When Minutes Matter: Why Do Patients Wait to Seek Treatment Following a Stroke or Heart Attack?

March 3, 2010

stopwatchLaurel Geraghty

Faculty peer reviewed

Both stroke and heart attack require rapid treatment following the onset of symptoms to minimize morbidity and mortality, but few patients seek help in a timely manner.[1] Only about half of patients with acute myocardial infarction (AMI) or stroke arrive to the emergency department within four hours of the onset of symptoms.[1],[2],[3],[4] Every 30-minute delay in treatment following AMI increases one-year mortality by 7.5%, and almost half of the 167,000 annual stroke deaths in this country occur before the patient reaches the hospital.[2],[5] Fibrinolytic therapy (tissue plasminogen activator, or tPA) improves the survival and prognosis of stroke patients if administered within 4.5 hours (ideally, within 90 minutes) of symptom onset, but only 3 to 8.5% of stroke patients receive tPA, partly due to delayed hospital arrival.[2],[5],[6],[7] The response time of medical professionals both inside and outside of the hospital is significantly less important in determining the time to treatment than patient delays in calling for help.[4],[8] So the important question remains: Why do people wait to seek medical attention when experiencing symptoms of a heart attack or stroke?

Indecision and reluctance to seek treatment are key components to the problem.[9] Many patients do not want to believe that they are having a heart attack or stroke, are not convinced that their symptoms are serious, or misattribute their symptoms to a relatively benign condition, such as acid reflux or indigestion.[4],[10] People commonly feel embarrassed about contacting a physician or emergency medical services, particularly if their symptoms occur at night or during the weekend.[4] In one study, nearly two-thirds of patients worried about troubling other people when experiencing symptoms of a stroke.[6],[11] Individuals also wait to contact emergency medical services if they perceive that they are too young to suffer from a heart attack or stroke, if they are responsible for taking care of children or others, or if they do not want to worry family members.[10] Rather than calling for help, many patients attempt to self-treat their illness by lying down or taking an aspirin, wishing or praying for symptoms to disappear, trying to relax, or discussing the symptoms with others, such as a friend, family member, or a primary care physician.[4],[12] These approaches cause significant delays or do not improve hospital arrival times.[4],[12] Ultimately, patients call 911 or present to the emergency room when they begin to feel incapable of comprehending or handling the situation due to a persistent sense of illness, discomfort, or pain.[13]

Only a few factors have been found to reduce the time it takes for patients to call for help. Those who correctly attribute their symptoms to heart attack or stroke, acknowledge that their symptoms are serious, or have feelings of anxiety about their symptoms are most likely to seek medical treatment quickly.[4],[6] Evidence suggests that those who view themselves as worthy of receiving care, or who consider others trustworthy to provide good medical care, are less likely to delay.[14] Among stroke patients, factors associated with reduced time to hospital arrival include severe neurologic impairment, facial droop, language impairment, and the presence of more than one symptom.[6]

Surprisingly, increased awareness of the symptoms and risk factors for heart attack and stroke does not prompt people to seek medical care rapidly.[4],[6],[9] Individuals with a history of AMI actually wait longer to get help than those experiencing their first cardiac event.[4] In addition, a recent study found that patients with AMI do not delay if they have fewer symptoms, but if they have a history of more symptoms, such as increased frequency of angina.[14] Women, blacks, Latinos, older individuals, patients of low socioeconomic status, those with limited education, and people who are untrusting of others are also more likely to stall before enlisting medical help for AMI or stroke, and may therefore face a worse prognosis.[4],[14]

Although over a hundred studies have examined factors contributing to treatment delays after a heart attack or stroke, educational programs geared to the public have so far failed to reduce hospital arrival times.[4],[9],[15] Most efforts have focused on teaching people to recognize the symptoms of acute coronary events and stroke.9 However, recent evidence indicates that patients don’t hesitate to seek medical attention because they are insufficiently fearful or knowledgeable about symptoms, but because they are too fearful of these conditions, suggesting that alternate strategies may be warranted.[9],[14] Some researchers recommend assisted-navigator programs, which educate high-risk individuals about how to seek medical help when experiencing symptoms of AMI or stroke.[14] The use of emergency medical services should be encouraged, since arrival to the emergency department by ambulance is associated with significantly shorter hospital arrival times and decreased treatment times once inside the hospital.[1],[16] The most effective strategy for speeding patient presentation may be multipronged: targeting high-risk patients, tailoring educational programs to different demographics, individuals, and personality types, and addressing common behaviors that contribute to the all-too-common wait-and-see approach.[4]

Laurel Geraghty is a 3rd year medical student at NYU School of Medicine.

 Commentary by Dr. Douglas Bails

The author makes compelling points regarding the poor rates of expedited presentation to the hospital after acute myocardial infarction and stroke. It is not ambulance response times or hospital inefficiency but patient-related factors that contribute the most to the significant delays we are seeing. Most surprisingly, it appears that the poor rates may not be due to poor education or awareness but to excessive fear regarding stroke and MI. Given these patient-related factors, the author’s suggestions for improvement seem to be on the mark: education and behavior modification of high-risk patients.

References

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[1]. Frankel M, Hinchey J, Schwamm LH, et al. Prehospital and hospital delays after stroke onset-United States, 2005-2006. MMWR. 2007;56(19);474-478.

[2] Reeves MJ, Arora S, Broderick JP, et al. Acute stroke care in the US; results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke. 2005;36(6):1232-1240.

[3] Evenson KR, Foraker RE, Morris DL, Rosamond WD. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke. 2009;4(3):187-199.

[4] Moser DK, Kimble LP, Alberts MJ, et al. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council . Circulation. 2006;114(2):168-182.

[5] De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004;109(10):1223-1225.

[6] Bouckaert M, Lemmens R, Thijs V. Reducing prehospital delay in acute stroke. Nat Rev Neurol. 2009;5(9):477-483.

 [7] Lansberg MG, Bluhmki E, Thijs VN. Efficacy and safety of tissue plasminogen activator 3 to 4.5 hours after acute ischemic stroke: a metaanalysis. Stroke. 2009;40(7): 2438-2441.

 [8] Dracup K, Moser DK, Eisenberg M, Meischke H, Alonzo AA, Braslow A. Causes of delay in seeking treatment for heart attack symptoms. Soc Sci Med. 1995;40(3):379-392.

 [9] Dracup K. The challenge of reducing prehospital delay in patients with acute coronary syndrome. Circ Cardiovasc Qual Outcomes. 2009;2:144-145.

[10] Heart attack-symptoms. Cleveland Clinic. http://my.clevelandclinic.org/heart/disorders/cad/mi_symptoms.aspx. Copyright 2009 Cleveland Clinic. Accessed October 23, 2009.

[11] Shah M, Makinde KA, Thomas P. Cognitive and behavioral aspects affecting early referral of acute stroke patients to hospital. J Stroke Cerebrovasc Dis. 2007;16(2):71-76.

[12] Zegrean M, Fox-Wasylyshyn SM, El-Masri MM. Alternative coping strategies and decision delay in seeking care for acute myocardial infarction. J Cardiovasc Nurs. 2009;24(2):151-155.

 [13] Nymark C, Mattiasson AC, Henriksson P, Kiessling A. The turning point: from self-regulative illness behavior to care-seeking in patients with an acute myocardial infarction [published online ahead of print Sept. 4, 2009]. J Clin Nurs. 2009;18(23):3358-3365.

[14] Sullivan MD, Ciechanowski PS, Russo JE, et al. Understanding why patients delay seeking care for acute coronary syndromes. Circ Cardiovasc Qual Outcomes. 2009;2:148-154.

[15] Kainth A, Hewitt A, Sowden A, et al. Systematic review of interventions to reduce delay in patients with suspected heart attack. Emerg Med J. 2004;21(4):506-508.

[16] Morris DL, Rosamond W, Madden K, Schultz C, Hamilton S. Prehospital and emergency department delays after acute stroke: the Genentech Stroke Presentation Survey. Stroke. 2000:31(11):2585-2590.

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