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Journal of Cardiovascular Nursing:
doi: 10.1097/JCN.0b013e31824bcebc
Articles

Older Women’s Prehospital Experiences of Their First Myocardial Infarction

Isaksson, Rose-Marie PhD, RN; Brulin, Christine RNT, PhD; Eliasson, Mats MD, PhD; Näslund, Ulf MD, PhD; Zingmark, Karin MD, RN

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Author Information

Rose-Marie Isaksson, PhD, RN Registered Nurse, Northern Sweden MONICA Myocardial Registry, Department of Research, Norrbotten County Council, Luleå, and Department of Nursing, Umeå University, Sweden.

Christine Brulin, RNT, PhD Professor, Department of Nursing, Umeå University, Sweden.

Mats Eliasson, MD, PhD Professor, Department of Medicine, Sunderby Hospital, Luleå, and Department of Public Health and Clinical Medicine, Umeå University, Sweden.

Ulf Näslund, MD, PhD Professor, Department of Public Health and Clinical Medicine, Umeå University, and Department of Cardiology, Heart Centre, University Hospital, Umeå, Sweden.

Karin Zingmark, MD, RN Research Manager, Department of Research, Norrbotten County Council, Luleå, Sweden.

This work was supported by Norrbotten County Council. Additional support for this project was provided through The Swedish Heart-Lung Foundation, The Joint Committee of Regional Authorities, and The Heart Foundation of Northern Sweden.

The authors have no conflicts of interest to disclose.

Correspondence Rose-Marie Isaksson, PhD, RN, Northern Sweden MONICA Myocardial Registry, Department of Research, Norrbotten County Council, 971 89 Luleå, Sweden (rose-marie.isaksson@nll.se).

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Abstract

Background: Few qualitative studies have been conducted on older women’s experiences of myocardial infarction (MI) and, in particular, the time before they seek medical care.

Objective: The aim of this study was to explore older women’s prehospital experiences of their first MI.

Methods: Qualitative content analysis was performed on data from individual interviews with 20 women, aged 65 to 80 years (mean, 73.0 years). The participants were interviewed 3 days after admission to a hospital for a confirmed first MI.

Results: The women perceived their symptoms as a strange and unfamiliar development from indistinct physical sensations to persistent and overwhelming chest pain. Throughout the prehospital phase, they used different strategies such as downplaying and neglecting the symptoms. The symptoms were seen as intrusions in their daily lives, against which the participants defended themselves to remain in control and to maintain social responsibilities. As their symptoms evolved into constant chest pain, the women began to realize the seriousness of their symptoms. When the pain became unbearable, the women took the decision to seek medical care.

Conclusion: Understanding the complex experiences of older women in the prehospital phase is essential to reducing their patient decision times. The findings of this study should be incorporated into the education of professionals involved in the care of cardiac patients, including those who answer informational and emergency telephone lines.

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Background

Because it influences care seeking, symptom recognition is an important aspect of myocardial infarction (MI). Studies have compared women and men for symptoms of MI, with varying results. According to some studies, it is more common for men than for women to report chest pain as the primary symptom of MI,1,2 and symptoms like fatigue, nausea, dizziness, fainting, weakness, shortness of breath, and indigestion are more common among women.1,3,4 These results have been widely reported in the media and have encouraged the belief that women do not experience chest pain as a symptom of MI.5 However, a majority of women do experience chest pain at the onset of MI.5–7 Interestingly, in a previous study based on individual interviews with 20 men with a first confirmed MI at ages 65 to 80 years, we found that their experiences in the prehospital phase were multifaceted, difficult to interpret, and marked by a dynamic development of symptoms, conceptions, and expectations as these older men strove to maintain their ordinary and familiar lives.8

Women have also been reported to use different language than men do in describing their symptoms.9 Studies of patients presenting to an emergency department with an MI found that although men and women were equally likely to present with chest pain, women were more likely to describe their symptoms as pressure, heaviness, or tightness and were less likely to describe the pain as located in the center or left of the chest.4,10 Women have been shown to experience symptoms such as unusual fatigue, insomnia, shortness of breath, and chest discomfort weeks, months, and even years before they experience an MI.4,11–13

The effect of an MI on mortality is greatly dependent on the time from onset of symptoms to the time of reperfusion therapy.14 Maximum benefit is achieved within 60 minutes of onset15 and decreases markedly after 3 hours, although there may still be some benefit up to 12 hours after the first symptoms.16 Because the benefit of medical treatment is time dependent, it is crucial to be able to identify, describe, and interpret reasons for delay in seeking care for MI symptoms. Delay occurs at several levels. The largest contributor to delay in treatment is the patient’s inability to recognize symptoms and decide to seek medical care (patient decision time); delays attributable to transportation to hospital and in-hospital waiting time for reperfusion therapy are both quite short by comparison.15 Decision times in 40% or more of patients remain longer than 4 hours, which is unacceptably long.17,18

The causes for delay are not completely understood, and results from earlier studies are conflicting. Several studies have shown that women have longer prehospital delays than men do,19,20 but other studies have found no such gender differences.2,21 In a previous study from the Northern Sweden Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) MI registry, we reported that up to the age of 65 years, no gender differences were seen in prehospital delay. In the age group 65 to 74 years, however, delay in seeking medical care was more common overall, but especially so in women.18

Although earlier studies offer useful insights into the delay in seeking care, there are limited data describing women’s own thoughts and actions during an MI. Incorrect interpretation of symptoms has been found to be a critical factor negatively influencing the prehospital phase.13,22,23 Other responses such as thinking that the pain will go away or not recognizing the importance of symptoms result in reluctance to seek medical care.13,24,25 Women hesitate to seek medical care for reasons including their perception of MI as a “male” problem, their preference to self-medicate, and their attribution of their chest pain to a noncardiac cause.26 It has also been reported that women do not want to bother their family or friends and often choose to place the welfare of others before their own needs.13,27 Consequently, women’s perceptions of themselves and the signs and symptoms of their illness may differ significantly from those of men and may quite possibly contribute to the extended delay times that women exhibit before seeking treatment for MI.28

Despite the fact that most women are not affected by MI until they are older than 65 years, to our knowledge, no qualitative interview studies have been published focusing explicitly on older women’s experiences of their first MI. Our aim, therefore, was to explore older women’s prehospital experiences of their first MI.

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Methods

The Multinational Monitoring of Trends and Determinants in Cardiovascular Disease Project

In the early 1980s, the World Health Organization (WHO) introduced the MONICA. The Northern Sweden MONICA project has been ongoing since 1985 in Västerbotten and Norrbotten counties, an area with a total population of around half a million. For the entire time, strict WHO criteria have been followed. Validations of the events in the MONICA manual are based on medical history, symptoms, electrocardiography, and troponin testing.29

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Participants and Setting

Participants who met the inclusion criteria were women aged 65 to 80 years diagnosed with their first MI, confirmed according to the standards of the WHO MONICA manual. Excluded were patients with unstable circulation, confusion, dementia, or other serious complications like cardiac arrest and/or heart failure. Twenty women were initially asked to participate; 3 declined and 3 others were invited and agreed to participate (n = 20). We judged that 20 women would be enough to allow sufficient variation of experiences and, further, to permit a deep analysis of the data. None of the participants had a previous history of MI or angina pectoris, ensuring that this event was a new experience for them. The participants were recruited from coronary care units at 3 hospitals in Northern Sweden. Their background characteristics, diagnoses, and prehospital delays are shown in Table 1.

Table 1
Table 1
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In this study, “patient decision time” is defined as the time the patient took to assess and interpret her symptoms before finally deciding to seek medical care.30

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Data Collection

The individual interviews took place from December 2007 to February 2009 and were conducted 3 days after admission to hospital to ensure that the women were physiologically stable and free of pain but that they still remembered the MI clearly. The interview questions had clearly identified topics and encouraged narrative responses to obtain as complete data as possible. The questions were designed to prompt the women to describe their symptoms and their reasoning up to the decision to seek care, for example: “Please describe what happened,” “Can you describe the symptoms?” and “Can you estimate how long it took from when the symptoms started until you decided to seek medical care?” Probing questions such as “Can you explain more?” and “What did you think then?” elicited further details of the women’s experiences, and the participants were encouraged to talk freely about their prehospital experiences of their first MI. The first author conducted 12 of the interviews. Two of the interviews were conducted by the last author; 2 interviews, by 1 of the coauthors; and 3 interviews, by a doctoral student, who all were highly experienced and familiar with the subject. The interviews took place in a private room in the hospital, were tape recorded, and lasted approximately 20 to 70 minutes. The first author transcribed all 20 interviews verbatim shortly after each interview. Before, during, and after the transcription process, the first author listened to and read through the interviews on several occasions.

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Data Analysis

The texts were analyzed using qualitative content analysis.31 Content analysis is a method of systematically analyzing written or verbal communication with a focus on differences and similarities within the text. The interpretation process results in themes, which are threads of meaning based on “meaning units” that run through the text and are coded interpretatively.31

The interviews were analyzed in several steps. First, all interviews were read through several times to gain a sense of the material as a whole. The text of each interview was broken down into meaning units, which included words, sentences, or paragraphs related to the research question. Then the meaning units were sorted into content areas: perceived symptoms and response to symptoms. The meaning units within the content areas were extracted, condensed, and coded. All coded material was then compared and sorted into 7 subthemes within 2 main interpretive themes. Subthemes are threads of meaning that run through the condensed text, whereas the themes embrace the content of the related subthemes on a more abstract and interpretative level.31 Throughout the analysis, the first and last authors compared and contrasted the codes, subthemes, and themes against the original text. This involved reading back and forth between the whole text and the selected segments to ensure stringent and trustworthy analysis.

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Ethical Considerations

The study was approved by the ethics committee at Umeå University (07-113M). The participants were informed about the study, and informed consent was obtained. They were assured that their participation was voluntary and that they could withdraw at any time. The participants were guaranteed confidentiality in the presentation of the findings. They were also assured that if they refrained or withdrew from participating in the interview, it would not in any way affect their care then or in the future.

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Results

During the prehospital phase, the older women experienced symptoms from vague to overwhelming. When we took account of the diagnosis—ST-elevation MI or non–ST-elevation MI—we found that the experience of the symptoms was similar regardless of the diagnosis. The symptoms did not differ either between women with shorter and longer prehospital delays or between those who chose ambulance and those who chose some other mode of transport to the hospital. Data related to diagnosis and prehospital delay are shown in Table 1.

The results consist of 2 themes and 7 subthemes about older women’s prehospital experiences of their first MI. Table 2 presents an overview of the identified themes and subthemes within the content areas: perceived symptoms and response to symptoms.

Table 2
Table 2
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Perceived Symptoms: Undergoing Unfamiliar and Strange Development of Discomfort and Pain

This theme demonstrates the stepwise development of symptoms from mild discomfort to severe pain. All of the women described their symptoms in all stages as unfamiliar, strange, and escalating. The progression of their symptoms and experiences are expressed in the 3 subthemes: “early indistinct physical sensations,” “warning stage of distinct ill-being,” and “persistent and overwhelming chest pain.”

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Early Indistinct Physical Sensations

Initially, the participants experienced indistinct physical sensations and symptoms. For some, these became clear retrospectively, often during the interviews. Some women did not notice these symptoms until someone else called attention to their difficulties:

Why are you breathing so heavily, Mom?

The participants found it difficult to specify exactly how long before the MI they experienced these initial symptoms, but it may have been for days, weeks, or even months. A primary physical sensation experienced by all the participants was unusual fatigue with nonspecific discomfort in different parts of the body, most often described as unusual or unpleasant weakness, malaise, or fatigue:

It was like my body had turned to jelly. I tend not to be listless, but I was. I felt like everything was a burden and hard work, and I didn’t feel alert.

Sensations in the chest were common and described by the women as “stitches,” “tightness,” or “pressure.” Other common early symptoms were experienced in the upper abdominal area, and some experienced shortness of breath that worsened with activities like walking and climbing stairs. Some also had difficulties breathing at night, often pointed out by relatives. Some participants described a combination of fatigue and nonspecific discomfort in various parts of their bodies.

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Warning Stage of Distinct Ill-being

The indistinct sensations led into a warning stage with distinct feelings of ill-being developing within hours or days. The participants described the same types of symptoms as in the indistinct early phase, such as shortness of breath and discomfort in the chest or stomach, but in this stage, the symptoms were experienced in a different way and felt like nothing they had ever experienced before. The symptoms were described as more distinct, increasing, intermittent, and variable.

I thought it was pretty good in the morning, so we went shopping, but when we were almost at the counter I began to feel worse and worse.

The participants experienced the pain as unfamiliar and strange. They described how they found it difficult to know what to relate the symptoms to and they did not associate them with the heart:

I had pain in my stomach and found it a very strange pain because I had not experienced it before. It was under the right ribs and so I thought, “Oh well, I must have gallstones.”

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Persistent and Overwhelming Chest Pain

In this acute stage, the participants described symptoms with long duration and high intensity. Chest pain came to dominate the event and was experienced by all participants. The chest pain was described as having increased rapidly, within seconds, minutes, or hours, to the point that participants were extremely distressed. The pain was usually described as intense; it could vary, but it never completely vanished. Most of the participants described the chest pain as occurring in the mid to upper part of the chest or over the breastbone.

Usually, the descriptions of symptoms in this stage were much different from descriptions of earlier symptoms. Instead of describing symptoms as indistinct or vague, the women now used a range of adjectives like “terrible,” “crushing,” “tightening,” “gripping,” and “stabbing.” Some participants reported “a pounding sensation in the chest,” and others described how the pain cut right through their body. The pain could erupt in their back, their left arm, or both arms, with or without heaviness or a squeezing sensation behind their shoulders. Some had pain in the diaphragm and right ribs. Some participants described how radiating pain could start in the chest and travel to one arm or through both arms. One woman described pain in both arms from the elbows up. For some, the pain was so intense that they could not bring themselves to move their arms. Some women described a “rushing” in their body, with their pulse racing such that “my heart was beating so hard I thought it would burst out of my chest.”

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Response to Symptoms: Struggling Against Intrusive Symptoms to Maintain Control and Responsibility

This theme encompasses the participants’ thoughts and reasoning about their symptoms during the prehospital phase. Despite their increasingly severe symptoms, the women struggled against them with different strategies, all with a strong desire to remain in control. Social responsibilities took priority over concerns about their own health. Finally, when the pain became unbearable and no strategies were successful, the women were compelled to give in to the symptoms and to seek medical care. This theme comprises 4 subthemes: “downplaying and doubting perceived ill-being,” “neglecting the seriousness of the symptoms,” “putting others’ well-being first,” and “giving in to symptoms.”

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Downplaying and Doubting Perceived Ill-being

The participants described how, during the early phase, they felt symptoms and thought that something was wrong in their bodies, but they did not understand what it was. The indistinct early sensations were something new that they had not experienced before. None of the women thought it could be their heart, and all wanted to find more “natural” explanations for the symptoms that would fit their previous experience. They did not realize that they might be experiencing a serious illness. The alternative explanations that women described were usually less severe than MI. For example, one woman blamed discomfort in her chest on pressure from her brassiere:

I had to unhook my bra because I felt such pressure crowding in and I thought it was because my bra was too tight.

The most common explanation for symptoms of discomfort and pain, however, was stomach trouble. Many of the women experienced indigestion, which they thought caused the symptoms. There were many alternative explanations for nausea, including medicines or having eaten or drunk something disagreeable.

The indistinct sensations became intruders in the women’s ordinary lives, and they downplayed their symptoms in an attempt to live their daily life as usual. Even when fatigue made them want to sleep day and night, they still considered their household responsibilities essential.

Yes, of course, I cooked dinner and fed the dogs, and I cleaned the freezer, even though I knew that I was tired and running out of breath.

Commonly, despite their fatigue, women interpreted their inability to cope with their usual routines as weakness and they felt ashamed. The women described how they did not want to let others see that they were not as strong and capable as they used to be. One woman was making dinner for her family and friends when she experienced fatigue:

I was embarrassed because my sister and niece were there and helped me, and it wasn’t only the family who saw.

Some participants who sought medical advice on the recommendation of relatives, or because they felt sure that something was not right, were sent home without having been tested or diagnosed. This made them feel ignored.

A doctor looked and felt and he was like, he did not think it was the heart, but he believed it was the stomach, so he said I should just go home and be glad that it was nothing serious. But it was serious.

At this time, some women began to doubt themselves and started wonder if they had only imagined their symptoms. This self-doubt was sometimes influenced by comments from healthcare professionals such as, “You’re just not physically fit.”

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Neglecting the Seriousness of the Symptoms

Although the symptoms increased in intensity and thereby became more serious, the participants refused to admit they were ill and tried to convince themselves that they were well. They wanted to carry on as usual with their lives and so they denied the seriousness of the symptoms in an effort to keep up the facade of being strong and healthy. Because their symptoms differed considerably from what they imagined an MI to be like, the situation was very confusing. Some women thought an MI would be associated with more crushing chest pain radiating to the left arm and not with the slow onset and sometimes intermittent symptoms they experienced. One woman with chest symptoms said:

It was a pretty intense pain, but it subsided and then came back again, so it was not the same pain all the time. I felt that it would certainly go away.

All participants tried to self-manage their symptoms, an action that delayed them in seeking medical care as they waited to see whether their home interventions were effective. Many tried to sleep and some took painkillers. Although the symptoms were strong and serious, the women tried to stay calm, keep still, and rest to make the symptoms abate. Those who experienced symptoms on waking in the morning tried to get back to sleep and used pillows to find a comfortable position in bed. Some got in and out of bed until they were able to rest comfortably. Most of the participants just waited and wished the symptoms would go away.

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Putting Others’ Well-being First

The severe pain overwhelmed the women. Nevertheless, rather than facing what was happening, the participants attempted to carry on as usual. The ability to carry on with their daily routines and responsibilities was tightly linked to their sense of personal identity. The participants seemed not to seek medical care when the pain was most intense but instead to wait for the least disruptive timing. The women often said they thought, “This cannot happen now” or “This is not the right time to get sick.” In their references to the timing of their illness, the women put the needs of others before their own. Social responsibilities were more important to the women than seeking medical care, and they did not want to disappoint anyone else. The women viewed their own health as a low priority compared with their obligations to family or friends, and they placed more importance on the health and well-being of others than on their own. For example, one woman was reluctant to leave a sick husband at home, and one did not want to interrupt a journey her daughter had been planning:

This was a journey that had been planned for such a long time and I would ruin it by getting sick. I put off calling [for help] to avoid causing any disruptions so they could just go away and enjoy themselves. I decided it could not happen right when they were ready to travel. It was not the right time to get sick.

One woman had a cafe that she was responsible for and she did not want to disappoint her guests by closing it. Despite the pain in her chest and arms, she stayed there and took care of her guests. Another woman who used a laundry room had chest pain that was so intense that she had to lie down on the stone floor, but the laundry room could not be left untidy:

I had to clean and sweep the floor or what would the next people to come have to say?

The participants thought that women should always be capable and work hard (“We should be good until the very end”) and never put themselves first but be accustomed to being secondary to others (“We are busy caring for others, husband, children, grandchildren, so we forget about ourselves”).

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Giving in to Symptoms

The participants seemed to be caught between the desire to maintain control and the realization that they may have a serious condition requiring medical care. Despite extreme discomfort, women described waiting several hours with severe symptoms while trying to cope on their own.

Participants described how they finally realized that something truly serious and life threatening was happening to them. Some participants who experienced expected symptoms of MI found it easier to understand their symptoms as cardiac in origin:

I knew for sure that it was a heart attack. I have read about heart attacks and heard about the symptoms on TV. Yes, there is pressure on your chest and into the arms and then the pounding sensation in the chest.

If the expected symptoms did not correspond with their actual symptoms, the reaction was the opposite:

Sure, I know you are supposed to have pain in one arm, but not in both arms! Nothing in my symptoms was what I expected to be a heart attack.

In this acute and alarming symptom stage, the participants were in severe pain but, despite that, hesitated to call until the pain became nearly unbearable, even when they knew the delay could endanger their lives. However, there did come a time, a tipping point, when they realized that they could not fight the symptoms anymore and realized that they had become seriously and life-threateningly ill:

I was just thinking that I would not be able to call before I died, because it was so different from everything else.

At this point, some women finally sought medical care because they could no longer cope, whereas others chose to seek advice from family or friends. Women who disclosed their symptoms to others were willing to comply with recommendations to seek medical care. At this point, the women allowed someone else to take control.

Despite strong and intense pain, the participants were still uncomfortable about seeking medical care. It would be embarrassing to seek treatment for a false alarm, not to mention the disruption of their ordinary lives and responsibilities that would follow if they had to go to the hospital. Some of the women had previously sought medical care for early warning symptoms and had been sent home, told that their symptoms were nothing to bother about, which made them feel ignored and reluctant to seek care again. They feared that healthcare personnel would think of them negatively, as hypochondriacs or as willfully ignorant, if they presented again with the same complaints. This made the participants afraid that they might not be believed or they might be rejected.

I’m not someone who whines about little things.

When forced to choose between embarrassment on the one hand, and illness on the other, watchful waiting was used as a strategy to avoid either unwelcome alternative. Avoiding embarrassment seemed to be more important than avoiding a serious health outcome.

When the participants finally decided to seek medical care, they worried about where to seek it and how to get there. They did not know if it was better to contact the medical center, call directly to the emergency room, or send for an ambulance. Calling an ambulance often felt too drastic and embarrassing because they did not consider themselves sick enough. They did not understand the possibly beneficial medical treatments they could receive from ambulance attendants and therefore felt they could save time by taking their own car instead of waiting for the ambulance. To the very end, women had difficulty putting themselves first and continued to think of the needs of others ahead of their own.

I thought it was best that we take the car instead of an ambulance, or how would my husband get home?

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Discussion

In this study, it was found that higher priority was assigned by older women to family responsibilities and social roles than to acting on symptoms possibly associated with their first MI. Even though the participants recognized their symptoms as abnormal, they did not acknowledge their meaning until a variety of coping mechanisms failed to reduce the threat or allow them to maintain control over the situation. Resistance to any disruption to their daily lives influenced their decision about seeking medical care.

Prodromal symptoms are defined as intermittent symptoms that increase in frequency and/or severity before an MI and disappear afterward.4 Most participants in our study initially experienced a wide array of diffuse symptoms in different parts of the body. In a Swedish study, Sjöström-Strand and Fridlund13 discuss the early symptoms experienced by women who were interviewed on the second or third day of hospitalization after their first MI and suggest that enough time might not have passed for the participants to recognize whether their prodromal symptoms had subsided. The women in our study were interviewed on the third day. We cannot be sure either that the women really experienced prodromal symptoms at a start of the MI. Perceptions of these symptoms may be a later rationalization of sensations that come and go normally, such as fatigue that occurred before, but did not necessarily presage the MI. However, our findings indicate that early indistinct symptoms that are described by patients describe as new and unfamiliar must receive attention.

Symptoms are subjective and reflect not only the physical aspects of the disease but also associated feelings, such as anxiety, and expectations.32 As their symptoms evolved, most participants in this study finally experienced chest pain, but many understood an MI to be characterized by excruciating, crushing chest pain and not the slow, stepwise onset of symptoms that they experienced. This finding is consistent with what we found in our previous study,8 in which older men described how their symptoms developed from a diffuse ill-being to a cluster of severe symptoms. The mismatch of expected and experienced symptoms has recently been described in a study by O’Donnell and Moser.33

Both typical and atypical symptoms resulted in misinterpretation among the participants in this study. Although pain located in both the chest and left arm were present, many women interpreted the symptoms as noncardiac. Similar results were shown in a study by Sjöström-Strand and Fridlund,13 in which women, despite severe chest pain, did not interpret the symptoms as potential signs of MI.

We found that it was not until chest pain became significant that the participants appreciated that something very serious was happening to them. Even then, they tended to downplay the impact of symptoms and look for credible, yet innocuous, explanations. Only after all coping strategies were exhausted and the symptoms persisted or worsened did the women begin to consider that something serious was happening to them. In addition, here, we can see similarities with our study in men,8 in which there was delay for all participants during which time they tried to make sense of what was happening to them, were unsure how to interpret the symptoms, and used different strategies to try to reduce the symptoms.

The findings support earlier reports that patients who seek medical care for MI symptoms consider many other factors that ultimately shape their actions. For example, researchers have reported that fear and embarrassment lead patients to hesitate or delay seeking medical care.34 In our study, the participants needed to be certain that their symptoms were life threatening before they felt justified in seeking medical care. This reluctance to seek care may also be related to our participants’ experiences of being dismissed or ignored when they presented with earlier symptoms.

This study suggests that older women’s prehospital delays are strongly influenced by the broader context of their social responsibilities and demonstrates an interaction between gender and MI. Misinterpretation of symptoms and prehospital delay in seeking treatment for MI remain clinical issues given the time-dependent nature of available medical treatments. According to Emslie,35 women often view their own health as a low priority compared with the well-being of family members, and they place more importance on the health of others than on their own.

The women in our study were all retired, but all talked about their social responsibilities as “work.” In a Swedish study36 about stress in women’s daily life before and after a first MI, it was found that the period before the MI had been stressful because of the different roles the women had to maintain in their private and professional lives. The women in that study were between 31 and 80 years old and said that they could not allow themselves to be ill because they had a great deal of responsibility for another person, their whole family, and/or their work duties. The women wanted to maintain control over their ordinary lives. The women in our study were older and all retired, but we can see similarities between our participants and those in the Sjöström-Strand and Fridlund36 study. We note that the women in our study experienced the same kind of stress because of their social responsibilities, which might be a barrier to women seeking prompt medical care when experiencing MI symptoms.

Although the results in our study fit many aspects of the stereotypical pattern of feminine and masculine behaviors in seeking medical care,37 several participants reported responses that were not reflective of their gender roles. Thoughts and actions that would more commonly be associated with masculine ideals were seen in the reports of several women who struggled against severe pain for as long as they were able, wanted to remain in control, and were accustomed to be being as strong, active, and independent of others—all qualities that could be interpreted and understood as typically masculine.38

During the prodromal period, many participants decided to seek medical care, often at the urging of family or friends. These women reported difficulty in obtaining a diagnosis. They were given no explanation for their symptoms and felt that they were not taken seriously. This resulted in their doubting themselves and downplaying their symptoms. It is important to note that this experience made the women hesitate to seek care when the symptoms became alarming. Some said it would be embarrassing to seek care for a false alarm. This supports findings in studies that show that women hesitate to seek medical care because they fear being ignored or dismissed.

Once the decision to seek medical care was made, the participants in this study did not know the level of care to seek or how to get there, which resulted in further delay. This accords with a Swedish study on men and women with their first or second MI, in which the participants had difficulties understanding and interpreting their symptoms. They did not think they were sick enough to call an ambulance; therefore, they commonly sought help by calling a general practitioner or a nurse at a healthcare center.39

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Methodological Aspects

The participants were well defined by the use of strict diagnostic criteria from the WHO MONICA manual.40 We considered it important to include only patients with a first MI and to exclude those who may have learned to report “expected” symptoms from a previous MI or from living with angina pectoris. The strength of this study was the insider perspective—the women’s descriptions of their own experiences during an MI. The results from this study cannot be generalized because this is not the goal of qualitative research. It would have been desirable to take part of the participants’ experiences at an earlier stage after admission to hospital. However, we chose to give priority to participants to be physiologically stable and free of pain before they were interviewed.

In qualitative content analysis, credibility, dependability, and transferability are markers most usually discussed in relation to trustworthiness.31 In this study, credibility was established by showing representative quotations from the transcribed text and by a dialogue among the research group. Dependability was established by open discussion within and among the research group and fellow researchers, to minimize inconsistencies and achieve a logical and clear documentation. Transferability was facilitated by providing a description of participants, the data collection, and the process of analysis together with appropriate quotations. Presenting relevant quotations along with our findings also allows the reader to judge the authenticity of our interpretations.

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Clinical Implications

To seek medical care promptly, older women need to be aware of the symptoms of an MI, know what action to take, and understand the importance and urgency of this action. If older women in general are told about the thoughts and feelings that the women in this study and others have experienced, they will be more likely when experiencing similar symptoms to reflect upon the possibility of an MI and to seek medical care more quickly.

To individualize care, it is important for healthcare personnel to invite women to freely describe their symptom history, using open questions to generate more detailed information about what caused them to seek medical treatment, rather than focusing on the presence or absence of traditional MI symptoms. This means that nurses and emergency physicians must take a broader view of symptom interpretation. It is also important to educate those nurses who staff information telephone lines at primary care or hospital care to recognize possible symptoms of MI and encourage callers with those symptoms to seek care. Equally important, patients who seek early care and are not found to have any signs of serious illness should always be encouraged to return promptly if symptoms worsen or other worrying signs should appear.

Nursing interventions aimed at reducing patient delay should be directed toward educating individuals to recognize and minimize the use of coping strategies that are likely to lead to decision delay. It is understandable that individuals who are faced with symptoms that are not immediately recognizable as cardiac in nature might engage in self-treatment activities, make efforts to reduce the psychological stress associated with symptoms, and consult with others in lieu of seeking prompt medical attention. Hence, to facilitate the recognition of MI symptoms as cardiac in nature, we recommend that teaching interventions should strive to ensure that the public and at-risk individuals and their relatives are aware of both typical and atypical MI symptom presentations and the fact that in both men and women, typical symptoms are by far the most common.

We recommend that such teaching interventions focus on informing individuals about the risks associated with delayed interventions for MI. Health education messages should focus on the delivery of specific warnings about the coping responses that tend to be associated with delays in deciding to seek hospital care for MI symptoms.

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Conclusion

Our findings demonstrate that the prehospital phase in older women with a first MI was a complex experience in which the symptoms evolved from indistinct physical sensations to persistent and overwhelming chest pain. The women struggled against the symptoms by downplaying and neglecting their seriousness and strived to remain in control. Social responsibilities took priority over concerns about their own health.

Understanding the complex experiences in older women’s prehospital phase is essential to reducing their patient decision times. The findings of this study should be incorporated into the education of professionals involved in the care of cardiac patients, including those who answer informational and emergency telephone lines.

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What’s New and Important

* In older women having their first myocardial infarction (MI), symptoms evolve gradually from indistinct physical sensations to persistent and overwhelming chest pain.

* The prehospital phase in older women is complex, clearly influenced by preconceptions and expectations about MI symptoms.

* Resistance to any disruption to daily life influences older women’s decision about seeking medical care.

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Keywords:

aging; myocardial infarction; prehospital delay; qualitative; symptoms

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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