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1.  Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the Northern Sweden MONICA Study 
Reperfusion therapy reduces both morbidity and mortality in myocardial infarction, but the effectiveness depends on how fast the patient receives treatment. Despite the time-dependent effectiveness of reperfusion therapy, many patients with myocardial infarction have delays in seeking medical care. The aim of this study was to describe pre-hospital delay in a first myocardial infarction among men and women with and without diabetes and to describe the association between pre-hospital delay time and diabetes, sex, age, symptoms and size of residential area as a proxy for distance to hospital.
This population based study was based on data from 4266 people aged 25–74 years, with a first myocardial infarction registered in the Northern Sweden MONICA myocardial infarction registry between 2000 and 2008.
The proportion of patients with delay times ≥ 2 h was 64% for patients with diabetes and 58% for patients without diabetes. There was no difference in delay time ≥ 2 h between men and women with diabetes. Diabetes, older age and living in a town or rural areas were factors associated with pre-hospital delay times ≥ 2 h. Atypical symptoms were not a predictor for pre-hospital delay times ≥ 2 h, OR 0.59 (0.47; 0.75).
A higher proportion of patients with diabetes have longer pre-hospital delay in myocardial infarction than patients without diabetes. There are no differences in pre-hospital delay between men and women with diabetes. The largest risk difference for pre-hospital delay ≥ 2 h is between women with and without diabetes. Diabetes, older age and living in a town or rural area are predictors for pre-hospital delay ≥ 2 h.
PMCID: PMC3565876  PMID: 23356233
Myocardial infarction; Diabetes mellitus; Pre-hospital delay; Sex differences
2.  Patients with suspected myocardial infarction: effect of mode of referral on admission time to a coronary care unit. 
The aim of this prospective study was to determine the delay between the onset of symptoms and arrival in the coronary care unit of patients with suspected acute myocardial infarction, and the relative contribution to the total delay of patient delay, method of referral (self referral or general practitioner referral) and delay in the hospital before reaching the coronary care unit. All patients admitted with chest pain to the coronary care unit at Dudley Road Hospital, Birmingham, over the six month period April-September 1989 were included in the study. Ninety five patients were referred by their general practitioner and 107 patients attended the accident and emergency department directly or arrived by ambulance without contacting their general practitioner. The proportion of self referred and general practitioner referred patients with acute myocardial infarction, angina and non-cardiac chest pain were not significantly different. The total delay was significantly longer for patients who had been referred by their general practitioner (median 5.3 hours) than for self referrals (3.2 hours, P less than 0.001), with a significantly higher proportion of self referrals arriving at the coronary care unit within six hours of the onset of symptoms (77% versus 54%, P less than 0.01). Among general practitioner referrals, initial patient delay accounted for a median of 2.5 hours and the general practitioner's response time for a median of 1.1 hours. The delay in hospital was similar for both groups of patients. In inner city areas, self referral may result in considerably less delay than general practitioner referral allowing a greater proportion of patients to receive effective thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1371891  PMID: 1586549
3.  Delays by patients in seeking treatment for acute chest pain: implications for achieving earlier thrombolysis 
Postgraduate Medical Journal  1999;75(880):90-94.
A study was set up to identify why patients delay seeking medical assistance after myocardial infarction. The study was performed in 100 consecutive patients with suspected acute myocardial infarction admitted to either the University Hospital of Wales, Cardiff, UK, or the Royal Jubilee Hospital, Victoria, British Columbia, Canada (50 patients from each centre). The main outcome measure was the delay from the onset of symptoms to admission to hospital. The mean total delay before admission was 385 minutes (SEM 45). The mean delay incurred by the patient in seeking assistance was 172 minutes (SEM 27), representing 45% of the total. Delay was longer in patients with crescendo angina and shorter in those later confirmed to have myocardial infarction. Patients with prior ischaemic heart disease (74% of patients) presented later than those with no such history. No other demographic or clinical factors predicted early or late presentation.
Delays in seeking medical assistance after the onset of severe chest pain contribute significantly to total delays in patients' hospital admission and thrombolysis. The unexpected observation that patients with known ischaemic heart disease delay longer before seeking help in spite of their frequent contact with doctors, suggests that opportunities for educating patients are being wasted. Major efforts are needed to understand and modify behaviour of patients with chest pain to further reduce delays in treatment.

Keywords: chest pain; myocardial infarction; thrombolysis
PMCID: PMC1741128  PMID: 10448469
4.  Factors Associated With Pre-hospital Delay in Patients With Acute Myocardial Infarction 
Treatment of patients with acute myocardial infarction (AMI) is time related, so delay in treatment could affect prognosis. Recognizing pre-hospital or in-hospital delays in initiating treatment and reducing these factors is very efficacious in treatment of these patients.
The aim of this study is evaluate the causes of pre-hospital delay just as other studies on effect of different variables such as socioeconomic and personal factors on pre-hospital delay in with patients with AMI.
Materials and Methods
A cross sectional study was carried out on 227 patients with acute myocardial infarction and demographic data, educational level, marital status, type of transfer to hospital and delay in arrival to hospital were recorded.
35.7% patients arrived during one hour of symptom onset, and 7.9% arrived after 24 hours. Patients having high level education (P = 0.0492) and with a family history of coronary artery disease (P = 0.01) had significantly less delay in arriving to hospital. Age, marital status, gender, and route of transfer to hospital were not related with pre-hospital delay (P > 0.05). Patients thought most common cause of delay in arrival was unawareness of coronary artery disease (38.8%) and self-medication (34.3%).
Increasing awareness of patients about cardiovascular symptoms and their risk factors could be helpful in patient's decision in seeking medical help. So general education via media and primary and middle schools could be helpful.
PMCID: PMC3785905  PMID: 24083004
Myocardial Infarction; Pre-Hospital Delay; Education
5.  Delays in Seeking Medical Care in Hospitalized Patients with Decompensated Heart Failure 
The American journal of medicine  2008;121(3):212-218.
The magnitude of, and factors associated with, prolonged delay in seeking medical care in patients with acute myocardial infarction has been well described. It is unknown, however, what the extent of, and factors associated with, prehospital delay are in patients hospitalized with acute heart failure.
The purpose of this study was to examine patterns of prehospital delay, and factors associated with delay in seeking medical care, in patients hospitalized with acute heart failure at all 11 medical centers in the Worcester, MA, metropolitan area.
The medical records of 2,587 greater Worcester residents with decompensated heart failure who were hospitalized in 2000 were reviewed for the collection of information about prehospital delay and demographic and clinical factors associated with extent of delay.
Information about acute symptom onset and duration of delay in seeking medical care was available in only 44% of the hospital charts of patients with heart failure. The average delay time was 13.3 hours while the median was 2.0 hours. Male sex, multiple presenting symptoms, absence of a history of heart failure, and seeking medical care between midnight and 6 a.m. were associated with prolonged prehospital delay.
The results of this study in residents of a large New England metropolitan area suggest that patients hospitalized with acute heart failure exhibit considerable delays in seeking medical care. Several demographic and clinical characteristics were associated with prolonged delay. More research is needed to better understand the reasons why patients with this serious and increasingly prevalent clinical syndrome delay seeking medical care in a timely fashion.
PMCID: PMC2377456  PMID: 18328305
heart failure; care seeking behavior; prehospital delay
6.  Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time 
STUDY OBJECTIVE: To measure the pre-hospital delay times in patients with proven acute myocardial infarction (AMI) and to identify possibilities for reduction of treatment delay. DESIGN: Descriptive three centre study. SETTING: One university teaching hospital and two regional hospitals in Groningen, the Netherlands. PATIENTS: 400 consecutive confirmed AMI patients, age below 75 years, admitted to coronary care departments. MAIN RESULTS: Mean age was 59 years and 78% of patients were men. Within two hours after onset of symptoms half of the patients with AMI arrived at the hospital. Patient, doctor, and ambulance delay times (median values) were 30, 38, and 35 minutes respectively. Calling the personal general practitioner (GP) or the locum tenens and whether or not the AMI occurred during a weekend or on a working day had no consequences for pre-hospital delay times. At night patients waited longer before calling a GP than in the daytime. There was a positive correlation between patient and doctor delay. Twenty two per cent of AMI patients waited two hours or more before calling a GP. Total pre-hospital delay times differed between men and women. Longer doctor delay in women (36 minutes for men and 52 minutes for women) was caused by displacement of specific symptoms, in particular in women. AMI patients who were alone during onset of symptoms showed higher patients delay (72 compared with 23 minutes). CONCLUSION: In hospital admitted patients younger than 75 years pre- hospital delay times are within acceptable limits. In some subgroups further reduction is attainable, for example in patient delay outside office hours and when patients are alone during onset of symptoms, in doctor delay in cases where women present with symptoms suggestive for AMI. Improvement of facilities for pre-hospital electrocardiographic diagnosis may facilitate decision making by GPs. Good opportunities for further reduction of treatment delay exist in shortening of hospital delay.
PMCID: PMC1756944  PMID: 10562863
7.  Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction 
BMJ : British Medical Journal  2002;324(7349):1328-1331.
Delay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.
Audit of “door to needle times” for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.
Background and setting
The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.
Key measures for improvement
Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes
Strategies for change
In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a “coronary care thrombolysis nurse.” If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).
Effects of change
Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.
Lessons learnt
Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework's targets for door to needle times can be achieved.
PMCID: PMC1123280  PMID: 12039831
8.  Patients' interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction 
Heart  2000;83(4):388-393.
OBJECTIVE—To examine whether the association between expected symptoms of acute myocardial infarction and actual symptoms predicted delay in reaching hospital and help seeking behaviour.
DESIGN—During hospital convalescence, participants completed a structured interview designed to measure symptom experience and help seeking behaviour following the onset of symptoms of acute myocardial infarction.
PATIENTS—88 patients admitted to hospital with their first myocardial infarction
MAIN OUTCOME MEASURES—Delay in reaching hospital from onset of worst symptoms, obtained from ambulance and hospital records.
RESULTS—The most common symptoms expected by patients with myocardial infarction were central chest pain (76%), radiating arm or shoulder pain (34%), and collapse (26%). The most common symptoms experienced were sweats or feeling feverish (78%), chest pain (64%), and arm, shoulder, or radiating pain (66%). A mismatch between symptoms experienced and those expected occurred in 58% of patients, and was associated with delay. Patients who experienced a mismatch between expectation and actual symptoms also were more likely to have a third party decide to call for help.
CONCLUSIONS—The experience and interpretation of symptoms is an important source of delay and help seeking following onset of myocardial infarction symptoms.

Keywords: myocardial infarction; symptoms; delayed diagnosis
PMCID: PMC1729385  PMID: 10722534
9.  Magnitude of benefit from earlier thrombolytic treatment in acute myocardial infarction: new evidence from Grampian region early anistreplase trial (GREAT) 
BMJ : British Medical Journal  1996;312(7025):212-215.
OBJECTIVE--To generalise from the results of the Grampian region early anistreplase trial (GREAT) and to express the benefit of earlier thrombolysis in terms of lives saved per hour of earlier treatment. DESIGN--Multivariate analysis of a randomised double blind trial. SETTING--29 rural practices in Grampian region and teaching hospitals in Aberdeen. SUBJECTS--311 patients with suspected acute myocardial infarction and without contraindications to thrombolysis who were seen by their general practitioners within four hours of the start of symptoms. INTERVENTIONS--Anisterplase 30 units given intravenously, either by general practitioners before hospitalisation or later in hospital. MAIN OUTCOME MEASURE--Death within 30 months of entry into trial. RESULTS--Death within 30 months was positively related to age (P < 0.0001) and to delay between start of symptoms and thrombolytic treatment (P = 0.0004). However, the probability of dying rose exponentially with earlier presentation, so death within 30 months was negatively related to the logarithm of the time of randomisation (P = 0.0163). In patients presenting two hours after start of symptoms each hour's delay in receiving thrombolysis led to the loss of 21 lives per 1000 within 30 days (95% confidence interval 1 to 94 lives per 1000) (P = 0.03) and 69 lives per 1000 within 30 months (16 to 141 lives per 1000) (P = 0.0004). CONCLUSIONS--The magnitude of the benefit from earlier thrombolysis is such that giving thrombolytic treatment to patients with acute myocardial infarction should be accorded the same degree of urgency as the treatment of cardiac arrest.
PMCID: PMC2350007  PMID: 8563585
10.  The impact of personality factors on delay in seeking treatment of acute myocardial infarction 
Early hospital arrival and rapid intervention for acute myocardial infarction is essential for a successful outcome. Several studies have been unable to identify explanatory factors that slowed decision time. The present study examines whether personality, psychosocial factors, and coping strategies might explain differences in time delay from onset of symptoms of acute myocardial infarction to arrival at a hospital emergency room.
Questionnaires on coping strategies, personality dimensions, and depression were completed by 323 patients ages 26 to 70 who had suffered an acute myocardial infarction. Tests measuring stress adaptation were completed by 180 of them. The patients were then categorised into three groups, based on time from onset of symptoms until arrival at hospital, and compared using logistic regression analysis and general linear models.
No correlation could be established between personality factors (i.e., extraversion, neuroticism, openness, agreeableness, conscientiousness) or depressive symptoms and time between onset of symptoms and arrival at hospital. Nor was there any significant relationship between self-reported patient coping strategies and time delay.
We found no significant relationship between personality factors, coping strategies, or depression and time delays in seeking hospital after an acute myocardial infraction.
PMCID: PMC3123302  PMID: 21595967
11.  Reasons for patients' delay in response to symptoms of acute myocardial infarction. 
Survival in the acute phase of myocardial infarction and the subsequent prognosis are critically dependent on the time between onset of symptoms and medical intervention. Studies have shown that the time that patients take to decide to seek help accounts for most of the delay. We documented the length of time from onset of symptoms to arrival in hospital for 201 patients consecutively admitted to one of four hospitals in the Regional Municipality of Ottawa-Carleton between October 1986 and February 1987 for suspected acute myocardial infarction. Of the 160 survivors 42% waited more than 4 hours (a critical time for effective thrombolytic therapy) before coming to hospital, and nearly a third did not arrive within 6 hours. On the basis of interviews conducted with 42 patients, sociodemographic factors, education, past experience with an acute myocardial infarction, a previous diagnosis of angina and a coronary-prone behaviour pattern did not explain the delay. How patients perceived the seriousness of their symptoms and how they used other illness-related coping strategies explained 46% of the variance in the delay. Interventions aimed at reducing the delay between onset of symptoms and treatment must focus on patients' preadmission behaviour.
PMCID: PMC1268340  PMID: 3179890
12.  Effect of time from onset to coming under care on fatality of patients with acute myocardial infarction: effect of resuscitation and thrombolytic treatment 
Heart  1998;80(2):114-120.
Objective—To examine the relation between time from onset of symptoms and coming under ambulance and hospital care on fatality in patients with evolving acute myocardial infarction, and on the proportions who survive because of resuscitation and thrombolytic treatment.
Design—Prospective community and hospital study over two years. Delay was measured from the onset of symptoms to arrival at hospital, and from the onset to coming under care from ambulance personnel.
Setting—Four general hospitals serving three United Kingdom health districts.
Patients—2213 patients under 75 years of age, 111 of whom had been successfully resuscitated from out of hospital cardiac arrest.
Interventions—Resuscitation from cardiac arrest; thrombolytic treatment.
Main outcome measures—30 day fatality and lives saved by the two forms of treatment.
Results—Times from symptom onset to coming under hospital care and to starting thrombolytic treatment (given to 53% of patients) were ⩽ 1 hour in 15% and 2% of patients respectively, ⩽ 2 hours in 54% and 25%, and ⩽ 4 hours in 67% and 55%. Overall, 30 day fatality was 138/1000 patients treated; 64/1000 (95% confidence interval 54 to 74) survived because of treatment, and 80% of this salvage was attributable to resuscitation. Delay was an important factor: 107/1000 (60 to 144) lives were saved for those coming under care within 1 hour compared with 21/1000 (5 to 37) for those who delayed for more than 12 hours. Further analysis including the 111 patients with out of hospital arrest showed that 34% of those coming to hospital by ambulance came under ambulance care within 1 hour; for this subset, 30 day fatality was 173/1000, and 136 (109 to 163) lives were saved by treatment.
Conclusions—Results of treatment are strongly related to delay in coming under care. Reduction in delay can reduce mortality from acute myocardial infarction.

 Keywords: acute myocardial infarction;  fatality;  resuscitation;  thrombolytic treatment
PMCID: PMC1728777  PMID: 9813553
13.  Patient and general practitioner delays in acute myocardial infarction 
The longest component of the total delay in coming under coronary care is patient delay, and it has been suggested that public education might be used to make it shorter. The patterns of patient delay were studied in 450 patients with acute myocardial infarction uncomplicated by cardiac arrest out of hospital, of whom 243 had a previous history of ischaemic heart disease. Patient delays had a skewed distribution with a modal delay of up to one hour, a median delay of two hours, and a mean delay of 10 hours. Two thirds of patients had sought help from their general practitioners within four hours of the onset of symptoms. During the first four hours the longer that patients delayed the lower was the subsequent mortality (27%, 18%, and 9% for delays of one hour or less, up to two hours, and up to four hours, respectively), but patients who delayed four to eight hours had the highest mortality of all (38%). Neither the median value nor the pattern of patient delays was altered by a previous history of ischaemic heart disease.
There were pronounced differences in doctor delays, depending on the patient's age, delay time, and ultimate place of treatment, showing that the doctors' behaviour was influenced before they had seen their patients. Nevertheless, the median total delay for patients aged up to 70 was one hour 35 minutes, and a higher proportion of patients were seen early after infarction than in recent hospital trials of thrombolytic treatment.
These findings suggest that the patients' call for help and the doctors' response may be at an instinctive level according to the patients' distress; these patterns of behaviour may be difficult to modify by public education.
PMCID: PMC2546282  PMID: 3129059
14.  Factor analysis of self-treatment in diabetes mellitus: a cross-sectional study 
BMC Public Health  2011;11:761.
Self-treatment is a treatment of oneself without professional help, which may cause health-related consequences. This investigation examined the self-treatment behaviors in patients with diabetes mellitus in Iran/kashan.
The patients who referred to the clinic of diabetes and those who were admitted to the General hospital in the city of Kashan due to diabetes mellitus were asked to participate in this cross-sectional study. For data collection, The 25 item questionnaire of Likert scale type with four scales was used. Factor analysis was performed to define the patterns of self-treatment.
398 patients participated in the study. The mean age of the study population was 54.9 ± 12.9 years. The majority (97%) had type 2 diabetes. 50% of patients reported self- treatment. The self-treatment score was 45.8 ± 8.8 (25-100). Female gender, lower education and co-morbid illnesses of hypertension, hyperlipidemia and cardiac disease had significant relationship with self-treatment. The factor analysis procedure revealed seven factors that explained the 43% of variation in the self-treatment. These seven factors were categorized as knowledge, deficiencies of formal treatments, available self-treatment methods, physician related factors, the tendency to use herbal remedies, underlying factors such as gender and factors related to diabetes.
There is a medium tendency for self-treatment in diabetic patients. The assessment of self-treatment practices must be an essential part of patients' management in diabetes care.
PMCID: PMC3205063  PMID: 21970577
Diabetes Mellitus; Self-Treatment; Factor analysis
15.  Improving door to needle times with nurse initiated thrombolysis 
Heart  2000;84(3):262-266.
OBJECTIVE—To evaluate the effect of nurse initiated thrombolysis on door to needle time (the interval between arriving at the hospital and starting thrombolytic treatment) in patients with acute myocardial infarction.
DESIGN—Comparison of door to needle times before and after the employment of nurses trained and approved to initiate thrombolysis without prescription by a doctor but with a protocol for rapid triage of patients with chest pain.
SETTING—A district general hospital.
SUBJECTS—All patients admitted with suspected myocardial infarction between April 1995 and March 1999.
MAIN OUTCOME MEASURES—Speed (door to needle time) and appropriateness of administration of thrombolytic drugs to patients with acute myocardial infarction who gave a characteristic history and had appropriate criteria on the admission ECG.
RESULTS—During seven periods (each of four months) before the introduction of nurse initiated thrombolysis and a new chest pain triage protocol, the median door to needle time varied from 50-58 minutes. In four periods (each of 4-6 months) following the introduction of the changes, the median door to needle time was 25-30 minutes. The improvement was significant (p < 0.001). Nurses trained to initiate thrombolysis currently provide cover for 66% of the time. Median door to needle time for nurses was 15 minutes. Median door to needle time for junior doctors improved to 35 minutes. The median door to needle times when nurses initiated thrombolysis was significantly shorter than when doctors did so (p < 0.001). There have been no inappropriate management decisions by nurses approved to initiate thrombolysis.
CONCLUSIONS—The use of nurse initiated thrombolysis has resulted in a clinically important reduction in the time taken for thrombolysis to be started in patients with acute myocardial infarction.

Keywords: thrombolysis; acute myocardial infarction; door to needle time
PMCID: PMC1760948  PMID: 10956286
16.  Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics 
BMJ : British Medical Journal  2003;327(7405):22-26.
Objectives To evaluate a system of prehospital thrombolysis, delivered by paramedics, in meeting the national service framework's targets for the management of acute myocardial infarction.
Design Prospective observational cohort study comparing patients with suspected acute myocardial infarction considered for thrombolysis in the prehospital environment with patients treated in hospital.
Setting The catchment area of a large teaching hospital, including urban and rural areas.
Participants 201 patients presenting concurrently over a 12 month period who had changes to the electrocardiogram that were diagnostic of acute myocardial infarction or who received thrombolysis for suspected acute myocardial infarction.
Main outcome measures Time from first medical contact to initiation of thrombolysis (call to needle time), number of patients given thrombolysis appropriately, and all cause mortality in hospital.
Results The median call to needle time for patients treated before arriving in hospital (n=28) was 52 (95% confidence interval 41 to 62) minutes. Patients from similar rural areas who were treated in hospital (n=43) had a median time of 125 (104 to 140) minutes. This represents a median time saved of 73 minutes (P < 0.001). Sixty minutes after medical contact 64% of patients (18/28) treated before arrival in hospital had received thrombolysis; this compares with 4% of patients (2/43) in a cohort from similar areas. Median call to needle time for patients from urban areas (n=107) was 80 (78 to 93) minutes. Myocardial infarction was confirmed in 89% of patients (25/28) who had received prehospital thrombolysis; this compares with 92% (138/150) in the two groups of patients receiving thrombolysis in hospital.
Conclusions Thrombolysis delivered by paramedics with support from the base hospital can meet the national targets for early thrombolysis. The system has been shown to work well and can be introduced without delay.
PMCID: PMC164234  PMID: 12842951
17.  Role of the general practitioner in managing patients with myocardial infarction: impact of thrombolytic treatment. Report of a British Heart Foundation Working Group. 
BMJ : British Medical Journal  1989;299(6698):555-557.
Thrombolytic treatment, combined with aspirin, has been shown to reduce mortality by half in patients in hospital with suspected acute myocardial infarction if it is given early after the onset of symptoms. This fact adds to the importance of prompt and skillful intervention. At present in the United Kingdom the median time for receiving suitable management for this condition is about four to six hours. With better organisation this delay could, in most areas, be reduced to two or three hours. A major change in the care of patients with myocardial infarction is needed in which the general practitioner should have a crucial role. Health authorities, hospital physicians, general practitioners, and the ambulance services must coordinate their efforts if the potential reduction in mortality is to be realised. The district medical officer should consult colleagues and draw up guidelines for organising the care of patients who have had heart attacks. The management of patients who have had heart attacks in the community and in hospital should be continually audited. There are dangers inherent in the use of thrombolytic treatment, particularly when conditions other than myocardial infarction are treated in error. This treatment should be given only when the diagnosis is highly probable and when close observation of the patient can be ensured during the ensuing hours. Thrombolytic treatment should not, therefore, be given out of hospital except when trained, equipped personnel are in attendance. Treatment can be given in any hospital (including community hospitals) provided there are adequate diagnostic facilities and suitably experienced nursing staff.
PMCID: PMC1837394  PMID: 2507069
18.  Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham heart attack register. 
BMJ : British Medical Journal  1997;315(7101):159-164.
OBJECTIVE: To assess longitudinal trends in admissions, management, and inpatient mortality from acute myocardial infarction over 10 years. DESIGN: Retrospective analysis based on the Nottingham heart attack register. SETTING: Two district general hospitals serving a defined urban and rural population. SUBJECTS: All patients admitted with a confirmed acute myocardial infarction during 1982-4 and 1989-92 (excluding 1991, when data were not collected). MAIN OUTCOME MEASURES: Numbers of patients, background characteristics, time from onset of symptoms to admission, ward of admission, treatment, and inpatient mortality. RESULTS: Admissions with acute myocardial infarction increased from 719 cases in 1982 to 960 in 1992. The mean age increased from 62.1 years to 66.6 years (P < 0.001), the duration of stay fell from 8.7 days to 7.2 days (P < 0.001), and the proportion of patients aged 75 years and over admitted to a coronary care unit increased significantly from 29.1% to 61.2%. A higher proportion of patients were admitted to hospital within 6 hours of onset of their symptoms in 1989-92 than in 1982-4, but 15% were still admitted after the time window for thrombolysis. Use of beta blockers increased threefold between 1982 and 1992, aspirin was used in over 70% of patients after 1989, and thrombolytic use increased 1.3-fold between 1989 and 1992. Age and sex adjusted odds ratios for inpatient mortality remained unchanged over the study period. CONCLUSIONS: Despite an increasing uptake of the "proved" treatments, inpatient mortality from myocardial infarction did not change between 1982 and 1992.
PMCID: PMC2127135  PMID: 9251546
19.  Effect of "fast track" admission for acute myocardial infarction on delay to thrombolysis. 
BMJ : British Medical Journal  1992;304(6819):83-87.
OBJECTIVE--To evaluate the impact of a fast track triage system for patients with acute myocardial infarction. DESIGN--Comparison of delays in admission to hospital and in receiving thrombolytic treatment before and after introducing fast track system with delays recorded in 1987-8. Patients fulfilling clinical and electrocardiographic criteria for myocardial infarction were selected for rapid access to the cardiac care team, bypassing evaluation by the medical registrar. SETTING--Major accident and emergency, cardiac and trauma centre. SUBJECTS--359 patients admitted to the cardiac care unit during 1 February to 31 July 1990 with suspected acute infarction. MAIN OUTCOME MEASURES--Accuracy of diagnosis and delay from arrival at hospital to thrombolytic treatment. RESULTS--248 of the 359 patients had myocardial infarction confirmed, of whom 127 received thrombolytic treatment. The fast track system correctly identified 79 out of 127 (62%) patients who subsequently required thrombolytic treatment. 95% (79/83) of patients treated with thrombolysis after fast track admission had the diagnosis confirmed by electrocardiography and enzyme analysis. The median delay from hospital admission to thrombolytic treatment fell from 93 minutes in 1987-8 to 49 minutes in fast track patients (p less than 0.001). Delay in admission to the cardiac care unit was reduced by 47% for fast tract patients (median 60 minutes in 1987-8 v 32 minutes in 1990, p less than 0.001) and by 25% for all patients (60 minutes v 45 minutes, p less than 0.001). CONCLUSION--This fast track system requires no additional staff or equipment, and it halves inhospital delay to thrombolytic treatment without affecting the accuracy of diagnosis among patients requiring thrombolysis.
PMCID: PMC1880988  PMID: 1737145
20.  Loss of quality adjusted days as a trial endpoint: effect of early thrombolytic treatment in suspected myocardial infarction. Grampion Region Early Anistreplase Trial (GREAT). 
STUDY OBJECTIVES--(1) To measure the quality of life and the loss of quality adjusted days (QADS) after suspected acute myocardial infarction in patients who received thrombolytic treatment either at home or in hospital. (2) To compare the loss of QADS as a trial endpoint with the conventional endpoints of mortality and Q-wave infarction. DESIGN--Randomised double blind parallel group trial of anistreplase (30 U given intravenously) and placebo given either at home or in hospital. SETTING--Rural practices in Grampian admitting patients to teaching hospitals in Aberdeen. PATIENTS--A total of 311 patients with suspected acute myocardial infarction and no contraindications to thrombolytic treatment seen at home within four hours of the onset of symptoms. MEASUREMENTS AND MAIN RESULTS--Loss of quality adjusted days (QADS) in the first 100 days after suspected myocardial infarction (365 QADS = 1 QALY) was the main outcome measure. Compared with later administration in hospital, anistreplase at home resulted in a relative reduction of mortality of 49% (95% confidence interval 3.95%, 2p = 0.04), and a relative reduction of 26% in the proportion of survivors with infarction who had Q-waves (95% CI 7.44%, 2p = 0.007). During the 100 day follow up, the median loss of QADS was 25 for all patients. This loss was significantly greater in those who died than in survivors (65 v 18, 2p < 0.001), and in survivors with infarction than in survivors without infarction (26 v 13, 2p < 0.01). However, there was no significant difference in loss of QADS in those with infarction with or without Q-waves (29 v 21, NS), and the median loss of QADS was not significantly different in those who had thrombolytic treatment at home or in hospital (median difference 0, 95% CI -5, +4 QADS). CONCLUSIONS--Loss of QADS had two serious limitations as an outcome measure: it was less sensitive than mortality and it failed to reflect physiological benefit. Palliative treatment with no physiological effect would have resulted in a greater gain in QADS (or QALYs) than did early thrombolytic treatment. Extreme caution is required in accepting a gain in QALYs as a valid outcome measure for health care.
PMCID: PMC1059832  PMID: 8289038
21.  In-hospital case fatality rates for acute myocardial infarction in Romania 
We describe the clinical characteristics, treatments and in-hospital case-fatality rates in an unselected population of patients admitted for acute myocardial infarction.
From January 2000 to June 2007, we tracked consecutive patients who were admitted to 7 tertiary referral and 21 county hospitals in Romania for medical treatment of ST-segment elevation acute myocardial infarction. These patients were enrolled in the Romanian Registry for ST-segment Elevation Myocardial Infarction. For this prospective study, we collected data on demographic characteristics, cardiovascular risk factors, various aspects of treatment for myocardial infarction, and in-hospital death.
The 9186 patients in the study group had a mean age of 63.8 years. The median time from onset of symptoms to thrombolysis was 230 (interquartile range 120–510) minutes. Of the 9186 patients, 4986 (54.3%) had hypertension, 1974 (21.5%) had diabetes mellitus, 3545 (38.6%) had lipid disorders and 4653 (50.7%) were smokers. The in-hospital mortality rate was 12.7% (1170 deaths). The study group consisted of 2893 women and 6293 men. The women were older than the men and had higher rates of hypertension and diabetes mellitus but were less likely to be smokers. A smaller proportion of women than men presented within 2 hours after onset of symptoms (23.1% v. 34.4%, p < 0.001). Smaller proportions of women received thrombolytics (40.8% v. 53.5%, p < 0.001), anticoagulants (93.4% v. 95.2%; p = 0.001), antiplatelet agents (88.3% v. 91.2%, p < 0.001) and primary percutaneous coronary interventions (1.5% v. 2.2%, p = 0.030). The risk of in-hospital death was greater for women, even after adjustment for confounders (odds ratio 1.33, 95% confidence interval 1.13–1.56; p < 0.001).
The rates of reperfusion therapy for patients with acute myocardial infarction were low, and in-hospital case-fatality rates were high in this study. Excess in-hospital mortality was more pronounced among women.
PMCID: PMC2691436  PMID: 19506280
22.  Alexithymia Affects Pre-Hospital Delay of Patients with Acute Myocardial Infarction: Meta-Analysis of Existing Studies 
The time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with acute myocardial infarction (AMI). Any delay in seeking help will affect patient’s outcome. Alexithymia can influence the information processing but also the skills to detect the signal of an ongoing AMI.
Systematic review and meta-analysis of studies investigating the role of alexithymia in pre-hospital delay after AMI. Pubmed/Medline and PsychINFO/Ovid search from 1990 until 2012.
Out of 29 studies investigating the role of psychological factors in pre-hospital delay after AMI, 3 studies specifically assessed alexithymia, involving 258 patients. All studies used the Toronto Alexithymia Scale to group patients into clusters by time to presentation after AMI. Meta-analysis of data showed that the patients with higher emotional awareness (i.e., low alexithymia) had shorter time to presentation after AMI.
Preliminary evidence indicates that alexithymia may have a role in seeking help delay after AMI. Further studies are necessary to better appreciate how alexithymia influence help-seeking in patients with an evolving AMI and in what extent their ineffective behavior can be changed.
PMCID: PMC3715755  PMID: 23878612
Pre-hospital delay; acute myocardial infarction; alexithymia; psychological factors; care seeking behavior.
23.  Age and Sex Differences, and Twenty Year Trends (1986–2005), in Pre-Hospital Delay in Patients Hospitalized With Acute Myocardial Infarction 
The prompt administration of coronary reperfusion therapy for patients with an evolving acute myocardial infarction (AMI) is crucial in reducing mortality and the risk of serious clinical complications in these patients. However, long-term trends in extent of pre-hospital delay, and factors affecting patient’s care seeking behavior, remain relatively unexplored, especially in men and women of different ages. The objectives of this study were to examine the overall magnitude, and 20 year trends (1986–2005), in duration of pre-hospital delay in middle-aged and elderly men and women hospitalized with AMI.
Methods and Results
The study sample consisted of 5, 967 residents of the Worcester, MA, metropolitan area hospitalized at all greater Worcester medical centers for AMI between 1986 and 2005 who had information available about duration of pre-hospital delay.
Compared with men <65 years, patients in other age-sex strata exhibited longer pre-hospital delays over the 20-year period under study. The multivariable adjusted medians of pre-hospital delay were 1.96, 2.07, and 2.57 hours for men <65 years, men 65 –74 years, and men ≥75 years, and 2.08, 2.33, and 2.27 hours for women <65 years, women 65–74 years, and women ≥75 years, respectively. These age and sex differences have narrowed over time which has been largely explained by changes in patient’s comorbidity profile and AMI associated characteristics.
Our results suggest that duration of pre-hospital delay in persons with symptoms of AMI has remained essentially unchanged during the 20 year period under study and elderly individuals are more likely to delay seeking timely medical care than younger persons.
PMCID: PMC3072274  PMID: 20959564
Pre-hospital Delay; Acute Myocardial Infarction; Age and Sex differences
24.  Temporal trends in revascularization and outcomes after acute myocardial infarction among the very elderly 
Few data are available on time-related changes in use and outcomes of invasive procedures after acute myocardial infarction in very elderly patients. Our objective was to describe trends in revascularization procedures and outcomes in a provincial cohort of very elderly patients who had experienced acute myocardial infarction.
We used a database of hospital discharge summaries to identify all patients aged 80 years or older admitted for acute myocardial infarction in Quebec. We used the provincial database of physicians’ services and medication claims to assess treatment and obtain data on survival.
Between March 1996 and March 2007, 29 750 patients aged 80 years or older were admitted to hospital for acute myocardial infarction. During this period, use of percutaneous coronary interventions increased from 2.2% to 24.9%, and use of coronary artery bypass graft surgery increased from 0.8% to 3.1%. Evidence-based prescriptions of medication increased over time (p < 0.001). The prevalence of reported comorbidities was higher during the period of 2003–2006 than during the 1996–1999 period. One-year mortality improved over time (46.5% for 1996–1999 v. 40.9% for 2003–2006, p < 0.001) but remained unchanged in the subgroup of patients who did not undergo revascularization.
The use of revascularization, especially percutaneous coronary interventions, in the very elderly after acute myocardial infarction has been growing at a rapid pace, while the prevalence of reported comorbidities has been increasing in this population. Revascularization procedures are no longer restricted to younger patients. In the context of an aging population, it is imperative to determine whether these changes in practice are cost-effective.
PMCID: PMC2942913  PMID: 20682731
25.  Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients. 
Prehospital delay is an important cause of out-of-hospital coronary mortality. To determine the effects of decision time delay in a patient population comprised mainly of blacks and the underprivileged, 74 consecutive patients with acute chest pain necessitating admission to the coronary care unit in a large urban hospital were studied. Delay time from onset of chest pain to the decision to seek medical care was markedly prolonged in patients with myocardial infarction (n = 24; mean time: 11.3 +/- 18 hours) as well as in patients with chest pain who did not develop myocardial infarction (n = 50; mean time: 20.5 +/- 26 hours). In addition, transfer time from the emergency room to the coronary care unit was likewise unduly long (mean time: 4 +/- 3.8 and 4.1 +/- 6 hours for patients with and without myocardial infarction, respectively). This study documents a significant delay in the decision time among patients with low socioeconomic status, mostly inner-city blacks, and in the transfer time from emergency room to the critical care unit in a large public hospital. These findings must be taken into consideration when planning strategies to improve the health-care delivery system to blacks and the underprivileged and further lend support to the practice of initiating thrombolytic therapy in the emergency room.
PMCID: PMC2571891  PMID: 8474130

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