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Family Voices Emotional Roadblocks, Misconceptions, Keep One Patient from Seeking Care Janet Perrella-D'Alesandro When my husband suffered a heart attack 3 years ago, fear and denial won a battle with common sense and led us to delay treatment over 18 hours, with heart damaging results. Dan was 36 at the time. While visiting relatives in neighboring Pennsylvania, he felt what he thought was heartburn and went alone to an upstairs bathroom. I found him about 45 minutes later vomiting and sweating. Aided by a lack of basic knowledge about acute myocardial infarction (AMI), we concocted an "it can't happen to us" scenario. In retrospect, we were a classic case of denial/resistance/spousal enabling. Fears vs. Facts Although Dan was young, physically fit, a non-smoker, and had tested negative on a stress test, the so-called "elephant" in the room we chose to downplay was a strong family history. His father and four uncles had all suffered from heart disease and died after multiple heart attacks and bypass surgeries. Even more significantly, Dan's sister, at age 35, had also suffered a heart attack 2 years before his. Dan refused a call to 911, saying that his symptoms were purely gastric, not cardiac. I checked his pulse rate, which was slow and steady, and ended up agreeing with him that this was probably a stomach virus. After Dan's symptoms receded slightly, we drove home to New Jersey. He had a restless night, punctuated by intermittent chest pain, but he was still attributing his symptoms to the flu. It was not until the next morning when I went to work and described what happened to a co-worker that I realized the life-threatening nature of Dan's symptoms. My co-worker, who was studying to be an RN, said she had been on a cardiac rotation and had observed that "heart attacks seem to follow no set pattern." Her words jolted me out of my denial. I left my office immediately and brought Dan to the local community hospital. An EKG and elevated blood enzyme levels showed that he had indeed suffered an AMI, and given that 18 hours had passed, had lost his opportunity to receive tissue plasminogen activator (TPA). Heparin was administered, and he was stabilized and transported to Thomas Jefferson University Hospital in Philadelphia. A catheterization revealed a clot in the left anterior descending artery and "significant" muscle damage to the front third of his heart. He had also formed a large clot in the right ventricle. Because the damage in the affected portion of his heart was irreparable, Dan did not receive an angioplasty. The rest of his heart appeared healthy. He was put on coumadin (later replaced by aspirin), a beta blocker, and an angiotension converting enzyme inhibitor and was sent home to recuperate. Preconceived Notions I do not find it shocking that, as mentioned in the preceding article by Christine Crumlish and Mary Hand, many people do not understand the basic signs and symptoms of AMI. After Dan's heart attack, I spoke with family, friends, neighbors, and co-workers and discovered the power of preconceived notions (perhaps fueled by television and movies) about cardiac arrest. I also realized that my own expectations had played a major role in my yielding to Dan's wish not to be taken to the hospital: I thought heart attacks happened quickly and dramatically. Another misconception that led me to dismiss a cardiac event was Dan's slow steady heartbeat - perfect testament of how crucial it is to tell patients not to self-diagnose. I also found that many people didn't know heart attacks can so clearly mimic a flu, or that nausea, sweating, and vomiting are common symptoms. "Normal" Tests Along with our lack of knowledge, we had also been lulled into thinking Dan had escaped his family history. Following his sister's heart attack, he had been thoroughly tested and had normal results on his stress test and EKG. His cholesterol was 200 mg/dI and his blood pressure 130/95. Later blood work did show that Dan had an elevated level of lipoprotein(a) [Lp(a)], 133 mg/dI, compared to the normal level of less than 35 mg/dI. Lp(a) is a genetic variation of plasma LDL, and although its physiologic functions are not fully understood, there is a positive association of plasma Lp(a) with premature myocardial infarction. Addressing the Psychosocial Issues Also speaking volumes to the strength of the psychological walls patients can erect is that, even with a prior history of AMI, coronary heart disease, angina, or congestive heart failure, delay times do not decrease. It seems that even a life-threatening shock is often not enough to get people to act quickly. Despite the potency of psychological defense mechanisms, there are effective methods nurses can use when counseling patients: Speak to the emotional component first. After a heart attack, patients and family members are lost in a whirlwind of emotions - shock, fear, quality of life concerns. They may not be able to hear crucial educational information over their own emotional noise. The most reassuring words a nurse can use is to tell the patient that all their feelings are normal. When counseling high-risk patients about what to do in the future if faced with a possible AMI, tell them that it is normal to want to deny or ignore the symptoms. I also think they need to hear that it is normal to feel afraid or embarrassed to be taken away in an ambulance.   Give them a real-life example. People relate to real stories about real people. Someone told me recently about a 53-year-old man who felt chest pain and immediately told his wife to call an ambulance. Because this man had never reacted with such urgency about a physical symptom before, his wife knew something serious was going on and called an ambulance immediately. The patient was indeed about to have a heart attack, which was averted by treatment. Suggest that they throw away the "Hollywood" concept of a heart attack. As my co-worker said, "heart attacks follow no set pattern." Women, most of whom do not experience the "classic" symptoms of chest pain, may especially need to hear this. Remind them that Olympic athletes, famous long-distance runners, and many other unlikely victims, have suffered heart attacks. Stereotypes don't apply. Caregivers or spouses should also be told that they must be very assertive if a patient is resisting treatment and that it is crucial they don't let the person talk them out of their concern. They can quickly identify the patient's most critical concern and address it. They should be told to expect denial and reluctance, but not to let this dissuade them from taking charge and getting the person to the hospital immediately (Bahr, 1996-97). Once patients and caregivers have been reassured about the emotional issues and have begun to shed some of their preconceived notions, nurses can begin educating them (see Table 2, page 80). The Red Flag-Recognizing Early Warning Symptoms Early warning signals of heart attack have been highlighted in public information campaigns such as the Early Heart Attack Care (EHAC program conducted by Raymond D. Bahr, MD, FACP, of St. Agnes HealthCare In Baltimore, MD. According to Bahr, 50% of patients with heart attacks have prodromal (early) symptoms. These symptoms can be specific or non-specific. Non-specific heart attack symptoms Include weakness, sweating, nausea, and dizziness. Specific symptoms (prodromal angina) include chest discomfort, chest pressure, chest ache, chest burning, and chest fullness. One major reason patients do not come immediately to the hospital is because these early symptoms occur intermittently, over hours and sometimes days, leading the patient to believe that they may go away (Bahr, 1996-97). (The early warning symptoms applied directly to Dan. He had been experiencing what he thought was heartburn for 2 weeks and he treated himself with an over-the-counter antacid.) Chest Pain Centers Along with the EHAC information campaign, Dr. Bahr has also spearheaded the creation and promotion of chest pain centers (CPC in hospitals nationwide. These centers are designed to fast track patients with AMI. The centers have observation areas for patients with acute myocardial ischemia and are staffed by critical care nurses and physicians who undergo continuous retraining for heart attack management. Tests at chest pain centers include enzymes (CPK/MB, myoglobin, and troponin), ST monitoring, technetium sestamibi, nuclear testing, echo, and stress tests. CPCs also have detection programs to target and educate high-risk patients and educational outreach programs. (Early Heart Attack Care [EHAC] Awareness, 1997). There are currently 1,200 chest pain centers in the United States with ongoing efforts by Dr. Bahr to have them in every emergency room in the country by the year 2000 (Krucoff, 1997). Because these centers are designed to help people experiencing any type of chest discomfort, patients may be less intimidated or embarrassed about seeking treatment. Encouraging Self-Education Along with giving educational materials to patients and caregivers (see Figure 1, page 86), nurses should encourage them to become as familiar as possible with cardiac risk factors, symptoms, and treatments on their own. Dr. Bahr's EHAC program has provided free videotapes for rental at all Blockbuster Video stores nationwide. In addition to the NHAAP page on the NHLBI Web site, (www.nhlbi.nih.gov/nhlbi/othcomp/opec/nhaap/ nhaapage.htm), nurses and patients may access the EHAC site at www.ehac.org (the site provides a phone number to call for the location of the chest pain centers In the U.S.), e-mail: info@ehac.org; or the American Heart Association main page at www.americanheart.org/. Conclusion My personal story has a happy ending. Since his heart attack, Dan has been very proactive in his care. He follows a very low-fat, vegetarian, high-fiber diet, and he exercises regularly. Our "time is muscle" lesson was well learned after his first heart attack and we now respond to symptoms by immediately going to the hospital. Although the artery to the front wall of Dan's heart remains blocked, new blood vessels (collaterals) have grown to take over circulation in this area, boosting overall function. Last year, to combat a new blockage, a stent was placed in the left circumflex coronary artery. Thanks to that technology and his lifestyle changes, Dan continues to enjoy his three children and leads an active, and certainly more heart-aware, life.

References Bahr, R. (1996-97). Heart attacks have beginnings! (Patient handout). Baltimore, MD: St. Agnes HealthCare. Early heart attack care (EHAC awareness. One gives more, who gives early. (Informational brochure). (1997). Baltimore, MD: Agnes HealthCare. Krucoff, C. (1997, February). He declared war on heart attacks. Reader's Digest, pp. 138-143. Janet Perrella-D'Alesandro is Associate Managing Editor, MEDSURG Nursing, Pitman, NJ.

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