms the present findings.
8 In this study the delay was on the part of the patients who used emergency service 115. In a study by Novis in 1998, the ones who called ambulances had a mean delay about 1/3 an hour less than the ones who had not called the ambulances directly.
16 The difference between these two studies is perhaps due to the long time of decision-making to use emergency service 115, the patient's last action after not being well, or pain and/or the decreased speed of transferring the patient by emergency call 115. In-time referal was mostly in patients who had pain in chest and left hand; perhaps the previous experience about similar non-cardiac pain in chest and after that or low severity of the pain have been the reasons for this delay which is considerable. The patients who had experienced symptoms like nausea, vomiting, sweating and dyspnea and etc. with cardiac pain came sooner than the group which did not have the accompanying symptoms. Existence of concomitant symptoms can reduce patient's pain and tolerance threshold and can make the pain ambiguous from the viewpoint of the patient.
21 The ones who have been inside the city at the time of the pain had more in-time refer comparing to those from outside the city. Lack of access to transfer means and rural culture can be the reasons for delay in referring of patients. The most common reason for long delay in an order of abundance are as follows respectively: waiting for spontaneous improvement, attributing to non-cardiac causes and not minding the pain and low educational information. Robin's study (1999) showed that many of patients wait for spontaneous recovery for 24 hours after the beginning of the symptoms and 60% of cardiac mortality has been before getting to hospital
19 and low medical information.
36 Low medical knowledge in illiterate people about ischemic heart disease has been the most common cause of delay with respect to the highly educated people, and this finding is similar to the other studies.
18,
23,
28 But Gilber has stated that the common factors in patients who delayed were being old, having low income, DM and relating the pain to non-cardiac causes and the intermittency of the symptoms.
20The difference between these two groups is probably related to the patient's anticipation for recovery or lack of an experienced physician and lack of sufficient equipment during night especially personal transportation. As far as Dracup showed, the mortality rate of patients with MI in hospital had a meaningful relation with the delay of treatment, and the reasons were lack of intervention such as patient and his family's education about the causes and complications of MI at the beginning of the treatment.
20,
33 Luepker reminded alarming program of the cardiac attacks outbreak regularly and widespread comprehensive education for decrease of delay from the beginning of the symptoms till presence in hospital.
37 But Dracup believes that instead of using general education, a face-to-face education should be done by a nurse so that these actions can reduce the main emotional, social and perceptive obstacles which were known as the progressive factors of delay before hospital in last studies.
3 The ones who used sublingual tablets to relieve pain had 25% long delay. Also the patients who took pain killer had the least percent of in-time refer. This shows that the lack of cognition of cardiac pain importance and its symptoms and waiting for recovery caused delay in in-time refer.
18,
24
