Why Heart Attack Patients Wait

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A middle-aged man gets crushing chest pain. He’s sweating, light-headed and short of breath. He has the telltale signs of a heart attack. Yet, he sits down and waits to see if the symptoms go away, instead of calling for an ambulance.
warning sings of heart attack and stroke
It’s an all-too-familiar scenario. Too often, people delay going to the hospital, waiting hours sometimes before they seek help for what is a life-and-death emergency. Every second counts in a heart attack. Cardiologists say the longer the delay, the greater the chance of damage to the heart and the lower the chance of surviving.

More than half of all coronary heart disease deaths in America take place before victims reach the hospital, according to the National Heart Attack Alert Program (NHAAP), which is a part of the National Institutes of Health’s National Heart, Lung, and Blood Institute. And mortality rates for sudden out-of-hospital cardiac arrest run as high as 99 percent in some communities.

“Going to the hospital promptly is what it’s all about,” says Rose Marie Robertson, M.D., president-elect of the American Heart Association (AHA), which has long led the campaign to educate Americans about heart disease, heart attacks and stroke. AHA is a member organization of the NHAAP.

“If you are seen in the first hour of a heart attack or stroke, there are very effective means to make those events have much less impact,” says Robertson, a cardiologist who is vice chairwoman of the department of medicine at Vanderbilt University Medical Center in Nashville, Tenn. “If you are seen many hours into a heart attack or stroke, the options are much more limited.”

Research presented at a spring conference on emergency cardiac care in Bethesda, MD, showed that patient inaction accounts for the longest delay (60 percent to 70 percent of the time) between onset of symptoms to treatment. The second period of delay, which is transport time to the hospital whether by ambulance, car or other means, is 3 percent to 8 percent of the total delay. The time from arrival at the hospital to definitive therapy comprises 25 percent to 33 percent of the total delay.

Studies have shown the longer heart attack and stroke patients wait to get to a hospital, the less likely they will benefit from emergency treatment. For example, research has shown that the sooner “clot-busting” drugs are given to a heart attack patient, the better the chance for survival. With stroke patients, it has been found that clot-buster treatment is only beneficial in the first three hours from the start of a stroke.

A study published in the Journal of the American Medical Association showed that timing is also critical in emergency angioplasty, another technique to increase blood supply to the heart muscle.

Researchers at Brigham and Women’s Hospital (BWH) found that the optimum time for performing angioplasty on heart attack patients in the study was the first two hours. If the time frame was more than two hours, researchers found a 40 percent to 60 percent increase in mortality. Angioplasty is a procedure in which a balloon is inserted through a catheter to open a blocked artery in the heart.

Waiting more than two hours for help

Despite those findings, heart attack patients often wait more than two hours to get to the hospital. A review of data from 12 U.S. and European studies published from 1969 to 1987 found that the median pre-hospital delay ranged from 2.5 to 7 hours with many patients waiting 12 to 24 hours or more.

“If you wait 12 hours and you are having a heart attack, the damage is basically done and it’s too late to benefit from all the terrific new treatments we have,” says Christopher P. Cannon, M.D., a cardiologist at BWH. Cannon was the lead author on the study of emergency angioplasty and survival time and is a scientific adviser to the Science Based Subcommittee of the NHAAP.

Why people wait

Why people delay going to the hospital confounds cardiologists, such as Cannon, because Americans have become better educated about heart attack and recognizing typical symptoms.

“We all guess at the reasons,” says Cannon.

However, he notes that several studies, including a recently completed National Institutes of Health study called REACT (Rapid Early Action for Coronary Treatment), have identified certain characteristics of heart attack patients who delay seeking medical help. The REACT study found that women, African Americans, older patients and those who have little or no insurance are more likely to delay seeking treatment.

Surprisingly, those who have previously had a heart attack have also been shown to be more likely to take extra time to go to the emergency room, Cannon says.

In a study published in the British Medical Journal, researchers interviewed dozens of heart attack survivors and found that people postponed seeking help for a variety of reasons:

  • They did not recognize symptoms. The study authors found that when patients had symptoms other than the stereotypical crushing chest pain, they often weren’t aware that these were signs of a heart attack. “Atypical symptoms are more common in women, so women may not think about it,” Robertson says. According to the AHA, atypical symptoms include stomach or abdominal pain, nausea and dizziness, difficulty breathing, anxiety, palpitations, and a cold sweat.
  • These patients attempted to treat themselves. Delayers tended to attribute their symptoms to other conditions, such as indigestion or exhaustion, and took medication on their own. As their heart attacks progressed, some thought that new symptoms were actually side effects of the drugs.
  • They followed bad advice from friends or family. Patients who waited for more than four hours after they began having symptoms had, in many cases, asked friends and family for advice. When those consulted suggested the problem was something other than a heart attack, the patients tended to postpone seeking medical attention.
  • They didn’t believe they were at risk for a heart attack. Many patients who delayed believed that heart attacks happen only to people who fit the classic risk profile of older men, for example, when, in fact, a heart attack can happen to anyone.

Researchers have a hypothesis as to why women are more likely to delay than men. There appears to be gender differences in pain thresholds with women tolerating pain better than men, Cannon says.

“Another issue is the difference in approach to problems,” he says. “Men try to fix a problem quickly, but the quick action approach is not always the case for a woman.” As a result, he says, men may go rushing off to the hospital to do something when they feel ill, whereas women may not.

Denial and embarrassment

Denial may be yet another reason heart attack patients delay going to the hospital. Robertson relates a story of a health care professional who started having chest pain a week after hiking and yet waited eight hours after suffering a full-blown heart attack to seek help.

“We call it denial, but it’s very complicated. It’s a deep-seated instinct to avoid the problem,” Robertson says. “It’s like children and magical thinking. ‘If I don’t tell my mom about a bad thing, it won’t have happened.’ ”

Cannon says embarrassment is also a factor. “You’ve got all kinds of flashing lights out on the street for something that might be a stomachache. People are very reticent to trigger that kind of alarm,” he says.

As a result, some researchers have recommended having different levels of emergency response based on a patient’s complaint, such as “having 911 for the super-serious and 811 for the serious,” Cannon says. Chest pain and other symptoms that are unrelenting (classic heart attack signs) would be considered super-serious, and serious would be chest pain or symptoms that got better, he says.

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