Cardiovascular disease is the number one killer in America. It is equally disturbing that almost 250,000 people die of coronary heart disease a year in their homes and communities without medical treatment—more than 680 Americans each day without being hospitalized. 1 Cardiovascular heart disease alone claims the lives of more than 500,000 women each year and is the single leading cause of death and disability in women older than 50. 1 Because of the aging of the population in the United States, the number of deaths in women with cardiovascular heart disease is actually increasing every year. 2 More than half of the deaths from cardiovascular heart disease are directly attributable to acute myocardial infarction (AMI), causing a quarter of a million people to die of coronary heart disease within 1 hour after the onset of symptoms, and before reaching the hospital. 1 Mortality rates for women who suffer from an AMI are substantially higher than for men, 38% of women versus 25% of men will die within one year after their AMI. 1 These statistics are very disturbing given the advances in medical science we have today.
Current treatment for an AMI focuses on reperfusion therapy, which must occur within a narrow time frame to be successful. 3 Results from large clinical trials demonstrate that if the patient receives care promptly, thrombolytics or other reperfusion therapies can be utilized to reduce or eliminate damage to the myocardium, 4,5 thereby reducing the morbidity and mortality of an AMI. 6 Because these new advances are useful only within a narrow time frame, it is essential that men and women alike seek treatment immediately after onset of symptoms for optimal outcomes. Multiple research studies have found that most patients do not seek medical treatment for at least 2 hours, and frequently, 4 or more hours after the onset of the symptoms of an AMI, 3,7,8 and populations in some communities have a mean delay of 12 hours. 9,10 Delay in seeking treatment is strongly correlated with increased mortality and increased disability. 11,12 The Myocardial Infarction Triage and Intervention (MITI) trial found a 7-fold decrease in mortality in patients treated with reperfusion therapy within 70 minutes of symptom onset, with continuing significant survival benefits when treatment was provided within 6 and 12 hours. 12
The majority of patient delay in treatment lies in the patient's decision-making processes after symptoms of AMI begin at home. 10,13 Results of many studies support that women and older individuals have been found to delay longer as compared to the general population; therefore, these 2 characteristics may constitute risk factors for death and disability with AMI. 11,14–18 However, some studies do not demonstrate longer delay times for women. This inconsistency may be the result of the study focus, characteristics of the sample, small sample sizes, or statistical sophistication. Because heart disease affects women at an older age, women have been described by Brophy et al as being in a “double jeopardy” type of situation; and therefore, twice as likely to delay longer than do men. 14 Prehospital delay is a critical factor for patient survival. The unparalleled focus of cardiac healthcare teams is to reduce the delay in taking a decision to seek treatment for all individuals.
Heart disease traditionally has been viewed as a man's disease. It has been portrayed in this manner by the media and in past studies that exclusively used men as research subjects. 19,20 In addition, healthcare providers tend to attribute women's complaints of vague symptoms to psychological distress more often than they do for men's symptoms. 21,22 Because noninvasive diagnostic testing has less predictive value in women, 23 and chest pain in women may not be appreciated as it is attributed to other causes, such as anxiety, stress, and heartburn, 23,24 the standard criteria used to determine the likelihood of coronary artery disease in men seems to be of limited value in women. Studies also indicate that men and women present and interact with their physicians differently, which may contribute to some variation in their treatment. 25,26 Because research has focused on symptoms primarily from men, both women and healthcare providers may fail to recognize women's different symptoms as cardiac in nature, thus promoting further delay in treatment.
Gender bias in the treatment of heart disease is documented in many research studies concerning differences in diagnosis and treatment of women. With regards to cardiovascular disease, women have fewer diagnostic tests, angiographic procedures, 27 thrombolytic administrations, implantable cardioverter defibrillators,21 coronary artery bypass surgeries, 28 and heart transplantations 21 than do their male counterparts. Consequently, gender disparities may play a role in the relationship of how women perceive themselves and their signs and symptoms of illness, and quite possibly contribute to the extended delay times that women exhibit before seeking treatment for AMI. 29
Because mortality and morbidity are unduly high when treatment is delayed, many researchers have attempted to explain why women delay longer than do men before seeking treatment for symptoms of AMI; however, to date, consensus does not exist. Therefore, the purpose of this scholarly inquiry was to synthesize the literature focusing on reasons women delay in seeking treatment and hypothesize upon the primary reason(s) for this delay. Development of future interventions that will reduce prehospital delay can then be grounded upon best scientific evidence.
A broad conceptual definition of prehospital delay, signs and symptoms, and treatment-seeking activities will be used. Specifically, prehospital delay is defined as the time from when the individual first notices a symptom, recognizes the symptom as a sign of illness, and decides to seek medical assistance as evidenced by leaving in a personal car or by contacting the emergency medical system (EMS). Although there is no uniform presenting syndrome for patients with an AMI, 30 Goldberg et al's study on AMI symptom presentation is utilized to operationally define the following as typical signs and symptoms: (a) pain in the chest, back, arms, shoulders, and/or jaw; (b) nausea, vomiting, heartburn, or epigastric discomfort; (c) diaphoresis; (d) shortness of breath (SOB) of any description; (e) syncope or any feeling of faintness. 16Treatment-seeking activities is defined as either calling the EMS or arranging transport in a personal vehicle.
State of Knowledge Before 1995
Three major reviews summarize the foundation for this update on delay in seeking treatment. The earliest review by Dracup and Moser surveyed 20 years of research to identify variables related to delay in treatment-seeking behavior of patients with symptoms of AMI. 8 Variables that decreased delay were recognition that symptoms were cardiac in origin; hemodynamic instability in people with large infarcts; seeking advice from a coworker, and sometimes, the severity of chest pain. A history of heart disease that may have been expected to decrease delay time actually had no effect. The salient variables that increased delay time included prior diagnosed hypertension, diabetes, or angina; African American (AA) race; consultation with a physician or family member; symptom experience during daylight hours; and a decision to self-treat symptoms. Variables that had slight increases in delay but appeared insignificant at this time were female sex and older age. The authors suggested that role theory, in particular symbolic interactionism, instead of the medical model be used to link the variables because other people had important roles in the process of seeking treatment.
Variables of 3 models formed the structure for a second review of the literature. 31 The models reviewed for their applicability to the “delay in seeking treatment for an AMI” issue were as follows: (a) the health belief model, which is based on motivational theory; (b) the self-regulation model of coping with health threats (Leventhal); and (c) symbolic interactionism, which is based on the sociological role theory. The following 4 concepts from these models addressed the delay issue: (a) the act of decision, (b) the individual's self-concept, (c) the counterroles played by others, and (d) periodic evaluation of the situation.
Act of decision variables include coping mechanisms, clinical status, and medical history. Those people who believe that their symptoms are cardiac in origin or that they are having an AMI seek help quickly. Prior research shows that distraction as a coping mechanism, attribution of symptoms to other causes, and slowly progressive trajectories tend to increase delay. Amazingly, people with a known risk for coronary heart disease, a prior history of AMI, congestive heart failure (CHF), a prior bypass surgery (coronary artery bypass graft [CABG]), angina, and, diabetes tended to have increased delay times. Indeed, even the intensity or presence of chest pain has not differentiated delayers from nondelayers. 31
Self-concept variables include sociodemographic factors of age, gender, race, socioeconomic status, education, and personality type. Despite some conflicting research, clinical studies with large sample sizes correlate increasing age with increasing delay, with regression analysis 2 studies identified older age as a risk factor for increased delay. Substantial studies indicate that women delayed 1 to 5 hours longer than did men. The scant research on minority groups and lower socioeconomic groups suggests these groups delay longer than do white men and women. Education, knowledge about AMI, and type A/B personality types do not necessarily reduce delay. Only people with somatic and emotional awareness of themselves appear to reduce delay. 31
Also included in the review by Dracup et al 31 was a description of counterrole variables, which are contextual and include witnessing, consulting a physician, time of day, day of week, activity, and place. The closer the relationship to the witness, the longer the time delay. Consulting a physician increases delay. Time of day, day of week, activity, and place give conflicting evidence. As might be anticipated, self-treatment as part of periodic evaluation significantly increases delay time. This review ends with 7 recommendations for further research including one to develop a theoretical model to assess the overall process rather than individual variables. It also appears that recognizing the symptoms as a heart attack, labeling, is a key issue in the decision of the person to seek treatment.
Lee's review focused on delay in AA populations where prior research indicates that AA people have longer delays than do whites. 32 Previous research suggests that AAs have more dyspnea than chest pain, which results in mislabeling the situation. Higher socioeconomic status in AAs results in a decreased delay time compared to AAs in lower socioeconomic status who use public hospitals. Even AA patients with acute chest pain who were poor, uninsured, or without a regular physician experienced significantly longer delay times. AAs have more hypertension than coronary artery disease, which was suggested to influence the difference in symptoms.
Integrative reviews of research literature provide essential information to conceptualize strengths and weaknesses in knowledge to develop interventions that maximize patient outcomes and move knowledge forward. Guidelines for conducting rigorous integrative reviews use the same standards of clarity, rigor, and replication as an experimental research design. 33 Cooper identified 5 stages of a research synthesis: (a) problem formulation; (b) data collection, or the literature search; (c) data evaluation, or the assessment of the quality of the studies; (d) analysis and interpretation; and (e) presentation of results. 33 Cooper's stages will be used as a framework to summarize past research and to draw overall thematic conclusions from the many separate investigations that address women's prehospital delay in seeking treatment for the signs and symptoms of an AMI.
This meta-synthesis of the literature includes an exhaustive search of published literature in English on reasons for delays in seeking treatment in women experiencing the signs and symptoms of an AMI. Medline, CINAHL, and PsychINFO databases were searched from 1995 with multiple subject headings and keyword combinations. Headings and keywords in the 3 databases had to include a heading or keyword in the first group with a heading or keyword in the second group: (1) myocardial infarction, acute coronary symptoms, heart attack, chest pain, angina and (2) delay, prehospital delay, treatment seeking, care seeking, help seeking, timely treatment, treatment delay, time factors, action, hospital arrival, emergency medical care, symptoms, decisions, decision making, women, and gender differences. Further inclusion criteria mandate the subject-matter of each study to include the following: (1) reasons, causes, and/or factors, or (2) interventions, and (3) delay, and (4) individuals who experienced signs and symptoms of/or experienced an AMI. Since women were the primary focus of this review, all studies were required to have at least 25% of their sample to be women. Men were not excluded from this review because of the applicability of reasons for delay that may crossover to the population of women. The electronic searches were supplemented by the ancestry approach described by Cooper, in which the reference lists of original reports are also reviewed for applicability and utilization. 33
Inclusion criteria for this synthesis included all published studies since 1995, including a separate section synthesizing the 3 published reviews of treatment-seeking delay in the event of an AMI. Inclusion of the previous research reviews provided understandings and knowledge from 20 years prior to 1995.
Exclusion criteria consisted of articles representing opinions or discussions, and not presenting original research. Reports that were not included in the data analysis group (a) did not address both concepts linking factors or reasons and prehospital delay; (b) were directed toward in-hospital time to treatment, EMS usage, general coronary artery disease articles, health behavior, or statistics; (c) did not have at least 25% women represented in their sampled population; and (d) reported on gender bias in treatment, or gender differences in AMI, and did not study prehospital delay.
In an attempt to retrieve an entire population of studies, 215 research reports and articles were exhumed, fully read, and reviewed. Articles were deleted according to inclusion and exclusion criteria, resulting in 48 studies that met criteria. Thirty-nine studies were descriptive, 4 experimental in design, including 2 randomized controlled trials, and 5 used qualitative methodology. The number of reports was further reduced by grouping into the following 3 major classifications: (a) clinical factors, including the nature and physiological component of the symptoms; (b) psychosocial factors, including emotional, cognitive, and behavioral responses in seeking treatment; and (c) sociodemographic factors, including age, gender, socioeconomic status, and ethnic factors identified as related to prehospital delay after AMI.
The sampled 48 reports used for analysis of reasons why women exhibit longer prehospital delay times were from around the world. Studies included people from the United States, Canada, United Kingdom, Switzerland, Singapore, Denmark, Scotland, Australia, Sweden, the Netherlands, Iran, and the 14 countries of the Global Registry of Acute Coronary Events (GRACE) report. Different states in the United States were embodied with all regions in the United States represented, but overall, the studies were lacking in minority representation. From the 48 studies, the total sample size for this synthesis was N = 1,051,382. Further demographic characteristics of the subjects sampled are included in Table 1. Three reports studied only women, 15,34,35 and 13 contrasted gender with factors related to prehospital delay after experiencing signs and symptoms of AMI (see Table 2, denoted by †). The other reports studied factors related to delay in mixed samples of both men and women. The number of minority women included in the studies could not be determined, but was considered to be very small, giving a low percentage of minority representation overall. This is consistent with the continued lack of adequate representation of women and minorities in cardiac studies also noted by others. 17,71
Data were extrapolated from each individual report and entered into Reference Manager Software, version 9.5. Program code sheets were developed within Reference Manager to reduce and organize data and to provide a means of searching and retrieving studies by keyword coding. Data on the code sheets included reference identification number, author, publication date, journal name, volume and issue, sample size, demographic characteristics of the sample, type of study, location of study, method of analysis, listing of keywords specific to the article, objective of study, results of study, conclusions, limitations, and notes. This software allows one to search for keywords or terms throughout the database, retrieve specific information from multiple studies, and group commonalities and/or differences within the database. Each coding sheet was printed and organized into 1 of the 3 categories: clinical, sociodemographic, and/or psychosocial factors. Information from the coded sheets was then entered and reduced into table format to give a summary of each study (see Table 2).
Cooper described evaluation of synthesis studies as judging the adequacy of each individual study by examining the validity of the study's methods. 33 Within the topic area of reasons for delay in seeking treatment for symptoms of AMI, descriptive studies were most prominent. There were 4 experimental or quasi-experimental studies that manipulated study time, but in the process also identified reasons for delay. 37,47,55,60 Qualitative methodology was used in 5 investigations providing depth and insight into the psychosocial factors involved in delayed treatment-seeking. Each of the retrieved studies was judged valid for inclusion in the review by Cooper's criteria. Strength of evidence was underscored by the consistency in reports about reasons for delay in seeking treatment and implications for the female gender. Further omissions of articles by restricting study types, methodologies, or sample characteristics could make the conclusions unreliable. 33
Analysis and Interpretation
After further analysis of the 48 research articles, significant factors for delay in each investigation were categorized as clinical in nature, sociodemographic variables, or psychosocial factors. A summary of each investigation is given in Table 2. Study location, sample size, mean age of sample, female sample size, investigation type and purpose, and study outcomes that were found to be related to prehospital delay time for each report are specified.
Interpretation and Presentation of Results
The purpose of this inquiry was to summarize the overall explanations given in this collective of previous research on why women delay in seeking treatment after the onset of the signs and symptoms of an AMI. Although a single reason could not be extrapolated from the current research into this delay, several explanations were collectively supported, and possible explanations for increased prehospital delay are discussed.
Clinical factors were investigated in 24 of the 48 reports and encompassed the physiological variables that influence prehospital delay, such as symptom presentation and the characteristics of the symptoms themselves. Specifically, the clinical factors found to affect delay according to the collective of data were as follows: (1) typical or atypical symptom presentation, (2) severity of symptoms, (3) influence of comorbidities or chronic illnesses, and (4) history of smoking.
The presentation of atypical symptoms and the severity of symptom presentation had the greatest influence on prehospital delay time. Each was repeatedly inversely associated with prehospital delay time. In fact, the great majority of studies that examined clinical factors noted the significance that atypical presenting symptoms had on increasing prehospital delay. Upon comparative examination of the studies addressing prehospital delay with regard to gender, a key influence for delay is symptom presentation in women—more often atypical, identified as nonspecific, slowly progressing in severity, or not severe, all influencing longer delay times. Additionally, the largest studies containing substantial sample sizes and power supported the effect that atypical clinical presentation had on delay. 17,42
The majority of the investigators agree that the more severe the symptoms were, the sooner the individual in their study sought treatment. Of the 11 studies that included a measure of symptom severity, 7,11,17,36,41,44,46,49,59,61,70 2 studies did not identify that increased severity of symptoms was associated with a reduced delay time. 41,44 Thirteen studies supported the association of atypical symptoms with longer delays in seeking treatment, 10,16,36,42,59,44,51,54,57,62,64,65,68 with 2 studies demonstrating no difference in delay time with typical versus atypical symptom presentation. 14,39 Smaller sample sizes, or longer delay times in both typical and atypical symptom groups, may have diminished the ability to detect significant outcomes in the 2 nonconforming reports. In contrast with Dracup et al's review, 31 atypical presentation was not consistently identified with delay prior to 1995. The authors reported that the presence or absence of chest pain had no effect on treatment-seeking time, but, consistent with the theme of atypical presentation, did note that those with slowly progressing symptoms experienced significant delays.
The data for this review strongly support the premise that patients with a history of comorbidities delay for much longer intervals before seeking treatment than do those without chronic illnesses. The comorbidities identified associated with markedly increased delay time in AMI responders are diabetes, 11,14,17,44,49,52,57,59,67 angina, 11,49,50,62,67 hypertension, 17,48,49,51,67 and other chronic conditions such as CHF, stroke, and chronic pulmonary disease. 42,49,51,67 Yet, individuals with a history of having an AMI or a recent cardiac procedure have an overall decreased delay interval in seeking treatment. 11,17,18,48–51,59,60,67,69
Patients with chronic illnesses visit their health providers regularly, yet, the data support that these individuals delay longer than do those without chronic illnesses. This is a perplexing issue, and may represent a failure in the healthcare field to provide adequate information or teaching to these high-risk patients. Counseling about one's high-risk profile of AMI, or the right type of education, may not be given to these individuals who are regularly seen by healthcare providers. 10,62,72
An explanation of delay in the older aged and those with comorbidities is the learned behaviors of self-management and self-treatment in dealing with day-to-day chronic illness, which has led to self-reliance and regulation of symptoms. The Self-Regulatory Theory conceptualized by Leventhal and others offers a possible explanation for this delay. 73 Simply stated, the individual has the goal of self-management of one's disease state, upon onset of symptoms the individual evaluates the symptoms and makes plans to deal with them, if these coping strategies are not effective, reevaluation and adjustments are made to again regulate the symptoms. It is only when continued coping fails, that the individual may seek treatment. Consequently, individuals who cope daily with symptoms of chronic illness may not choose to seek treatment initially because they may wrongly evaluate the presenting symptoms, attributing them to their preexisting illness, and because they have acquired patterns of coping with these problems.
Although smokers should know that they are at higher risk for an AMI because of media education and attention, smoking was an inconsistent variable in delay time. Three investigations associated smoking with decreased delay, 36,48,49 with others finding no association with prehospital delay time. 11,52
Five reports focused only on characteristics and descriptions of patients who delayed, but many studies included this information as part of the demographic profile of delayers. The sociodemographic and temporal factors identified in this synthesis as affecting delay time are listed according to the frequency of study: (1) female gender, (2) older age, (3) minority groups, (4) low income, (5) lower educational level, (6) living alone, (7) after routine office hours, and (8) insurance coverage.
The sociodemographic factors that describe the candidate most likely to delay in presentation to the hospital after symptoms and signs of an AMI are as follows: women, older-aged individuals, minorities, those with a low income and a lower educational level, and individuals living alone. The characteristics of prehospital delay that are derived from data analysis of this synthesis are representative of the characteristics for delay according to National Institutes of Health, National Heart, Lung, and Blood Institute publication 66,74 (refer to Table 3).
According to data in this review, the sociodemographic factors presented are current risk factors for delay that have been consistent with time. The 3 reviews also support this profile, with the exception of inconsistencies in gender, low socioeconomic status, and low educational levels, which were understudied prior to 1995.
Contradictory evidence continues to be found in relation to gender. In scattered studies throughout the last 20 years, significant differences in delay time between men and women have not been demonstrated. Several studies in this review did not demonstrate longer delay intervals for women. 16,44,52,70 Research studies that do not exhibit women's longer delay intervals remain perplexing, and may be the result of regional differences, statistical technique, or small sample sizes. The studies with the largest sample sizes demonstrate that women delay longer than do men: Canto et al. (N = 434,877) 42; Gibler et al (N = 27,849) 48; and Sheifer et al (N = 102,339). 67
Low socioeconomic status and, especially, education have been independently associated with an increased risk of all cardiovascular diseases. 75,76 Education may not only serve as a means to increase knowledge, but may also influence lifestyle behaviors and enable problem-solving abilities. Higher education, higher income levels, and medical insurance have been described as enabling factors for access to healthcare by others. 72,73
Consistent with findings prior to 1995, this analysis demonstrates that older-aged individuals of both genders tend to have a longer prehospital delay than do their younger counterparts. Also consistent with the reviews, women were identified as having a longer prehospital delay time. With the largest and most representative sample of US patients admitted for cardiac ischemia, Goff et al 64 explained that the demographic differences found in delay represent substantial cultural and socioeconomic barriers that must be overcome to affect change in these groups. Elderly women have been referred to as the poorest of the poor, and more often have the combined influences of poverty, barriers of access to treatment, and living alone. This review suggests there are barriers to treatment for older aged, women, and minorities, but more research is needed with these populations.
Canto et al investigated clinical and sociodemographic characteristics in their large multicenter study. The researchers found that 33% of their large sample (N = 434,877) did not have chest pain (atypical presentation), a higher proportion of these being the aged and women. Furthermore, this sample of delayers also had a higher prevalence of comorbidities, a risk factor already mentioned. 42 Consequently, a combination of several different factors, including the atypical nature of symptoms, dealing with symptoms from chronic illnesses, and psychosocial factors to be discussed, increase the likelihood of delay in women and older-aged individuals.
Women have traditionally put their families and house obligations before their own health. 27,30 The implication is that subtle signs of impending AMI experienced by many women, such as mild angina or fatigue, may not be acknowledged as important enough to put aside family obligations to seek treatment. McSweeney and Neill suggested that women's reactions to pain and sickness are culturally mediated and may be expressed in a different manner than in men. 26,71
Ethnicity related to delay in seeking treatment needs further study, although data in this review illustrate that minority groups delay longer before seeking treatment than do whites. 10,13,17,40,42,45,48,65,67,70 Additionally, 3 of the reviewed studies reveal that pain perception and pain threshold seem to be different for minorities, influencing longer delay times. 10,13,31 In exploring ethnic pain styles in the AMI patient, Neill suggested that through modeling of families or others in their culture, people acquire integrated patterns of behavior and these patterns mediate perceptions and subsequent responses, such as pain. 71 This further underscores the emphasis that culture, role, and ethnicity has on perception, expressions, and evaluations of symptoms.
The only temporal variable that trended toward longer delay time was the onset of symptoms after normal office hours. This may play a part in the affective response of the patient: “not wanting to bother anyone” or being “embarrassed if it turns out to be nothing.” Both emotional responses are associated with increased delay time. 45,57,58
Psychosocial variables include the emotional, cognitive, and behavioral responses by the individual when experiencing symptoms. These responses include the patient's thoughts about the symptoms of AMI, and her/his coping strategies. Twenty-seven of the 48 reports discuss psychosocial reasons for treatment-seeking delay (see Table 2). The psychosocial factors identified in this synthesis according to frequency are as follows: (1) correct attribution of symptoms to the heart, (2) perceived seriousness of symptoms, (3) contacting others for advice, (4) low self-perceived risk of AMI, (5) self-treatment strategies, (6) various other coping strategies, (7) knowledge of symptoms or risk factors for heart attack, (8) presenting symptoms did not match expectations, and (9) symptom uncertainty.
From the data, the most significant psychosocial reason is the correct interpretation and attribution of presenting symptoms, more often concluding in treatment-seeking actions by the patient. Twelve investigations support the assumption that patients who correctly attribute their presenting symptoms to their hearts have decreased delay intervals. 7,24,34,38,41,44–46,54,57,61,66 Similarly, 6 investigations examined perceived seriousness of presenting symptoms and reported that if the symptoms were not perceived by the individual as serious in nature, substantial delays occurred. 7,15,24,41,44,57 Data support the assumption that women do not perceive themselves as much at risk for heart attack as do men, contributing to substantial treatment-seeking delays with AMI. 25,34,45,46,61 As a rule, the media has driven a social construction of the male norm for heart disease, which has promoted an idea that women are not the “type of person” who has a heart attack. This erroneous interpretation of women's risk perception is further supported by surveys that indicate that women overwhelmingly (76%) identify cancer, particularly breast cancer, as their most serious health threat. 77,78 In summary, women, more often than men, did not interpret their symptoms as cardiac in nature, did not perceive them as serious, and engaged in more consultations with sons or daughters and other coping strategies. These actions contribute substantially to prehospital delay.
Knowledge of symptoms and signs of AMI was associated with shortened delay times in 5 of the investigations. 38,39,45,46,66 Although knowledge of symptoms did not compel one to take action in 4 studies, 38,44,55,60 the Rapid Early Action for Coronary Treatment (REACT) trial, the largest theoretically grounded, randomized controlled trial yet undertaken, used mass media public education and other methods to increase knowledge and awareness of heart attack. Unfortunately, delay time was not reduced in the intervention communities despite multifaceted educational interventions. 55 A possible explanation is offered according to the Transtheoretical Model of Behavior Change. Consciousness-raising education and media campaigns affect awareness about causes, consequences, and cures for a particular problem, but if the population is not prepared to take action, or do not perceive themselves to be vulnerable, they will not be served by these prevention programs. 73
Other psychosocial variables that are identified by the data less often, but reported as influencing increased delay in seeking treatment for symptoms of AMI, include various coping strategies like waiting, 10,44,57,61,63 self-treatment with medications and rest, 15,36,61,66,70 and consulting others for advice. 24,25,45,52,66 Additionally, when presenting symptoms do not match with the patient's expectations of the symptoms, prolonged delay resulted. 30,45,70 Feelings of uncertainty, 7,35,58 fearing embarrassment, 45,53,58 and fearing consequences of action 44,57 were also related to an increased delay time interval.
The nonproductive coping mechanisms and behavioral responses to symptoms of AMI entreat intervention. Dracup and Moser discovered that after having symptoms of AMI, about 10% of their patients did not take any action in regard to their symptoms. 44 Similarly, this research demonstrates that women experience much uncertainty when faced with the decision of seeking treatment. Women also experienced difficulty when interpreting and labeling the origin of symptoms to the heart. When women did label and attribute their symptoms correctly, prehospital delay time was reduced. Future research including these multifaceted aspects of decision making is recommended by the analysis of this data.
Researchers to-date have not been able to develop an intervention that considers psychosocial variables in such a way as to reduce treatment-seeking delay. Information from this analysis demonstrates that a single variable will not significantly influence delay time. To affect decision making and learned behavioral responses, a holistic and multifaceted approach to intervention is required.
This synthesis reported data from 48 investigations in an attempt to explain why women delay longer than do men before seeking treatment for symptoms of AMI. Information was presented from 1969 (review data) until the present, to bring the reader up-to-date with the state of knowledge obtained from the collective of investigations to 2003. Limitations of this synthesis include the exclusion of unpublished reports and investigations in progress. Furthermore, no meta-analytic techniques were used for the synthesis except frequency and mean reporting. Strengths include an exhaustive study of the literature and an extensive table from which to link investigations to information and outcomes.
1. American Heart Association. Heart Disease and Stroke Statistics—2003 Update
. Dallas, Tex: American Heart Association; 2002.
2. Mosca L, Manson JE, Sutherland SE, Langer RD, ManolioT, Barrett-Connor E. Cardiovascular Disease in Women: A Statement for Healthcare Professionals From the American Heart Association
. Dallas, Tex: American Heart Association 1997. Available at: http://www.americanheart.org
. Accessed June, 2001.
3. Ryan TJ, Antman EM, Brooks NH, et al. ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction
. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Dallas, Tex: American Heart Association; 1999.
4. Berger PB, Ellis SG, Holmes DR, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction
: results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial. Circulation
5. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction
: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Lancet
6. The ISIS-2 Collaborative Group. ISIS-2: 10 year survival among patients with suspected acute myocardial infarction
in randomized comparison of intravenous streptokinase, oral aspirin, both, or neither. Br Med J
7. Meischke H, Ho MT, Eisenberg MS, Schaeffer SM, Larsen MP. Reasons patients with chest pain delay or do not call 911. Ann Emerg Med
8. Dracup K, Moser DK. Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction
. Heart Lung
. 1991;20(5, pt 2):570–575.
9. Ghali JK, Cooper RS, Kowatly I, Liao Y. Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients. J Nat Med Assoc
10. Lee H, Bahler R, Chung C, Alonzo A, Zeller RA. Prehospital delay with myocardial infarction
: the interactive effect of clinical symptoms and race. Appl Nurs Res
11. Ottesen MM, Kober L, Jorgensen S, Torp-Pedersen C. Determinants of delay between symptoms and hospital admission in 5978 patients with acute myocardial infarction
. Eur Heart J
12. Newby K. Clinical outcomes according to time to treatment. Clin Cardiol
. 1997;20(suppl III):11–15.
13. Goff DC, Feldman HA, McGovern PG, et al. Prehospital delay in patients hospitalized with heart attack symptoms in the United States: the REACT trial. Am Heart J
14. Brophy JM, Diodati JG, Bogaty P, Theroux P, on behalf of the Quebec Acute Coronary Care Working Group. The delay to thrombolysis: an analysis of hospital and patient characteristics. Can Med Assoc J
15. Dempsey SJ, Dracup K, Moser DK. Women
's decision to seek care for symptoms of acute myocardial infarction
. Heart Lung
16. Goldberg RJ, O'Donnell C, Yarzebski J, Bigelow C, Savageau J, Gore JM. Sex differences in symptom presentation associated with acute myocardial infarction
: a population-based perspective. Am Heart J
17. Goldberg RJ, Gurwitz JH, Gore JM. 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
18. Meischke H, Eisenberg MS, Larsen MP. Prehospital delay interval for patients who use emergency medical services: the effect of heart-related medical conditions and demographic variables. Ann Emerg Med
19. Pittman DA, Kirkpatrick M. Women
's health and the acute myocardial infarction
. Nurs Outlook
20. Wenger NK, Speroff L, Packard B. Cardiovascular health and disease in women
. N Engl J Med
21. Beery TA. Gender bias in the diagnosis and treatment of coronary artery disease. Heart Lung
22. Ziegler J. The gender gap: health care's next frontier. Bus Health
23. Jensen L, King KM. Women
and heart disease: the issues. Crit Care Nurse
24. Leslie W, Urie A, Hooper J, Morrison C. Delay in calling for help during myocardial infarction
: reasons for the delay and subsequent pattern of accessing care. Heart
25. Richards HM, Reid ME, Watt GM. Why do men and women
respond differently to chest pain? A qualitative study. J Am Med Womens Assoc
26. McSweeney JC. Women
's perceptions of the causes of their myocardial infarctions and changes in health behavior. Rehabil Nurs Res
27. Pramparo P. The first international conference on women
, heart disease and stroke: science and policy in action: diagnosis, treatment and access to care. Women
's Health Conference Summaries. 2000. Available at: Medscape.com
. Accessed July, 2002.
28. Khan SS, Nessim S, Gray R, Czer LS, Chaux A, Matloff J. Increased mortality of women
in coronary artery bypass surgery: evidence for referral bias. Ann Intern Med
29. Lefler LL. Perceived risk of heart attack: a function of gender? Nurs Forum
30. Johnson JA, King KB. Influence of expectations about symptoms on delay in seeking treatment during a myocardial infarction
. Am J Crit Care
31. Dracup K, Moser DK, Eisenberg MS, Meischke H, Alonzo A, Braslow A. Causes of delay in seeking treatment for heart attack symptoms. Soc Sci Med
32. Lee H. Typical and atypical clinical signs and symptoms of myocardial infarction
and delayed seeking of professional care among Blacks. Am J Crit Care
33. Cooper H. Synthesizing Research
. 3rd ed. London: Sage; 1998.
34. Meischke H, Yasui Y, Kuniyuki A, Bowen DJ, Andersen R, Urban N. How women
label and respond to symptoms of acute myocardial infarction
: responses to hypothetical symptom scenarios. Heart Lung
35. Schoenberg NE, Peters JC, Drew EM. Unraveling the mysteries of timing: women
's perceptions about time to treatment for cardiac symptoms. Soc Sci Med
36. Ashton KC. How men and women
with heart disease seek care: the delay experience. Prog Cardiovasc Nurs
. 1999;14:53–60, 74.
37. Blank FSJ, Smithline HA. Evaluation of an educational video for cardiac patients. Clin Nurs Res
38. Bleeker JK, Lamers LM, Leenders IM, et al. Psychological and knowledge factors related to delay of help-seeking by patients with acute myocardial infarction
. Psychother Psychosom
39. Blohm MB, Hartford M, Karlsson T, Herlitz J. Factors associated with pre-hospital and in-hospital delay time in acute myocardial infarction
: a 6-year experience. J Intern Med
40. Brown DL, Schneider DL, Colbert R, Guss D. Influence of insurance coverage on delays in seeking emergency care in patients with acute chest pain. Am J Cardiol
41. Burnett RE, Blumenthal JA, Mark DB, Leimberger JD, Califf RM. Distinguishing between early and late responders to symptoms of acute myocardial infarction
. Am J Cardiol
42. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction
presenting without chest pain. J Am Med Assoc
43. Davis LL, Evans JJ, Strickland JD, Shaw LK, Wagner GS. Delays in thrombolytic therapy for acute myocardial infarction
: association with mode of transportation to the hospital, age, sex, and race. Am J Crit Care
44. Dracup K, Moser DK. Beyond sociodemographics: factors influencing the decision to seek treatment for symptoms of acute myocardial infarction
. Heart Lung
45. Finnegan JR, Meischke H, Zapka JG, et al. Reduced delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions. Prev Med
46. Foster S, Mallik M. A comparative study of differences in the referral behavior patterns of men and women
who have experienced cardiac-related chest pain. Intensive Crit Care Nurs
47. Gaspoz JM, Unger PF, Urban P, et al. Impact of a public campaign on pre-hospital delay in patients reporting chest pain. Heart
48. Gibler WB, Armstrong PW, Ohman EM, et al. Persistence of delays in presentation and treatment for patients with acute myocardial infarction
: the GUSTO-I and GUSTO-III experience. Ann Emerg Med
49. Goldberg RJ, Steg PG, Sadiq I, et al. Extent of and factors associated with, delay to hospital presentation in patients with acute coronary disease (The GRACE registry). Am J Cardiol
50. Goldberg RJ, Yarzebski J, Lessard D, Gore JM. Decade-long trends and factors associated with time to hospital presentation is patients with acute myocardial infarction
: the Worcester Heart Attack Study. Arch Intern Med
51. Gurwitz JH, McLaughlin TJ, Willison DJ, et al. Delayed hospital presentation in patients who have had acute myocardial infarction
. Ann Intern Med
52. Ho KK, Lee SW, Ooi SBS, Lateef F, Lim SH, Anantharaman V. Acute coronary syndrome—factors causing delayed presentation at the emergency department. Ann Acad Med Singapore
53. Ho PM, Rumsfield JS, Lyons E, Every NR, Magid DJ. Lack of an association between Medicare supplemental insurance and delay in seeking emergency care for patients with myocardial infarction
. Ann Emerg Med
54. Klingler D, Green-Weir R, Nerenz D, et al. Perceptions of chest pain differ by race. Am Heart J
55. Luepker RV, Raczynski JM, Stravoula O, et al. 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. J Am Med Assoc
56. Magid DJ, Koepsell TD, Every NR, et al. Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction
. N Engl J Med
57. McKinley SM, Moser DK, Dracup K. Treatment-seeking behavior for acute myocardial infarction
symptoms in North America and Australia. Heart Lung
58. Meischke H, Mitchell P, Zapka J, et al. The emergency department experience of chest pain patients and their intention to delay care seeking for acute myocardial infarction
. Prog Cardiovasc Nurs
59. Meischke H, Larsen MP, Eisenberg MS. Gender differences in reported symptoms for acute myocardial infarction
: impact on prehospital delay time interval. Am J Emerg Med
60. Meischke H, Dulberg EM, Schaeffer SS, Henwood DK, Larsen MP, Eisenberg MS. “Call fast, call 911”: a direct mail campaign to reduce patient delay in acute myocardial infarction
. Am J Public Health
61. Meischke H, Eisenberg MS, Schaeffer SM, Damon SK, Larsen MP, Henwood D. Utilization of emergency medical services for symptoms of acute myocardial infarction
. Heart Lung
62. Mumford AD, Warr KV, Owen SJ, Fraser AG. Delays by patients in seeking treatment for acute chest pain: implications for achieving earlier thrombolysis. Postgrad Med J
63. Okhravi M. Causes for pre-hospital and in-hospital delays in acute myocardial infarction
at Tehran teaching hospitals. Aust Emerg Nurs J
64. Penque S, Halm M, Smith M, et al. Women
and coronary disease: relationship between descriptors of signs and symptoms and diagnostic and treatment course. Am J Crit Care
65. Richards SB, Funk M, Milner KA. Differences between blacks and whites with coronary heart disease in initial symptoms and in delay in seeking care. Am J Crit Care
66. Ruston A, Clayton J, Calnan M. Patients' action during their cardiac event: qualitative study exploring differences and modifiable factors. Br Med J
67. Sheifer SE, Rathore SS, Gersh BJ, et al. Time to presentation with acute myocardial infarction
in the elderly: associations with race, sex, and socioeconomic characteristics. Circulation
68. Tresch DD, Brady WJ, Aufderheide TP, Lawrence SW, Williams KJ. Comparison of elderly and younger patients with out-of-hospital chest pain. Arch Intern Med
69. Zapka JG, Oakes JM, Simons-Morton DG, et al. Missed opportunities to impact fast response to AMI symptoms. Patient Educ Couns
70. Zerwic JJ, Ryan CJ, DeVon HA, Drell MJ. Treatment seeking for acute myocardial infarction
symptoms: differences in delay across sex and race. Nurs Res
71. Neill KM. Ethnic styles in acute myocardial infarction
. West J Nurs Res
72. Goff DC, Sellers DE, McGovern PG, et al. Knowledge of heart attack symptoms in a population survey in the United States: the REACT trial. Arch Intern Med
73. Shumaker SA, Schron EB, Ockene JK, McBee WL, eds. The Handbook of Health Behavior Change
. 2nd ed. New York: Springer; 1998.
74. National Heart, Lung, and Blood Institute, Educational Strategies Working Group. Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction
. Bethesda, MD: National Institutes of Health; 1997. NIH publication no. 97-3787.
75. Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health
76. Kenyon LW, Ketterer MW, Gheorghiade M, Goldstein S. Psychological factors related to prehospital delay during acute myocardial infarction
77. American Heart Association. Women and Heart Disease: A Study Tracking Women's Awareness of and Attitudes Towards Heart Disease and Stroke
. Dallas, Tex: American Heart Association; 2000. Available at: http://www.americanheart.org
. Accessed June, 2002.
78. Legato MJ, Padus E, Slaughter E. Women
's perceptions of their general health, with special reference to their risk of coronary artery disease: results of a national telephone survey. J Womens Health
References marked with an asterisk indicate studies included in the synthesis.