What Causes ACS Treatment Delays?

Jeannette Y. Wick, RPh, MBA, FASCP
Published Online: Wednesday, May 1, 2013
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A study of patients hospitalized with acute coronary syndrome found that delays between symptom onset and arrival at the emergency department were largely due to patient hesitancy to seek treatment.

When a patient presents to the emergency department with suspected acute coronary syndrome (ACS), clinicians use the patient’s report of time of symptom onset in treatment algorithms to help determine the most appropriate interventions. Pre-hospital delay—the time that patients wait after symptoms start before going to the emergency department—is a major barrier to good outcomes and best prognosis. When symptoms start, patients need to seek help immediately. However, the majority of patients wait 1 to 4.5 hours before going to the emergency department, with the vast majority at the 4.5-hour end of the scale. Regardless of ACS type, delays of this length are too long.
 
Researchers in Ireland and Kentucky recently studied 1894 hospitalized ACS patients, using a questionnaire to gather information on their sociodemographic; clinical; situational, appraisal and behavior; and knowledge and belief characteristics. The study results, which were published online on April 11, 2013, in the International Journal of Cardiology, indicated that most pre-hospital delays were due to patient behavior, including patients’ hesitance to acknowledge symptoms as cardiac, and symptom nature and onset.
 
Surprisingly, a patient’s history of poor cardiac health did not predict delay time. Those who had had cardiac events in the past were no more likely to go to the emergency department immediately than those who had not. The researchers suggested that vague ACS symptoms may confuse patients and lead them to believe that their event is due to a less serious cause. Yet even typical chest symptoms and commonly known symptoms were not associated with taking rapid action to seek help. This indicates that health care providers must educate cardiovascular patients even more comprehensively about ACS symptoms at hospital discharge.
 
The researchers also noted concerns about the transportation method patients used to seek help and some patients’ tendency to attempt to treat symptoms themselves. Upon experiencing symptoms, fewer than 40% of patients in the study called an ambulance, the transportation mode associated with best outcomes. Some went to their physician’s office before going to the emergency department, creating significant treatment delays. Patients who self-medicated with nitroglycerin or other medications also tended to wait longer before receiving treatment than those who did not.
 
Education emphasizing the need to act quickly and underscoring the range of symptoms associated with ACS is critical. It is important to stress that not just classic chest and arm pain signals an ACS event. Chest discomfort, chest pressure or heaviness, left arm discomfort, shortness of breath, sweating, neck or jaw pain, upset stomach or nausea or indigestion, a sense of dread, and fatigue are all indications that a cardiac event may be beginning. Remind at-risk patients that even if they self-medicate with aspirin or nitroglycerin, they should call an ambulance and go to the nearest emergency department if they experience these symptoms.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.

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