Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: Experience in 4 US communities from 1987-2000

doi:10.1016/j.ahj.2005.03.064

American Heart Journal

Volume 150, Issue 3, September 2005, Pages 392-400

https://doi.org/10.1016/j.ahj.2005.03.064 Get rights and content

Background

Prolonged delay in seeking care for acute myocardial infarction (AMI) is associated with decreased use of time-dependent treatments and increased mortality and morbidity.

Methods

Time from symptom onset to arrival at hospital and emergency medical service use were abstracted from medical records of 18 928 patients hospitalized for AMI and captured in the community surveillance component of the ARIC study from 1987 to 2000. A cut point of 4 hours was used to assess clinically relevant delay time recommendations for treatment with current therapies.

Results

In 2000, the overall proportion of persons with delays from symptom onset to hospital arrival of ≥4 hours was 49.5%. Blacks and women consistently delayed longer than whites and men. Between 1987 and 2000, there was no statistically significant change in the proportion of patients delaying ≥4 hours (relative change +0.6% in men, −7.4% in women, −2.3% in whites, −8.9% in blacks, −7.9% in persons with diabetes, and −0.8% in persons without diabetes); however, there is a noticeable narrowing of gaps between sex, race, and diabetes status over the study period. The percentage of those who used emergency medical services increased significantly over the study period (1987 37.1%, 2000 44.5%, P ≤ .0001).

Conclusions

Many patients continue to experience prolonged delays from onset of symptoms to hospital arrival. Delay time for hospitalized AMI changed little in the ARIC communities from 1987 to 2000. New public health strategies should be developed to facilitate rapid access to acute care for AMI.

Section snippets

Methods

The ARIC Study includes a community surveillance component, the methods of which have been described in detail elsewhere.16, 17 Briefly, the ARIC study includes a retrospective hospital surveillance program designed to monitor hospitalizations for AMI and deaths due to coronary heart disease (CHD) occurring in or out of the hospital among men and women aged 35 to 74 years in 4 US communities: Forsyth County, North Carolina (n = 136 378), Jackson, Mississippi (n = 71 218), Washington County,

Results

Between 1987 and 2000, 21 551 definite or probable hospitalized myocardial infarctions occurred in the ARIC communities. We excluded 284 events that were transferred from other hospitals, 1993 events without acute cardiac symptoms before arrival at the hospital, and 198 events with missing delay time from the medical record. An additional 148 events occurring in persons of nonwhite and nonblack race were excluded because of representation insufficient for use in examining racial differences in

Discussion

Contrary to our hypothesis, we found prehospital delay did not improve significantly from 1987 to 2000 in 4 US communities. However, consistent with other observational studies, we found that increased age,18, 19, 20, 21, 22, 23, 24, 25 female sex,19, 21, 24, 26 and black ethnicity18, 19, 23, 27, 28 were all associated with longer delay times. Our results also generally agree with the published literature,19, 20, 21, 22, 24, 25, 29 which shows persons with a history of angina, diabetes, and

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Ethnic differences of the care pathway following an out-of-hospital cardiac event: A systematic review
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This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations.
A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines.
Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies.
The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations.
Racial Differences in Fatal Out-of-Hospital Coronary Heart Disease and the Role of Income in the Atherosclerosis Risk in Communities Cohort Study (1987 to 2017)
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Black patients have higher incident fatal coronary heart disease (CHD) rates than do their White counterparts. Racial differences in out-of-hospital fatal CHD could explain the excess risk in fatal CHD among Black patients. We examined racial disparities in in- and out-of-hospital fatal CHD among participants with no history of CHD, and whether socioeconomic status might play a role in this association. We used data from the ARIC (Atherosclerosis Risk in Communities) study, including 4,095 Black and 10,884 White participants, followed between 1987 and 1989 until 2017. Race was self-reported. We examined racial differences in in- and out-of-hospital fatal CHD with hierarchical proportional hazard models. We then examined the role of income in these associations, using Cox marginal structural models for a mediation analysis. The incidence of out-of-hospital and in-hospital fatal CHD was 1.3 and 2.2 in Black participants, and 1.0 and 1.1 in White participants, respectively, per 1,000 person-years. The gender- and age-adjusted hazard ratios comparing out-of-hospital and in-hospital incident fatal CHD in Black with that in White participants were 1.65 (1.32 to 2.07) and 2.37 (1.96 to 2.86), respectively. The income-controlled direct effects of race in Black versus White participants decreased to 1.33 (1.01 to 1.74) for fatal out-of-hospital and to 2.03 (1.61 to 2.55) for fatal in-hospital CHD in Cox marginal structural models. In conclusion, higher rates of fatal in-hospital CHD in Black participants than in their White counterparts likely drive the overall racial differences in fatal CHD. Income largely explained racial differences in both fatal out-of-hospital CHD and fatal in-hospital CHD.
Patient characteristics and outcomes of acute myocardial infarction presenting without ischemic pain: Insights from the Atherosclerosis Risk in Communities Study
2023, American Heart Journal Plus: Cardiology Research and Practice
Our objective was to describe characteristics of patients presenting with and without ischemic pain among those diagnosed with acute myocardial infarction (MI) using individual-level data from the Atherosclerosis Risk in Communities Study from 2005 to 2019.
Acute MI included events deemed definite or probable MI by a physician panel based on ischemic pain, cardiac biomarkers, and ECG evidence. Patient characteristics included age at hospitalization, sex, race/ethnicity, comorbidities (smoking status, diabetes, hypertension, history of previous stroke, MI, or cardiovascular procedure, and history of valvular disease or cardiomyopathy) and in-hospital complications occurring during the event of interest (pulmonary edema, pulmonary embolism, in-hospital stroke, pneumonia, cardiogenic shock, ventricular fibrillation). Analyses were stratified by MI subtype (STEMI, NSTEMI, Unclassified) and patient characteristics and 28-day case fatality was compared between MI presenting with or without ischemic pain.
Between 2005 and 2019, there were 1711 hospitalized definite/probable MI events (47 % female, 26 % black, and age of 78 [6.7 years]). A smaller proportion of STEMI patients presented without ischemic pain compared to NSTEMI patients (20 % vs 32 %). Race, sex, age, and comorbidity profiles did not differ significantly across ischemic pain presentations. Patients presenting without ischemic pain had a higher 28-day all-cause case fatality after adjusting for age, race, sex, and comorbidities. However, after further adjustment, time from symptom onset to hospital arrival, time to treatment, and in-hospital complications explained the difference in 28-day case fatality between ischemic pain presentations.
Future research should focus on differences in treatment delay across ischemic pain presentations rather than sex differences in acute coronary syndrome presentation.
82-Year-Old Man With Chest Pain and Shortness of Breath
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Implanted Monitor Alerting to Reduce Treatment Delay in Patients With Acute Coronary Syndrome Events
2019, Journal of the American College of Cardiology
Increased pre-hospital delay during acute coronary syndrome (ACS) events contributes to worse outcome.
The purpose of this study was to assess the effectiveness of an implanted cardiac monitor with real-time alarms for abnormal ST-segment shifts to reduce pre-hospital delay during ACS events.
In the ALERTS (AngeLmed Early Recognition and Treatment of STEMI) pivotal study, subjects at high risk for recurrent ACS events (n = 907) were randomized to control (Alarms OFF) or treatment groups for 6 months, after which alarms were activated in all subjects (Alarms ON). Emergency department (ED) visits with standard-of-care cardiac test results were independently adjudicated as true- or false-positive ACS events. Alarm-to-door (A2D) and symptom-to-door (S2D) times were calculated for true-positive ACS ED visits triggered by 3 possible prompts: alarm only, alarms + symptoms, or symptoms only.
The Alarms ON group showed reduced delays, with 55% (95% confidence interval [CI]: 46% to 63%) of ED visits for ACS events <2 h compared with 10% (95% CI: 2% to 27%) in the Alarms OFF group (p < 0.0001). Results were similar when restricted to myocardial infarction (MI) events. Median pre-hospital delay for MI was 12.7 h for Alarms OFF and 1.6 h in Alarms ON subjects (p < 0.0089). Median A2D delay was 1.4 h for asymptomatic MI. Median S2D delay for symptoms-only MI (no alarm) in Alarms ON was 4.3 h.
Intracardiac monitoring with real-time alarms for ST-segment shift that exceeds a subject’s self-normative ischemia threshold level significantly reduced the proportion of pre-hospital delays >2 h for ACS events, including asymptomatic MI, compared with symptoms-only ED visits in Alarms OFF. (AngeLmed for Early Recognition and Treatment of STEMI [ALERTS]; NCT00781118)
Addressing Health Care Disparities
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Clinical InvestigationCongestive Heart FailureTrends in prehospital delay time and use of emergency medical services for acute myocardial infarction: Experience in 4 US communities from 1987-2000

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

J Clin Epidemiol

Am Heart J

Am J Emerg Med

Am Heart J

Am Heart J

Ann Emerg Med

Heart Lung

Appl Nurs Res

J Am Coll Cardiol

Lancet

Am Heart J

Am J Cardiol

Am J Cardiol

Ann Emerg Med

Ann Emerg Med

National Heart Attack Alert Program Coordinating Committee 60 minutes to treatment working group. Emergency department: rapid identification and treatment of patients with acute myocardial infarction

Ann Emerg Med

GISSI-2; a factorial randomized trial of altaplase versus streptokinase and heparin versus no heparin among 12,490 patients with acute myocardial infarction

Lancet

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 1,000 patients

Lancet

Clinical Investigation
Congestive Heart Failure
Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: Experience in 4 US communities from 1987-2000