Prehospital Delay,Contributing Aspects and Responses to Symptoms among Norwegian Women and Men with First Time Acute Myocardial Infarction

Abstract

Background: In patients with acute myocardial infarction (AMI), the delay between the onset of symptoms and hospital admission is a critical factor in reducing morbidity and mortality.

Aims: To assess gender differences in prehospital delay among women and men with first time AMI, generate more knowledge about aspects influencing this delay and investigate responses to acute symptoms.

Methods and result: Of 738 eligible patients, 149 women and 384 men responded to a questionnaire (72%). Over half of both women and men waited over one hour before they called for medical assistance and more than half the patients had a total prehospital delay exceeding two hours. Rapid development of symptoms and symptoms matching expectations reduced, self medication and consulting the spouse increased patient delay in both genders. Calling the Emergency Medical Service (EMS) reduced and calling a general practitioner increased total prehospital delay in both genders.

ST-elevation: (STEMI), symptoms experienced as unbearable and attributed as cardiac reduced patient delay, and symptoms from the back, shoulders or between scapulae increased prehospital delay, only in men.

Conclusion: How patients responded to symptoms had vital impact on prehospital delay among both genders, but the experience and interpretation of symptoms had more influence in men than in women.

Keywords

Acute myocardial infarction Prehospital delay Gender (sex) differences

1 Introduction

The efficacy of thrombolysis and percutaneous coronary intervention (PCI) in reducing morbidity and mortality in acute myocardial infarction (AMI) is well documented [1–4]. For maximal benefit of this treatment, patients must recognize cardiac symptoms and seek prompt medical assistance. According to international guidelines, the patients' decision time should not exceed 45 min and reperfusion therapy should be performed within 90 min after the onset of symptoms [5]. The period between the onset of symptoms to the decision to call for medical assistance, patient delay, remains by far the most significant cause of total prehospital delay [6–8]. Reported median prehospital delay time from symptom onset to hospital arrival ranges from 1.6 to 4 h and more in Western countries [6–19].

There are conflicting data whether there are gender differences in prehospital delay, as well as whether there are gender differences in the associated factors. Suggestions include the possibility that older age, self medication, a mismatch between symptoms experienced and those expected, consulting a family member and calling a non-Emergency Medical System (EMS) contribute to increased prehospital delay [10,14,15,17,20–24].

Interventions to reduce prehospital delay have not been particularly successful [18], and a new approach in public health campaigns has been suggested [19,25]. The process from symptom onset until hospital admission is complex, and how patients make sense of their symptoms and determine whether they need urgent help, are aspects that need to be more investigated in greater detail.

The aim of the study was to assess gender differences in prehospital delay among Norwegian women and men with first time acute myocardial infarction (AMI), their responses to acute symptoms, and the aspects influencing their decision to seek medical assistance.

2 Methods

Patients under 76 years admitted to the coronary care unit with their first AMI, with ST-elevation (STEMI) and non ST-elevation (NSTEMI), between February 2003 and March 2004 were invited to participate, and questionnaires were sent by mail within two weeks after hospital discharge. The diagnoses of patients with first time AMI was based on serum cardiac troponin beyond cut off, electrocardiogram changes with ST-segment elevation, ST-segment depression or T wave abnormalities, and a history of clinically appropriate symptoms.

The patients were consecutively recruited from the coronary care units in five Norwegian hospitals, two University hospitals with 900–1200 beds and three district hospitals with 200–400 beds, with emergency medical function for the surrounding urban and rural areas. Patients being hospitalized, or staying in another health institution at symptom onset, were not invited.

The questionnaire was sent to 777 patients. Of them 39 patients were excluded due to information in the questionnaire, the medical records, information from relatives and the National Death Register. This exclusion was due to incorrect diagnosis (twenty patients), coincident serious mental health problems (four patients), age over 75 years (five patients) and death (ten patients).

The questionnaire was developed by the researcher, and the validation of the questions was based upon a previous qualitative study [26], a quantitative study [27], a pilot study on twenty AMI patients in 2002 and research published on the topic.

The questionnaire included 48 items, with patient characteristics, medical history, experiences and responses to acute symptoms prior to hospitalization and prehospital delay. Acute symptoms were classified as early when experienced initially; the first occurring symptoms, and late when experienced after the onset of other initial symptoms. This question had multiple-choice alternatives. Chest symptoms were described as pain, discomfort, pressure and tightness, several classifications permitted. Musculoskeletal symptoms were defined as pain between the scapulae, or in the back or shoulders. The incentive for this definition was that such symptoms are often associated with musculoskeletal problems. Typical symptoms were defined as experiencing chest symptoms without symptoms from back, shoulders or between scapulae. They also graded the intensity (unbearable, moderate or strong) and symptom progress, whether or not the symptoms corresponded with expectations on a cardiac origin, and finally stated whether they attributed their acute symptoms to the heart, abdomen, musculoskeletal system, flu or stress, one or more alternatives permitted. Time and day at symptom onset, place of residence and activity at symptom onset was also included. Prehospital delay comprised two questions: time from symptom onset to call for medical assistance (patient delay) and time from symptom onset to hospital arrival (total prehospital delay). Patient delay was classified into 13 categories, from under ½ h to over 24 h. Prehospital delay was classified into 14 categories, from under one hour to over 24 h, to obtain more detailed information on prolonged delay. Responses to acute symptoms included self medication with pain killers, tranquilizers or nitroglycerin. Consulting other lay persons before calling for medical assistance included spouse, other members of the family and friends/colleagues. Arrangement for medical assistance included general practitioner, Emergency medical system (EMS) and own transportation to the hospital. Some of the patients had used more than one alternative, and in the regression analysis patients using exclusively one method were analyzed. Positive family history was defined as having siblings or parents who had suffered an AMI before 60 years of age. Hypercholesterolemia, hypertension and diabetes were defined as being diagnosed by a physician and medically treated for these conditions, based upon information in the questionnaire. Distance to hospital was classified into six categories between under 10 km and over 50 km. A folder with information about the study was given to the patients while in hospital. Patients not responding to the invitation received a reminder letter. Patients who agreed to participate were asked to give their written consent about the participation and permission to obtain information from their medical records. They were requested to call the principal researcher if items in the questionnaire were difficult to understand. The calculation of sample size was based on data from a previous study on prehospital delay [27] with power 0.80, mean 3.0 vs. 3.5 h and standard deviation 1.7. The sample size required was 448 patients.

The rationale behind the analysis of the data was that symptoms associated with musculoskeletal symptoms, symptom appraisals, expectations and attributions of symptoms and self care interventions influenced patient delay, and that chest symptoms and methods for calling for medical assistance influenced further in the delay process. As we hypothesize that symptoms associated with the musculoskeletal system might have an impact on both the patients' decision process and health professionals' interpretation of symptoms, we analyzed this aspect according to both patient delay and prehospital delay.

The investigation conforms with the principles outlined in the Declaration of Helsinki and was approved by the Regional Ethics Committee for Medical Research in Norway.

2.1 Data analyses

The analyses were conducted with SPSS for Windows version 11.5 (SPSS Inc. Chicago, Illinois). Twin-tailed chi square tests were used to compare patient characteristics among women and men. Logistic regression adjusted for age (classified into four categories), education and employment was used to analyze aspects contributing to patient delay and also adjusted for distance to hospital (classified into four categories) regarding total prehospital delay. The rationale for these adjustments (the three first variables) was to avoid bias, due to gender differences in these characteristics. Variables included in the regression analysis were those who were statistically significant in the univariate tests. Musculoskeletal symptoms were also analyzed in a model in which symptoms from chest and left arm, dyspnoea and nausea, were additionally included. Power analysis was included for some of the variables (unadjusted) associated with delay. Continuous variables are presented as mean (SD). P-values < 0.05 or 95% CI that excluded the null value were considered statistically significant.

3 Results

3.1 Characteristics of study objects

Of 738 eligible patients 533 (149 women and 384 men, 67% vs. 74%) responded. Mean age was 61.2 (9.8) years for the women and 58.5 (9.5) years for the men. Mean age for non-responders was 59.0 (10.4) years. Non-responders did not differ significantly to responders regarding gender. Hypertension and hypercholesterolemia were significantly more frequent in women than in men. There were no gender differences as to prescribed Nitroglycerin, previously diagnosed angina and positive family history (Table 1). Information about infarct location and STEMI has been previously reported [28]. Among the patients on social security, 96% of the women and 93% of the men were retired or had health related pension.

Table 1
Patient characteristics, medical history and gender differences among Norwegian women and men with first time AMI

Women n = 149(%) Men n = 384(%) p

Age: (years)

≤ 45 9(6) 44(11) 0.061

46–55 33(22) 108(28) 0.160

56–65 48(32) 150(39) 0.142

66–75 59(40) 82(21) <0.01

Education

≤ 10 years 89(60) 127(33) <0.01

11–13 36(24) 148(39) <0.01

≥ 14 13(9) 102(27) <0.01

Employment

Full time 29(19) 229(60) <0.01

Part time 20(13) 23(6) <0.01

On social security 96(64) 140(36) <0.01

Marital status 0.04

Married/cohabitant 97(65) 304(79)

Single 52(35) 80(21)

Living alone 39(26) 70(18) 0.04

Medical history

Hypertension 57(38) 113(30) 0.046

Hypercholesterolemia 39(26) 57(15) <0.01

Diabetes 12(8) 27(7) 0.684

Prescribed Nitroglycerin 19(13) 43(11) 0.616

Previously diagnosed angina 20(13) 50(13) 0.902

Positive family history 55(37) 133(35) 0.621

Infarct location

Anterior 50(34) 119(31) 0.598

Posterior 46(31) 152(40) 0.055

Other 52(35) 108(28) 0.136

STEMI^∗ 75(55) 216(62) 0.162

NSTEMI ^∗ 61(45) 132(38) 0.162

	Women n = 149(%)	Men n = 384(%)	p
Age: (years)
≤ 45	9(6)	44(11)	0.061
46–55	33(22)	108(28)	0.160
56–65	48(32)	150(39)	0.142
66–75	59(40)	82(21)	<0.01
Education
≤ 10 years	89(60)	127(33)	<0.01
11–13	36(24)	148(39)	<0.01
≥ 14	13(9)	102(27)	<0.01
Employment
Full time	29(19)	229(60)	<0.01
Part time	20(13)	23(6)	<0.01
On social security	96(64)	140(36)	<0.01
Marital status			0.04
Married/cohabitant	97(65)	304(79)
Single	52(35)	80(21)
Living alone	39(26)	70(18)	0.04
Medical history
Hypertension	57(38)	113(30)	0.046
Hypercholesterolemia	39(26)	57(15)	<0.01
Diabetes	12(8)	27(7)	0.684
Prescribed Nitroglycerin	19(13)	43(11)	0.616
Previously diagnosed angina	20(13)	50(13)	0.902
Positive family history	55(37)	133(35)	0.621
Infarct location
Anterior	50(34)	119(31)	0.598
Posterior	46(31)	152(40)	0.055
Other	52(35)	108(28)	0.136
STEMI^∗	75(55)	216(62)	0.162
NSTEMI ^∗	61(45)	132(38)	0.162

^∗ n = 136 vs. 348.

3.2 Patients' responses to acute symptoms

Self medication was reported among 33% of the women and 25% of the men (p = 0.066): the use of pain killer in 19% vs. 14% (p = 0.2), nitroglycerin in 15% vs. 12% (p = 0.34) and tranquilizers in 1% vs. 2% (p = 0.57). Other self-care interventions were sitting down (54% vs. 65%, p = 0.045) and lying down (43% vs. 46%, p = 0.5).

Consulting a lay person before calling for medical assistance was reported by 84% of all the patients; the spouse in 52% of the women and 66% of the men (p = 0.012), other family members in 33% vs. 19% (p < 0.01) and friends/colleagues in 19% vs. 22% (p = 0.4).

3.3 Calling for medical assistance

More than half of both women and men called exclusively a GP (53% vs. 52%, p = 0.81), while 26% vs. 30% called the EMS (p = 0.388) and 7% vs. 8% (p = 0.597) went to the hospital by own transportation. Some of the patients used more than one alternative, 9% of the women and 8% of the men called both EMS and GP and 5% vs. 2% called a GP before they went to the hospital by own transportation. Age had no significant influence on how the patients arranged for medical assistance.

3.4 Patient delay and total prehospital delay

More than half the patients waited more than an hour before they called for medical assistance, and more than half the patients had a total prehospital delay exceeding two hours. More women than men had a patient delay between 2 and 6 h (Table 2). A very short patient delay (< ½ h) was reported among 23% of the women and 28% of the men (p = 0.271) and a very long patient delay (> 24 h) was reported among 11% vs. 10% (p = 0.84). Age had no significant impact on delay.

Table 2
Patient delay, total prehospital delay and gender differences among women and men with first time myocardial infarction

Patient delay Total prehospital delay

Women Men p Women Men p

n = 140(%) n = 376(%) n = 142(%) n = 374(%)

≤ 1 h 62(44) 178(47) 0.536 29(20) 86(23) 0.531

1–2 h 16(11) 49(13) 0.626 39(27) 97(26) 0.725

2–6 h 32(23) 52(14) 0.014 42(30) 94(25) 0.306

> 6 h 30(21) 97(26) 0.306 32(22) 97(26) 0.426

	Patient delay	Total prehospital delay
≤ 1 h	62(44)	178(47)	0.536	29(20)	86(23)	0.531
1–2 h	16(11)	49(13)	0.626	39(27)	97(26)	0.725
2–6 h	32(23)	52(14)	0.014	42(30)	94(25)	0.306
> 6 h	30(21)	97(26)	0.306	32(22)	97(26)	0.426

Self medication and particularly the use of pain killers as well as consulting the spouse increased, and rapid development of symptoms and symptoms matching expectations reduced patient delay among both genders (Table 3). ST-elevation (STEMI), symptoms experienced as unbearable and attributed as cardiac reduced patient delay only in men.

Table 3

Patient delay </> one hour and patient characteristics among women and men with first time myocardial infarction

	Patient delay among women			Patient delay among men
≤ 1 h	> 1 h	OR (CI)	≤ 1 h	> 1 h	OR (CI)
n = 62(%)	n = 78(%)	n = 178(%)	n = 198(%)
STEMI ^∗	34(62)	35(49)	0.65(0.30–1.44)	108(69)	108(58)	0.60(0.38–0.96)
NSTEMI ^∗	21(38)	37(51)	1.53(0.69–3.37)	48(31)	77(42)	1.66(1.04–2.65)
Symptoms
Musculoskeletal early	30(48)	35(49)	0.84(0.41–1.73)	50(28)	80(40)	1.66(1.06–2.60)
Symptom appraisal
Unbearable symptoms	32(52)	38(49)	0.73(0.35–1.52)	82(46)	63(32)	0.50(0.33–0.78)
Rapid development	52(84)	43(55)	0.14(0.05–0.37)	134(75)	101(51)	0.29(0.18–0.47)
Matches expectations	30(48)	26(33)	0.42(0.19–0.90)	95(53)	67(34)	0.43(0.28–0.66)
Attributed cardiac	34(55)	38(49)	0.66(0.32–1.36)	113(63)	91(46)	0.46(0.30–0.71)
Responses to symptoms
Self medication totally	14(23)	33(42)	2.79(1.23–6.33)	30(17)	62(31)	2.42(1.45–4.03)
Taking pain killer	7(11)	21(27)	3.87(1.32–11.3)	11(6)	42(21)	4.02(1.98–8.14)
Consulting spouse	27(43)	48(61)	2.34(1.11–4.96)	103(58)	146(74)	2.06(1.31–3.23)

^∗ n = 55 vs. 72 in women and 156 vs. 185 in men.

Adjusted OR (95% CI) for age, education and employment.

Calling the EMS reduced and calling a GP increased total prehospital delay among both genders (Table 4). Musculoskeletal symptoms increased both patient delay and total prehospital delay only among men, and were statistically significant also in regression analyses including symptoms from chest, left arm, dyspnoea and nausea. In these analyses of patient delay and musculoskeletal symptoms experienced initially, odds ratio (OR) was 1.77 (95% CI 1.14–2.73), and in the analyses of total prehospital delay OR was 2.08 (95% CI 1.28–3.38) for initially symptoms, and 1.64 (95% CI 1.03–2.61) for musculoskeletal symptoms experienced totally. Experiencing chest symptoms as well as typical symptoms (chest without musculoskeletal symptoms) had no significant influence on patient delay and total prehospital delay, and neither had age, infarct location, diagnosed angina, prescribed nitroglycerine, positive family history, consulting other persons than the spouse, activity, place of residence, day of the week or time of day.

Table 4

Total prehospital delay </> two hours and patient characteristics among women and men with first time acute myocardial infarction

	Prehospital delay among women (n = 142)			Prehospital delay among men (n = 374)
≤ 2 h	> 2 h	OR(CI)	≤ 2 h	>2 h	OR(CI)
n = 68(%)	n = 74(%)	n = 183(%)	n = 191(%)
Symptoms
Chest totally	58(85)	66(89)	1.49(0.46–4.87)	170(93)	176(92)	1.14(0.46–2.83)
Chest-typical	32(47)	24(32)	0.68(0.29–1.57)	110(60)	98(51)	0.67(0.42–1.07)
Musculoskeletal early	27(38)	39(53)	1.37(0.62–3.04)	51(28)	78(41)	2.15(1.31–3.53)
Musculoskeletal totally	31(46)	48(65)	1.92(0.85–4.38)	62(34)	85(44)	1.71(1.06–2.76)
Calling for assistance
General practitioner	25(38)	52(71)	4.97(2.05–12.03)	65(36)	124(65)	3.73(2.30–6.07)
Emergency call (EMS)	25(37)	11(15)	0.30(0.11–0.77)	73(40)	41(21)	0.34(0.20–0.58)

Adjusted OR (95% CI) for age, education, employment and distance to hospital.

4 Discussion

In this patient sample less than half the patients reached the hospital within two hours, and no gender differences were found regarding prehospital delay. Musculoskeletal symptoms, as defined in the methods, increased prehospital delay only in men.

We classified prehospital delay time into 14 categories between ½ and 24 h or more, because we hypothesized that it might be difficult to recall the exact time. Both patient delay and total prehospital delay time in our study are similar or somewhat shorter than in other comparable studies [7,15,19,21,23,29]. More than half of the patients in this study had a prehospital delay that contributed to a reduced efficacy of reperfusion therapy, according to international guidelines [5]. There are conflicting data whether there are gender differences in prehospital delay. Our findings that neither gender nor age was associated with delay are consistent with others reports [10,20,21,24,30]. Others reporting prolonged delay among older patients, particularly women [9,13,15,22,23], included older patients than we did, and this might explain the different findings.

Our findings agree with other published reports that calling EMS reduces, and calling a GP increases prehospital delay [9,17,21,24,30]. According to a Danish study [6] half the patients calling a physician were delayed by wrong advice or misinterpretation.

Rapid development of symptoms, symptoms matching expectation, symptoms attributed as cardiac and self medication influencing prehospital delay is consistent with previous reports [6,9,10,14,17,20,21,24,27,30–32]. Nevertheless, no other reports have shown whether symptom attribution has less influence on women's delay. In power analysis regarding cardiac attribution among women, a sample of 2160 was required to achieve a power 0.80, which indicated that the negative result may be due to a lack of statistical power. However, with the sample size required, the clinical significance may be questioned.

Experiencing musculoskeletal symptoms as well as unbearable symptoms have not been reported so far to influence prehospital delay. Whether musculoskeletal symptoms have a more significant influence in men than in women, and whether these symptoms are most important when they are experienced initially, needs to be carefully assessed. Whether the intensity and attribution of symptoms have no influence on women's delay is of vital interest to better understand the decision process.

That most patients consulted a lay person about their symptoms, and men more likely than women consulted their spouse is in agreement with another study [19] as is increased delay by consulting the spouse [33]. Spouses that involved themselves in self medication rather than quickly recommending their partner to seek medical assistance, has been reported [34].

ST-elevation (STEMI) contributing to a reduced prehospital delay has been reported [15]. As information about STEMI was missing for some patients, the negative result regarding women's delay might be due to the sample size. In power analysis a sample of 460 women was required to achieve a power 0.80, which indicate that we cannot disregard an association between STEMI and patient delay in both genders.

Our findings demonstrated some major gender differences in patient characteristics, which demonstrate the importance of adjusting for such variables in data analysis.

4.1 Limitations

We cannot comment on aspects related to the oldest AMI patients because we imposed an age limit of 76 years. The patients' experiences of symptoms were elicited retrospectively within two weeks after hospital discharge, with the possibility of inaccuracy. However, this possibility would be similar among women and men. The patient population did not differ from non-responders as to age and gender, but any differences regarding clinical conditions which might have influenced the symptom experience are unknown. Due to the lower number of female participants, some of the difference between women and men may be due to lack of statistical strength in the female population. The strength of this study, however, is that it was a population-based sample, including public hospitals of various sizes. These hospitals were the only options for AMI patients in the acute setting in the regions in Norway we studied. All patients experienced a first time AMI, verified by the patients' medical records. The response rate was considered high (72%) which reduced selection bias.

5 Conclusions and clinical implications

Over half of both women and men waited over an hour before they called for medical assistance, and more than half the patients had a prehospital delay exceeding two hours. There were no clinical important gender differences in patient delay and total prehospital delay. Musculoskeletal symptoms, the experience of symptoms and how these were interpreted and assessed, had a stronger impact in men than in women. These gender differences are important to better understand the patients' decision process. Altering public perception of AMI and the importance of seeking early treatment is a complex undertaking which demands thorough implementation plans. Nurses who care for patients with coronary artery diseases are in a unique position to guide and inform patients and their families about interpretations of symptoms, and stress the importance of using EMS and not contact their GP if AMI is suspected.

Footnotes

Acknowledgements

The Ministry of Education and Research in Norway and the Molde University College have funded all parts of the study. The Norwegian Heart and Lung association has partially funded the data collection.

References

[1]

De Luca

Suryapranata

Ottervanger

J.P.

Antman

E.M.

Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction

Circulation 109 2004 1223–1225

[2]

Avorn

Knight

Ganz

D.A.

Schneeweiss

Therapeutic delay and reduced functional status six months after thrombolysis for acute myocardial infarction

Am J Cardiol 94 2004 415–420

[3]

Lundergan

C.F.

Reiner

J.S.

Ross

A.M.

How long is too long? Association of time delay to successful reperfusion and ventricular function outcome in acute myocardial infarction

Am Heart J 144 3 2000 456–462

[4]

Boersma

Maas

A.C.P.

Deckers

J.W.

Simoons

M.L.

Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour

Lancet 348 1996 771–775

[5] ACC/AHA Guidelines for the management of patients with ST-elevation myocardial infarction — executive summary. A report of ACC/AHA Task Force on Practice Guidelines (Writing committee to revise the 1999 Guidelines for the Management of patients with acute myocardial infarction) J Am Coll Cardiol 44 2004 671–719

[6]

Ottesen

M.M.

Dixen

Torp-pedersen

Køber

Prehospital behaviour of patients admitted with acute coronary syndrome ore witnessed cardiac arrest

Scand Cardiovasc J 37 2003 141–148

[7]

Ghanima

Skulstad

Falk

Ringstad

Time delay in the thrombolytic treatment of myocardial infarction

Tidsskr Nor Laegeforen 120 2000 1851–1853

[8]

Hirvonen

T.P.

Halinen

M.O.

Kala

R.A.

Olkinuora

J.T.

Delays in thrombolytic therapy for acute myocardial infarction in Finland. Results of a national thrombolytic therapy delay study

Eur Heart J 19 1998 885–892

[9]

McGinn

A.P.

Rosamond

W.D.

Goff

D.C.

Taylor

H.A.

Miles

J.S.

Chambless

Trends in Prehospital delay and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987–2000

Am Heart J 3 2005 392–400

10.

[10]

Moser

D.K.

McKinley

Dracup

Chung

M.L.

Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms

Patient Educ Couns 56 2005 45–54

11.

[11]

Rosenfeld

A.G.

Treatment-seeking delay among women with acute myocardial infarction

Nurs Res 53 2004 225–236

12.

[12]

Grace

S.L

Abbey

S.E.

Bisaillon

Shnek

Z.M.

Irvine

Stewart

D.E.

Presentation, delay and contraindication to thrombolytic treatment in females and males with myocardial infarction

Womens Health Issues 13 2003 214–221

13.

[13]

Dracup

Moser

D.K.

McKinley

Ball

Yamasaki

Kim

C.J.

An international perspective on the time to treatment for acute myocardial infarction

J Nurs Scholarsh 35 2003 317–323

14.

[14]

Rasmussen

C.H.

Munck

Kragstrup

Haghfelt

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission

Scand Cardiovasc J 37 2003 183–186

15.

[15]

Goldberg

R.J.

Steg

P.G.

Sadiq

Granger

C.B.

Jackson

E.A.

Budaj

Extent of, and factors associated with delay to hospital presentation in patients with acute coronary disease (The GRACE registry)

Am J Cardiol 89 2002 791–796

16.

[16]

Heer

Schiele

Schneider

Gitt

A.K.

Wienbergen

Gottwik

Gender differences in acute myocardial infarction in the era of reperfusion (The MITRA Registry)

Am J Cardiol 89 2002 511–517

17.

[17]

Horne

James

Petrie

Weinman

Vincent

Patients' interpretations of symptoms as cause of delay in reaching hospital during acute myocardial infarction

Heart 83 2000 388–393

18.

[18]

Luepker

R.V.

Raczynski

J.M.

Osganian

Goldberg

R.J.

Finnegan

J.R.

Hedges

J.R.

Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: the Rapid Early Action for Coronary Treatment (REACT) Trial

JAMA 284 2000 60–67

19.

[19]

Aschton

K.C.

How women and men with heart disease seek care: the delay experiment

Prog cardiovasc Nurs spring 1999 53–60

20.

[20]

Schoenberg

N.E.

Amey

C.H.

Stoller

E.P.

Drew

E.M.

The pivotal role of cardiac self-care in treatment timing

Soc Sci Med 60 2004 1047–1060

21.

[21]

Johansson

Strømberg

Swahn

Factors related to delay times in patients with suspected acute myocardial infarction

Heart Lung 33 2004 291–300

22.

[22]

Gibler

W.B.

Armstrong

P.W.

Ohman

E.M.

Weaver

W.D.

Stebbins

A.L.

Gore

J.M.

Persistence of delays in presentation and treatment for patients with acute myocardial infarction: the GUSTO-I and GUSTO III experience

Ann Emerg Med 39 2002 123–130

23.

[23]

Goldberg

R.J.

Gurwitz

J.H.

Gore

J.M.

Duration of, and temporal trends (1994–1997) in, prehospital delay in patients with acute myocardial infarction: the second National Registry of Myocardial Infarction

Arch Intern Med 59 1999 2141–2147

24.

[24]

Zerwic

J.J.

Ryan

C.J.

DeVon

H.A.

Drell

M.J.

Treatment seeking for acute myocardial infarction symptoms

Nurs Res 52 2003 159–167

25.

[25]

Caldwell

M.A.

Miaskowski

Mass media interventions to reduce help-seeking delay in people with symptoms of acute myocardial infarction: time for a new approach?

Patient Educ Couns 46 2002 1–9

26.

[26]

Løvlien

Are womens hearts taken seriously?

Vard Nord Utveckl Forsk 1 2001 15–19

27.

[27]

Løvlien

Schei

Gjengedal

Are there gender differences related to symptoms of acute myocardial infarction? A Norwegian perspective

Prog Cardiovasc Nurs 21 2006 14–19

28.

[28]

Løvlien

Schei

Hole

Women with myocardial infarction are less likely than men to experience chest symptoms

Scand Cardiovasc J 40 2006 342–347

29.

[29]

Leslis

W.S.

Urie

Hooper

Morrison

C.E.

Delay in calling for help during myocardial infarctions: reasons for the delay and subsequent pattern of accessing care

Heart 84 2000 137–141

30.

[30]

Hwang

S.Y.

Ryan

Zerwic

J.J.

The influence of age on acute myocardial infarction symptoms and patient delay in seeking treatment

Prog Cardiovasc Nurs 21 2006 20–27

31.

[31]

McKinley

Dracup

Moser

Ball

Yamasaki

Kim

C.J.

International comparison of factors associated with delay in presentation for AMI treatment

Eur J Cardiovasc Nurs 3 2004 225–230

32.

[32]

Schmidt

S.B.

Borsch

M.A.

The prehospital phase of acute myocardial infarction in the era of thrombolysis

Am J Cardiol 65 1990 1411–1415

33.

[33]

Alonzo

A.A.

The impact of the family and lay others on care-seeking during life-threatening episodes of suspected coronary artery disease

Soc Sci Med 22 1986 1297–1311

34.

	Patient delay			Total prehospital delay
Women	Men	p	Women	Men	p
n = 140(%)	n = 376(%)	n = 142(%)	n = 374(%)
≤ 1 h	62(44)	178(47)	0.536	29(20)	86(23)	0.531
1–2 h	16(11)	49(13)	0.626	39(27)	97(26)	0.725
2–6 h	32(23)	52(14)	0.014	42(30)	94(25)	0.306
> 6 h	30(21)	97(26)	0.306	32(22)	97(26)	0.426