AHA 2008: Studies assess decisions to seek care among patients with chest pain

New Orleans-Early reperfusion is crucial to maintaining cardiac myocytes in patients suffering a heart attack yet many patients refuse to seek medical care until hours after symptom onset, if at all.

Two studies presented here assessed the reasons people with symptoms delay seekingcare and the types of patients most likely to respond to an intervention designedto encourage early transport to the emergency department (ED).

As part of a larger study of 274 patients with witnessed cardiac arrest, AnneRosenfeld, PhD, RN, interviewed witnesses of 99 patients with known symptoms beforesudden cardiac death, 19 of whom refused care. The suggestion to seek care camefrom someone other than the victim in 18 of the 19 cases, and usually includedmultiple attempts, she says. Fifteen of the patients had “persistent refusal”of 15 minutes to as long as 6 hours until collapse.

The reasons the witnesses gave for the victim refusing to seek care were the victim’sbelief that the symptoms were due to something else (n = 10), other obligations(n = 3), an expressed dislike of hospitals and doctors (n = 4), and recent reassuranceof their health status (n = 2).

“Patient with chest pain and no history of heart disease are more likelyto refuse advice to seek medical care,” says Dr. Rosenfeld, professor, Schoolof Nursing, Oregon Health and Science University, Portland. Those with chest painwere more than three times likely to seek care than those with an atypical symptomand those with a history of heart disease were 90 percent less likely to seekcare those with no such history.

Public health strategies need to be expanded to reach those patients who delayseeking care, believes Dr. Rosenfeld. The same messages don’t work for everybody,”she says.

Another study examined the reasons that patients with a diagnosis of coronaryheart disease (CHD) sought care when having cardiac symptoms. In the study, 1,777patients with CHD underwent an educational intervention designed to reduce treatment-seekingdelay, and 265 of them were admitted to an ED at least once for a suspected acutecoronary syndrome (ACS). Their mean age was 66.4 years, 91.2 percent were Caucasian,and 80.5 percent were under the care of a cardiologist.

Among 14 hypothesized predictors of time to first ED admission, three were foundto predict a shorter delay time:

• Positive beliefs about the need to seek care for symptoms, as reflected by a lower score on the ACS Beliefs scale (eg, “I would be embarrassed to go to the hospital if I thought I was having a heart attack but I wasn’t”)

• A low level of perceived control

• No history of angina

“We need to test an intervention that is focused on positively influencing ACS beliefs and perceived control,” says Barbara Riegel, DNSc, RN, lead investigator of the study and professor of nursing, University of Pennsylvania School of Nursing, Philadelphia.