By Christine M. Crumlish, PhD, RN, CS, CCRN, Julie Bracken, MS, RN, CEN, Mary M. Hand, MSPH, RN, Kathleen Keenan, RN, CCRN, Hannah Ruggiero, RN, COHN-S, and David Simmons, MSN, RN, CNN

Every minute spent praying, chewing antacids, or trying to relax after the onset of acute myocardial infarction symptoms leads to irreversible heart damage and, possibly, death. But that’s exactly how thousands of Americans respond. Nurses can change this picture.

An hour can often seem insignificant: How many 60-minute fragments do most of us spend getting to work, reading the paper, or sipping coffee? But that very same hour has grave significance for someone suffering from acute myocardial infarction (AMI). It will most likely determine his fate.

Approximately 1.1 million Americans suffer an AMI every year; nearly 500,000 of them die. At least half of these deaths occur within 60 minutes of symptom onset and before patients reach the hospital. 1 {note: the #s refer to the references at the end of the article}

It doesn’t have to be this way.

In recent years, treatments that reestablish coronary artery blood flow have been developed to halt or reduce the damage caused by an AMI—even while it’s in progress. One such treatment is acute reperfusion therapy, which involves the use of pharmacologic methods, such as thrombolytic drugs (streptokinase or recombinant tissue plasminogen activator, for instance), or mechanical methods, such as angioplasty, coronary artery bypass surgery, or coronary stenting. Adjunctive approaches using anticoagulant and antiplatelet agents can enhance reperfusion and prevent reocclusion. Treatment with beta blockers can minimize the long-term damage caused by AMI.2, 3

But the success of these treatments—particularly thrombolytic therapy—depends on how quickly they are initiated. The shorter the period between symptom onset and treatment, the better the resulting cardiac function and the greater the number of lives saved. The goal is “60 minutes to treatment” (according to the National Heart Attack Alert Program [NHAAP] of the National Heart, Lung, and Blood Institute [NHLBI], National Institutes of Health).4

The reality, however, is still far from that goal—only 5% of patients presently receive reperfusion therapy within the first crucial hour after symptom onset. This is primarily because patients arrive at the emergency department too late. 5

Why the Delay?

Delays in hospital presentation can occur at any point—when the patient first experiences AMI symptoms, during transport (whether by emergency medical services [EMS] or by car), or after arrival in the emergency department. But the delay most often occurs before the patient arrives at the hospital.  Median delays from symptom onset until arrival at the hospital reportedly range from two to 6.4 hours, with more than half of all patients delaying more than four hours.6, 7   The mean delay time (4.6 to 25 hours) is even longer because some patients wait hours or even days before seeking treatment.  6, 7

Why do people delay? The reasons vary but usually include the following.

Uncertainty or misconception. Classic symptoms of AMI include uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting more than a few minutes; pain that spreads to the shoulders, neck, or arms; or chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath.1 But many people don’t recognize their symptoms as heart related.6, 8 This may be because they don’t experience the classic symptoms of AMI. Less common warning signs of AMI include atypical chest pain; stomach or abdominal pain; nausea or dizziness; shortness of breath and difficulty breathing; unexplained anxiety, weakness, or fatigue; and palpitations, cold sweats, or pallor.1 Another reason is that many people expect an AMI to be accompanied by a sudden, crushing chest pain, followed by unconsciousness—as portrayed by the media.9  Symptoms that don’t disrupt activities of daily living, therefore, tend to be dismissed.10

What Factors Affect Delay?

uncertainty about or misconception of AMI symptoms denial consulting with family or a physician instead of going directly to the ED gender (women) race (blacks and Hispanics) age (over 55 years) presence of other chronic conditions, such as diabetes or hypertension low socioeconomic status

But a “Hollywood heart attack” is quite different from a real one. Patients and bystanders have revealed in focus groups that their experience was markedly distinct from their expectations.11  Patients whose expectations matched their experience sought treatment faster. 10

Denial. Patients may also experience some degree of denial or disbelief when faced with cardiac symptoms (see The Heart of Denial, May 1999). They may attribute symptoms to some other source or condition and “wait it out.” One study showed that the majority of patients with chest pain initially responded by relaxing, taking antacids, or praying.6 Older people, individuals with chronic conditions, and those who perceive themselves to be at low risk are most likely to deny their symptoms.11 This also seems to hold true for people who’ve had a previous AMI.

Consulting with family or a physician. Patients who consult with a family member or a physician have a tendency to delay presentation.12 Family members may share the patient’s denial or be unwilling to confront it. Increases in delay associated with physician consultation may be attributed to the physician’s belief that the symptom isn’t cardiac in nature, the physician’s recommendation that the patient self-medicate, or the physician’s unavailability, in which case the patient may wait for a response.

Conversely, the patient who experiences symptoms in the company of an unrelated person—a friend, coworker, or stranger—is less likely to delay taking appropriate action. This is because an unrelated person is more willing to challenge the patient’s denial of symptoms and less likely to take on the responsibility of a negative outcome.12

Reducing Delay:  Points to Remember

At Home
If you’re a community nurse or are involved in discharge planning at the hospital educate patients about AMI symptoms and the best responses to these indicators. work out an action plan with patients and their families. prepare patients and their families to initiate the action plan if symptoms occur.
At Work
If you’re a workplace nurse advise employees to familiarize themselves with workplace protocols regarding cardiac emergencies. If an employee experiences AMI symptoms obtain a brief assessment and triage the patient to EMS. perform an EKG if the equipment is available. provide EMS with EKG results and copies of any prior EKGs in the patient’s record.
In the Hospital
If you’re an ED nurse initiate AMI standing protocols. ensure that the ED is fully equipped and staffed to receive patients with AMI. provide in-service training about delay in treatment. evaluate the ED team’s response to an AMI.

Gender. Until recently, most studies examining heart disease focused predominantly on men; therefore, the conclusions drawn couldn’t necessarily be generalized to women. This disparity in research has had two significant consequences. The first is a tendency among both health care practitioners and the public to underestimate the occurrence and severity of heart disease in women. According to various studies and polls, women hardly ever consider heart disease to be a personal health concern.13   But 12% of women aged 45 to 64 years, and 30% of those over age 65, have some form of cardiovascular disease. The second consequence is that less is known about the symptoms of AMI in women, which can differ from those in men.14 In a study of women who previously had an AMI, only 24% reported experiencing classic symptoms. The others reported atypical symptoms, such as epigastric pain, chest cramping, “flutters,” and shortness of breath.15   Many women, as well as their health care practitioners, don’t associate these symptoms with AMI,  16 an oversight that often leads to delays.

Race. Blacks and Hispanics have been reported to delay longer than do whites. One study showed an average delay of two hours among whites, three hours among blacks, and four hours among Hispanics.  17

In general, minority patients have been reported to exhibit lower levels of symptom recognition and belief in treatability.17 In one study, black inpatients admitted for coronary heart disease exhibited fewer painful symptoms and were more likely to attribute symptoms to noncardiac origins.18

Age. The elderly may experience vague symptoms,19 and they’re also more likely to have a history of hypertension, congestive heart failure, and MI, as well as longer delay times.

History of chronic conditions. Patients with a history of anginal pain or diabetes are more apt to delay than are those without these conditions. A striking finding across all studies is that patients already diagnosed with coronary heart disease or heart failure, or those who’ve had a previous MI, have delay times equal to or greater than those without prior MI or coronary heart disease.20

 Wasted Minutes versus Lifesaving Weapons

Educating the public about reducing delay, whether at home or at work, and ensuring that all hospital emergency departments are always ready to receive patients experiencing an AMI, can potentially reduce irreversible damage and deaths.

In June 1991, the NHLBI founded the NHAAP to reduce the morbidity and mortality associated with AMI through rapid identification and treatment. The NHAAP suggests several interventions, including educating patients to ensure that they can correctly identify symptoms; assisting patients and their families to formulate an action plan; and helping patients to handle their feelings of uncertainty, fear of losing control, or embarrassment over calling for emergency assistance.

National Heart Attack Alert Program (NHAAP) One of the NHAAP’s main objectives is to increase public awareness of the symptoms and signs of AMI and to promote immediate action by patients, their families, and health practitioners. The organization publishes various reports and booklets that address how to minimize delay. You can download this information free of charge from the Internet by logging on to . Complete catalogues may be requested by phone ([301] 592-8573), fax ([301] 592-8563), or e-mail (nhlbiinfo@rover.nhlbi.nih.gov). (If requesting a catalog by fax or e-mail, provide your full name, complete mailing address, and telephone number.) You can also purchase publications for a nominal fee by calling the telephone number listed above.

 Reducing delay at home. You can implement several measures to help improve response time if you’re a community nurse or are involved in hospital discharge planning.

So even though all patients should be educated about AMI symptoms, those with established coronary heart disease (or with clinical atherosclerotic disease of the aorta, arteries of the limbs, or carotid arteries) should be targeted.20 Patients with established heart disease include those who’ve suffered an MI or ischemia or those with a history of coronary bypass surgery, coronary angioplasty, or related procedures. Others at risk include patients with arterial disease (such as abdominal aortic aneurysm and ischemia to the extremities), and those with carotid atherosclerosis (causing transient ischemic attacks or stroke). Others who are likely to delay and should be targeted are the elderly, women, blacks, Hispanics, and those with chronic conditions, such as diabetes.20