Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction

National Heart Atttack Alert Program Coordinating Committee...

Many effective therapies are now available for patients with acute cardiac ischemia, acute myocardial infarction (AMI), potentially fatal arrhythmias, and cardiogenic shock if they seek and receive care expeditiously. However, delays in accessing and receiving care are a continuing problem, threatening the effectiveness of available treatments. Patients with previously diagnosed coronary heart disease (CHD), including a previous AMI, have the same or greater delay times as those without prior AMI or CHD. Because of the high-risk status of these patients, combined with the problem of delay in seeking care, a Working Group of the National Heart Attack Alert Program (NHAAP), National Heart, Lung, and Blood Institute, of the National Institutes of Health advises physicians and other healthcare providers of their important role in reducing treatment delay in these patients. The Working Group recommends that primary care clinicians in the office and in inpatient settings provide these patients and their family members or significant others contingency counseling about actions to take in response to symptoms of an AMI/acute cardiac ischemia.

Ideally, education regarding the symptoms and signs of AMI and the need to seek treatment promptly should be directed at all individuals and is a long-term goal of the NHAAP. However, in order to focus resources on individuals who might derive the greatest potential benefit, educational and counseling interventions should be aimed at reducing patient delay for those individuals who are at high risk for a future AMI. Based on health interviews conducted in 1992, approximately 7 million Americans have CHD, about 3 million have cerebrovascular disease, and about 2 million have peripheral vascular disease. (1) Patients with established CHD, clinical atherosclerotic disease of the aorta or peripheral arteries, or clinical cerebrovascular disease are at high risk for subsequent AMI or CHD death. (2-4) The risk for subsequent AMI and death in patients with established CHD (or other atherosclerotic disease) is fivefold to sevenfold higher than for the general population. (2) It is particularly important to focus within this high-risk patient group on women, African Americans, and the elderly; these populations have longer reported delays in seeking care in response to AMI symptoms.

Education should be targeted at patients with established CHD or clinical atherosclerotic disease, including their family members/significant others. Patients with established CHD include those with a history of AMI, angina, coronary artery bypass surgery, or angioplasty. In addition, patients with previously diagnosed peripheral arterial disease (eg, patients with claudication or an abdominal aortic aneurysm) should be targeted. Substantial carotid atherosclerosis is documented by cerebral symptoms (eg, patients with transient ischemic attacks or stroke) and demonstration of significant atherosclerosis on ultrasound or angiogram. (5)

The content of the recommended educational message includes three essential components: information, emotional issues, and social factors. Patients should be given information about the typical symptoms of AMI and the action steps to take if they experience any of those symptoms. Although the presentation of AMI can be atypical, (6,7) the majority of patients will present with chest pain/discomfort, left arm pain/heaviness, shortness of breath, or a feeling of dread. (8) The differences in presentation profiles, if any, between patients with a CHD history and those presenting for the first time are not well delineated.

Providers should keep in mind that presenting symptoms of AMI in the elderly may be vague. Older patients more often have a history of hypertension, congestive heart failure, and MI, as well as longer delay times, than younger patients. Among 1,848 patients more than 65 years of age from the Myocardial Infarction Triage and Intervention (MITI) trial, a relatively high proportion of these elderly individuals had no chest pain when first evaluated in the hospital, and fewer elderly patients had ST elevation on the initial electrocardiogram (ECG). (9)

Clark et al (10) found that minority patients have lower levels of symptom recognition and belief in treatability. According to Raczynski et al, (11) African-American patients admitted for CHD report fewer painful symptoms and are more likely to attribute symptoms to noncardiac origins (eg, gastrointestinal tract).

Since many patients believe that an AMI is accompanied by sudden, crushing chest pain and unconsciousness, (12) patients should be told that the symptoms may come on gradually or may be intermittent. The educational message should be adapted to an individual patient's history of symptom presentation; for example, the physician can emphasize jaw discomfort if this symptom occurred in the past as part of the patient's ischemic presentation. However, all of the more frequent presenting symptoms should be addressed since a second heart attack may not manifest itself exactly the same way as the first (something patients should also be told, even though this has not been well studied).

Patients must be clear about the actions they should take if AMI symptoms occur. These behaviors include taking nitroglycerin (if prescribed), taking aspirin, and calling the emergency medical services (EMS). Advice about medications should be tailored to the needs of individual patients. The guideline for the use of nitrates for anginal pain published in the Clinical Practice Guideline, Unstable Angina: Diagnosis and Management, by the Agency for Health Care Policy and Research Guideline Panel (13) appears sound. Patients are directed to take one nitroglycerin tablet as soon as they feel discomfort, take a second tablet if the discomfort does not go away in 5 minutes, and take a third tablet after 5 more minutes if symptoms persist. If the medication does not relieve the discomfort in 15 minutes, they should go to the hospital immediately by activating EMS.

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National Heart Atttack Alert Program Coordinating Committee...

Because of aspirin's demonstrated benefit in the case of an acute ischemic event, (14) patients should additionally be advised to chew an adult-strength (325 mg), noncoated aspirin tablet as part of their emergency action plan.

Activation of EMS shortens delay for almost all patients with suspected AMI (15); therefore, high-risk patients and their families should be told to call 9-1-1 or their seven-digit emergency number when a patient has symptoms suggestive of AMI. If a patient lives in a rural area or is a long distance from the nearest hospital, the healthcare provider should discuss the appropriateness and merits of alternative plans. Having a family member or friend drive is not recommended because the person driving the patient cannot render any patient care and usually cannot communicate with the hospital while en route. Arrival at the emergency department (ED)/trauma center by private vehicle has been shown to delay triage and assessment of trauma patients compared with patients conveyed by EMS. (16) For the AMI patient, prehospital identification by history or ECG has been shown to decrease time to treatment in the ED. (17,18)

A sample form for presenting patient information is presented in Figure 1.

Figure 1

Patient Advisory Form

It can be individualized by physicians and other healthcare providers to include any unusual symptoms a patient may experience suggesting an evolving AMI, instructions for any special medications such as nitrates, aspirin, or others (eg, beta blockers) that the patient may need, the EMS phone number in the community, and the location of the hospital with 24-hour ED service closest to the patient's home and work. Physicians and other healthcare providers can suggest that patients keep the form on their refrigerators or with their other emergency numbers, as well as keep a copy at work. The selected message regarding symptom constellation and recommended action steps should also be recorded in the patient's medical record so it can be reinforced by other healthcare providers in the setting. All instructions should be entered in the patient's record so other members of the healthcare team can reinforce them during future visits.

Counseling should address the emotional aspects (eg, fear and denial) that patients and those around them may experience, as well as barriers that may be associated with the healthcare delivery system. Because the majority of patients consult a family member or significant other about their symptoms, (19,20) the latter should be included in all education and counseling interactions and have a good understanding of the nature of AMI symptoms and the importance of calling EMS quickly. Assistance from other healthcare providers (eg, nurses) should be solicited to initiate, reinforce, and supplement the counseling. A Patient Advisory Form is offered as an aid to providers in counseling their high-risk patients about these issues. Other materials and aids should be considered as well. Physicians' offices and clinics should devise a system to triage patients rapidly when they call or walk in seeking advice for possible AMI symptoms. Further research is needed to learn more about effective counseling strategies, symptom manifestation in high-risk groups, including women and minorities, and healthcare delivery systems that enhance access to timely care for CHD patients.

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National Heart Atttack Alert Program Coordinating Committee...

National Heart Attack Alert Program Coordinating Committee
Working Group on Educational Strategies To Prevent Prehospital
Delay in Patients at High Risk for Acute Myocardial Infarction

Kathleen Dracup, RN, DNSc (Chair)
Professor and LW Hassenplug Chair of Nursing
School of Nursing
University of California at Los Angeles
Los Angeles, CA

Angelo A. Alonzo, PhD
Associate Professor of Sociology
The Ohio State University
Columbus, OH

James M. Atkins, MD, FACC
Medical Director, Dallas Emergency Medical Services
Professor of Medicine
Department of Internal Medicine
University of Texas Southwestern Medical
Center at Dallas
Dallas, TX

Nancy M. Bennett, MD, MS
Assistant Professor of Medicine
Assistant Professor of Community and Preventive Medicine
University of Rochester School of Medicine and Dentistry
Deputy Health Director
Monroe County Health Department
Rochester, NY

Allan Braslow, PhD
President
Braslow and Associates
Alexandria, VA

Luther Clark, MD
Director of Preventive Cardiology
Associate Professor of Clinical Medicine
Department of Medicine
State University of New York Health Science Center
Brooklyn, NY

Mickey Eisenberg, MD, PhD
Professor of Medicine
University of Washington
Emergency Medical Services
University of Washington Medical Center
Seattle, WA

Keith Copelin Ferdinand, MD, FACC
Medical Director
Heartbeats Life Center of New Orleans
Associate Professor, Clinical Pharmacology
College of Pharmacy
Xavier University of New Orleans
New Orleans, LA

Robert Frye, MD, FACC
Chair, Internal Medicine
Professor of Medicine
Cardiovascular Consultant
Mayo Clinic
Rochester, MN

Lee Green, MD, MPH
Assistant Professor
Department of Family Practice
University of Michigan Medical School
Ann Arbor, MI

Martha Hill, PhD, RN
Associate Professor
School of Nursing
Johns Hopkins University
Baltimore, MD

J. Ward Kennedy, MD
Professor of Medicine
University of Washington
Director, Division of Cardiology
University Hospital
Seattle, WA

Eva Kline-Rogers, MS, RN
Clinical Nurse Specialist
Cardiology Department
University of Michigan Medical Center
Ann Arbor, MI

Debra K. Moser, DNSc, RN
Assistant Professor of Nursing
College of Nursing
Ohio State University
Columbus, OH

Joseph P. Ornato, MD, FACC
Professor of Internal Medicine (Cardiology)
Director of Research
Department of Emergency Medicine
Virginia Commonwealth University/Medical College of Virginia
Richmond, VA

Bertram Pitt, MD
Professor of Internal Medicine
Division of Cardiology
University of Michigan Hospital
Ann Arbor, MI

Jane D. Scott, ScD, MSN
Health Scientist Administrator
Center for Medical Effectiveness Research
Agency for Health Care Policy and Research
Rockville, MD

Harry P. Selker, MD, MSPH
Chief, Division of Clinical Care Research
Director, Center for Cardiovascular Health Services Research
New England Medical Center
Associate Professor of Medicine
Tufts University School of Medicine
Boston, MA

Sharon Silva, PhD
Evaluation Associate
Public Policy and Planning
American Red Cross National Headquarters
Washington, DC

William Thies, PhD
Director
Emergency Cardiac Care Programs
American Heart Association
Dallas, TX

W. Douglas Weaver, MD
Professor of Medicine
Director, Cardiovascular Critical Care
University of Washington
Seattle, WA

Nanette K. Wenger, MD
Professor of Medicine (Cardiology)
Emory University School of Medicine
Director, Cardiac Clinics
Grady Memorial Hospital
Atlanta, GA

Suzanne K. White, MN, RN, FAAN, FCCM, CNAA
Vice President, Cardiovascular Services/Clinical Affairs
St. Joseph's Hospital of Atlanta
Atlanta, GA

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National Heart Atttack Alert Program Coordinating Committee...