Patients with previous myocardial infarction or angina; patients who have had coronary angioplasty or coronary artery bypass surgery. Also consider at high risk patients with transient ischemic attacks or stroke or demonstrated carotid atherosclerosis, or patients with clinical symptoms and signs of peripheral vascular disease. (Keep in mind those likely to delay: the elderly, women, minorities, those with low socioeconomic status, as well as those with a history of angina/CHD, diabetes, and heart failure.)

WHAT: Message content to discuss

• Information about:

- Typical symptoms of an AMI

• Chest discomfort/pain, possibly radiating to the arm, neck, or jaw
• Shortness of breath
• Sweating
• Gastrointestinal complaints (nausea)

- Expectations about symptoms

• Symptoms may come on gradually or may be intermittent.
• A heart attack is not necessarily accompanied by sudden, crushing chest pain and unconsciousness.
• Patient's symptoms may or may not resemble prior symptoms.

- Action steps to take if experiencing symptoms

• Take appropriate medications:

- Nitroglycerin (if prescribed)
- Aspirin (chew one adult-strength, noncoated tablet)

• Access EMS by calling emergency telephone number (911 or seven-digit emergency number) if the symptoms continue for more than 15 minutes.
• Know the location of the hospital with 24-hour ED service closest to the patient's home or work.

- Interfacing with patient's third-party health care provider so that delays are minimized.

• Emotional aspects:

- There is a big reward for acting quickly and getting definitive treatment before irreversible myocardial damage occurs.
- Denial or suppression of the serious nature of symptoms contributes to treatment delay.
- Attribution of symptoms to a system other than cardiac is common, but contributes to delay.
- Prior negative experiences in seeking care need to be reconciled.

• Social aspects:

- Family members/significant others should be included in all education and counseling and have a good understanding of the nature of AMI symptoms and the importance of calling EMS quickly.
- Family members/significant others should consider taking a CPR class.
- Family members/significant others have an important role in preventing patient denial and in facilitating the call to access EMS.

WHEN AND WHERE (TO EDUCATE):

• Office/clinic visits
• Inpatient setting and at discharge
• Cardiac rehabilitation programs
• Community (e.g., home health nurse, pharmacist)

HOW:

• One-on-one instruction always important

- Keep message simple and consistent.
- Repeat message in a variety of settings
- Elicit counseling skills of nurses and other health care providers.

• Supplementary means of delivering the educational message about symptoms and action steps to reinforce

- Written materials (at approximately sixth grade reading level)
- Patient advisory form
- Video
- Interactive computer programs

• Encourage patients to have a plan and to review/rehearse it periodically.
• Devise a system in office/clinic to triage and treat patients rapidly who may have an evolving AMI.
• Office/clinic staff should understand and support triage system developed to handle calls/walk-ins with chest pain.