- Email: [email protected]
The Pharmacist’s Role in Reducing Patient Delay in Seeking Treatment for Acute Myocardial Infarction
FEATURE
The Pharmacist's Role in Reducing Patient Delay in Seeking Treatment for Acute Myocardial Infarction M. Ray Holt and Mary M. Hand
The key to achieving behavioral change is to deliver a simple, consistent message repeatedly in a variety of settings. In 1997 a working group of the National Heart Attack Alert 'rogram (NHAAP) Coordinating Committee published a report for health care providers highlighting the increased future risk of an acute myocardial infarction (AMI) in individuals with preexisting coronary heart disease, peripheral vascular disease, or cerebrovascular disease. In addition, the working group cautioned that this patient group has the same or greater delay times in seeking care as those without prior cardiovascular disease. Given the importance of early reperfusion treatment for acute MI in general, coupled with the high-risk status of this group and their tendency to delay timely evaluation in particular, the NHAAP has continued to emphasize the ongoing need for health care providers to educate their high-risk patients and their family members about early symptom recognition and appropriate response. Accordingly, in this article, M. Ray Holt, PharmD, representing the American Pharmaceutical Association on the NHAAP Coordinating Committee, and Mary Hand, MSPH, RN, program coordinator, describe the pivotal role of the community pharmacist as a key intermediary for reaching these high-risk patients with this important and potentially lifesaving information. Coronary heart disease (CHD) continues to be the leading cause of death among Americans. About every 29 seconds, someone in the United States experiences a new or recurrent acute myocardial infarction (AMI), and every 60 seconds a death occurs as a result of an AMI. l Innovations in reperfusion therapies (e.g., thrombolysis, percutaneous transluminal coronary angioplasty) have the potential to reduce CHD morbidity and mortality associated with AMI if treatment is begun within the first few hours of the onset of symptoms. However, delays in accessing and receiving care are a continuing problem, threatening the effectiveness of these therapies. 2 Patients diagnosed with CHD, including patients who have experienced an AMI, have the same or greater delay times as
752
Journal of the American Phannaceutical Association
those without prior AMI or CHD.2 Because of the high-risk status of these patients, along with the problem of delay in seeking care, a Working Group of the National Heart Attack Alert Program (NHAAP) (see text box) advises physicians and other health care providers of their important role in reducing delays in treatment. The working group recommends that these patients and their family members and significant others be counseled about actions to take in response to symptoms of an AMI. Although the NHAAP recognizes universal education about the symptoms and signs of AMI and the need to seek treatment as a long-term goal, the current recommendations focus attention
National Heart Attack Alert Program The National Heart Attack Alert Program (NHAAP) is a national education program initiated by the National Heart, Lung, and Blood Institute in 1991 to educate health care providers, patients, and the public about the importance of rapid identification and treatment of individuals with symptoms and signs of acute myocardial infarction (AMI), including sudden cardiac arrest. By educating these groups, the NHAAP hopes to achieve its primary goal of reducing the morbidity and mortality associated with AMI. The program's coordinating committee, a main component of the NHAAP, consists of individuals from more than 40 multidisciplinary national professional, voluntary, and government liaison organizations. The American Pharmaceutical Association is a member of this committee and is the sole representative for the pharmacy profession. Learn more about the NHAAP by visiting the program's Web site at http://www.nhlbi.nih.gov/aboutlnhaap/index.htm.
NovemberlDecember 1999
Vol. 39, No.6
Reducing AMI Treatment Delay
on individuals who have the greatest potential benefit. Therefore, education and counseling should be aimed at reducing treatmenteeking delay for patients at high risk for a future AMI. This would include patients with established CHD, clinical atherosclerotic disease of the aorta or peripheral arteries, or clinical cerebrovascular disease. 3- 5 The risk for subsequent AMI and death in patients with established CHD (or other atherosclerotic disease) is fivefo ld to sevenfold higher than for the general population. 3 It is particularly important to focus within this high-risk patient group on women, African Americans, and elderly patients; these populations have longer reported delay times in seeking care in I response to AMI symptoms.6-8 No single intervention, no matter how carefully designed, will be sufficient to alter a high-risk individual's propensity to delay seeking treatment for a potential AMI. Multiple interventions are necessary throughout the entire course of treatment. The key to achieving behavioral change is to deliver a simple, consistent message repeatedly in a variety of settings. 9,10 The primary care physician should provide the initial educational intervention, addressing the early recognition of heart attack symptoms and the appropriate steps to take to ensure rapid evaluation and treatment. Additional education and counseling would be appropriate during hospitalization for CHD, and the message should be reiterated at discharge. Ambulatory care settings, including pharmacies, are appropriate settings for further reinforcement of the educational message (e.g., by the cardiac rehabilitation nurse or community pharmacist). The community pharmacist is an excellent resource for reinforcing the physician's initial intervention for two reasons. First, the pharmacist is readily accessible to high-risk patients. The community pharmacist is only a telephone call away, or more importantly, he or she is available for face-to-face consultation during pharmacy visits. Second, patients' trust in their pharmacist has been well documented. Several Gallup Polls, including the most recent, have identified pharmacists as the most trusted professionals in America. People are more likely to accept and act on information provided from a source they trust. Some of the information on AMI provided during a consultation may be difficult for the patient to accept or understand. Hearing this information again from someone they trust and respect makes it less likely that the individual will disregard or not act on what is presented to them. Therefore, the availability of and the confidence placed in community pharmacists makes them a logical resource for providing the additional educational interventions needed to effect behavioral change in this high-risk group. The NHAAP has issued recommendations about a health care providers preparing to educate high-risk patients for potential AMI evenL II Pharmacists and other health care providers should consider whom to educate, what to tell them, when and where to deliver the information, and how best to present the message about early recognition and response to AMI symptoms. These recommendations are summarized in Table 1 and in the text below.
Vol. 39, No.6
NovemberlDecember 1999
FEATURE
Whom to Educate It is important for pharmacists to focus their educational efforts on patients with established CHD, peripheral arterial disease, or substantial carotid atherosclerosis. Particular attention should be given to patients who are likely to delay--elderly patients, 12-14 women,IS-20 minorities,17,18,21 those of low socioeconomic status,22,23 patients with a history of angina or diabetes,15,16,24-26 and patients with known CHD including heart failure or prior MI. 12,27
What to Tell High-Risk Patients The message to high-risk patients should focus on three areas: information, emotional issues, and social factors. Individuals need to be given information about the typical symptoms of AMI and the actions to take if they experience those symptoms. Emotional issues surrounding the AMI experience may contribute to delay behaviors. Social factors surrounding the decision to seek treatment should be discussed, as well. Information
The symptoms of AMI can be atypical; however, the majority of patients will present with chest pain/discomfort, left arm painiheaviness, shortness of breath, or a feeling of dread. 28 Differences in presentation profiles between individuals will occur, and counseling should take into account significant generational or cultural differences that might affect a patient's receptiveness. Pharmacists should keep in mind that presenting symptoms of AMI in elderly patients might be vague. The elderly more often have a history of hypertension, congestive heart failure, and MI, as well as longer delay times than younger patients. I4 Minority patients appear to have lower levels of symptom recognition and belief in treatability.1 8 Raczynski et a1. 29 found that black inpatients admitted for CHD reported fewer painful symptoms and were more likely to attribute symptoms to noncardiac origins (i.e., gastrointestinal tract). Because many believe an AMI is accompanied by sudden, crushing chest pain and unconsciousness,30 patients need to be told that the symptoms may come on gradually or may be intermittent. Thus, to the extent possible, the pharmacist should tailor the message to the individual's history of symptom presentation. For instance, counseling might emphasize jaw discomfort if this symptom occurred in the past as part of the individual's ischemic presentation. However, all of the more frequent presenting symptoms also need to be discussed, because a second heart attack may not involve the same symptoms as the first. Pharmacists must ensure that patients are clear about the actions they should take if AMI symptoms occur, including taking nitroglycerin (if prescribed) or aspirin, and calling emergency medical services (EMS). Counseling should reinforce prior instructions given by the physician. Pharmacists can tailor advice about medications to the needs of the individual. The guideline for the use of nitrates for anginal pain published by the Agency
Journal of the American Pharmaceutical Association
753
FEATURE
Reducing AMI Treatment Delay
Table 1. Counseling Plan for High-Risk Patients
Who 1. Patients with a diagnosis of coronary heart disease (CHD); patients with clinical atherosclerotic disease of the aorta, arteries to the limbs, or carotid arteries (includes patients with previous myocardial infarction [MI] or angina; patients who have had coronary angioplasty or coronary artery bypass surgery); patients with clinical symptoms and signs of peripheral vascular disease; patients with transient ischemic attacks or past stroke or demonstrated carotid atherosclerosis. 2. Elderly patients, women, minorities, low- income patients, those with a history of angina/CHD, diabetes, and heart failure.
What to Discuss 1. Typical symptoms of an acute myocardial infarction (AMI) a. Chest discomfort/pain, possibly radiating to the arm, neck, or jaw b. Shortness of breath c. Sweating and gastrointestinal complaints (nausea) 2. Expectations about symptoms a. Symptoms may come on gradually or may be intermittent b. A heart attack is not necessarily accompanied by sudden, crushing chest pain and unconsciousness c. Symptoms mayor may not resemble prior symptoms 3. Steps to take if experiencing symptoms a. Take appropriate medications i. Nitroglycerin (if prescribed) ii. Aspirin (chew one 325 mg adult uncoated tablet) b . Call emergency medical services (EMS) if symptoms continue for more than 15 minutes c. Know the location of the hospital with 24-hour emergency services closest to home or work d. Identify and address potential health care system barriers 4. Emotional aspects a. Emphasize the big reward for acting quickly and getting definitive treatment before irreversible myocardial damage occurs b. Denial of the serious nature of symptoms contributes to treatment delay c. Attribution of symptoms to a system other than cardiac is common, but contributes to delay d. Prior negative experiences in seeking care need to be reconciled 5. Social aspects a. Family members/significant others should be included in all education and counseling and have a good understanding of the nature of AMI symptoms and importance of calling EMS quickly b. Family members/significant others should consider taking a cardiopulmonary resuscitation (CPR) class c. 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 1. Physician office/clinic, inpatient hospital setting, and cardiac rehabilitation programs 2. Community setting such as pharmacy or a home health nurse
How to Educate 1. One-on-one instruction a. Keep message simple and consistent b. Repeat message in variety of settings 2. Use supplementary means of reinforcing your message about symptoms and action steps a. Written materials (at approximately sixth-grade reading level) b. Patient Advisory Form c. Videos 3. Encourage individuals to have a plan and to review/rehearse it periodically (Patient Advisory Form) Adapted from : Reference 11 .
for Health Care Policy and Research Guideline PanePl would be appropriate for nitroglycerin dosing. Patients are directed to take one nitroglycerin tablet as soon as they feel discomfort, take a second tablet if the discomfort does not disappear 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 call EMS and go to the hospital immediately. Because of aspirin's demonstrated benefit in treating an AMI,32 pharmacists should advise high-risk individuals to chew an adult-strength (325 mg),a noncoated aspirin tablet when symptoms are experienced. Immediately contacting EMS shortens the delay in treatment
754
Journal of the American Pharmaceutical Association
for most patients with suspected AMI. 33 Pharmacists should, therefore, tell high-risk individuals and their families to call 911 or their 7-digit emergency number if 911 is not available when AMI symptoms occur. Pharmacists should stress that patients should never drive themselves because of the potential for cardiac arrest. It is also inadvisable for a family member or friend to drive the patient to the hospital, because the person driving cannot provide any care and may not be able to safely communicate with the hospital while in transit. Arrival at the emergency department by private vehicle has been shown to delay triage and assessment of AMI patients compared with patients conveyed by EMS.34
NovemberlDecember 1999
Vol. 39, No.6
Reducing AMI Treatment Delay
FEATURE
........
-
Figure 1. Patient Advisory Form What to Do If You Have One or More Heart Attack Warning Signs Name: _________________________________________________________________________________ Physicians now have treatments that can stop heart attacks and lessen damage to the heart. To make sure you can benefit from these treatments, you need to act promptly if you begin to experience symptoms that might signal a heart attack. 1. You may feel: • Chest pain, discomfort, or pressure • Left arm pain or discomfort • Pain radiating to neck or jaw • Shortness of breath • Sweating • Upset stomach • Discomfort in the area between breastbone and navel • A sense of dread • Other:
2. Medication instructions: • Chew one 325 mg tablet of uncoated adult aspirin • Place 1 tablet of nitroglycerin under your tongue as soon as you feel discomfort. Take a second tablet if the discomfort does not go away in 5 minutes. Take a third tablet after 5 more minutes if the discomfort does not go away. • Other:
3. If the symptoms stop, call your physician at: 4. If symptoms continue for more than 15 minutes, call the emergency medical services phone number below immediately. (Often this is 911, but you should check to make sure.) Never wait longer than 15 minutes. • At home, the emergency phone number is: • At work, the emergency phone number is: • At
, the emergency phone number is:
5. Know the location of the nearest 24-hour emergency department. • At home, the closest emergency department is: • At wo rk, the closest emergency depa rtme nt is: _________________________________________ • At
, the closest emergency department is:
Place this form next to the phone, near your other emergency numbers! Adapted from: Reference 11.
Table 2. Patient Advisory Form: Instructions for Use Background: This form is designed for health care providers to use or adapt when teaching high-risk patients about heart attack symptoms and the appropriate steps for rapid action. Identified "high-risk" patients have a five to seven times greater risk of subsequent myocardial infarction and sudden death than the general population. Note about use: This form is not copyrighted. You may duplicate as many copies as you need. Instructions: Review the form with your high-risk patients, filling in the blanks so that it is tailored for them. Address the emotional and social barriers that may contribute to patient delay in the event of a heart attack. These include: •
The tendency to attribute heart attack symptoms to less serious, noncardiac causes (e.g., indigestion).
•
The tendency to wait and see if symptoms will go away.
•
The tendency to self-medicate (e.g., to take an antacid).
•
The tendency to seek advice from family, friends, and coworkers.
•
The tendency to call one's physician (in preference to emergency medical services).
•
A reluctance to use the emergency medical services system.
Advise your patients that, in the event of heart attack symptoms, they should wait no longer than 15 minutes before calling the emergency medical services system ( 911 in most cases). Emphasize the reward of acting quickly and getting definitive treatment before irreversible myocardial damage occurs. Suggest that your patients keep the completed form on their refrigerator or with their other emergency numbers, as well as keep a copy at work. Adapted from: Reference 11.
Vol. 39, No.6
NovemberlDecember 1999
Journal of the American Pharmaceutical Association
755
FEATURE
Reducing AMI Treatment Delay
Preadrni i n identification of an AMI by EMS per onnel by hi t ry or ele tr cardiogram ha been hown to decrea e time to treatm nt in the emergency department. 35 ,36 A mple patient advi ory form (Figure 1) i provided to a i t the pharmaci t in c un eling patient at high ri k for AMI. The form may be individualized to include any unu ual symptoms an individual may experience ugge ting an evolving AMI, instruction for any pecial medication uch a nitrates or aspirin, the EMS telephone number in the community, and the location of the ho pital with 24-hour emergency department ervice closest to the patient' home and work. Patients should be asked to post the form on their refrigerator or keep it with their other emergency number , and to keep a copy at work. Emotional Issues
Much of the delay in seeking treatment for a potential AMI can be attributed to the belief that one's symptoms are not serious and not due to cardiac causes. 29,34,37,38 It is natural for an individual to alleviate his or her anxiety about cardiac symptoms by attributing a cause that is less threatening than an AMI. Therefore, patients and their families need to anticipate this defense and recognize that denial of cardiac symptoms contributes to treatment delay and its consequences. The pharmacist should also determine whether patients, their family members or significant others have had a prior negative experience related to seeking care for a potential acute health problem, especially if it was cardiac in nature. Such an experience could cause an individual to delay seeking treatment, and this should be noted and addressed. When counseling a high-risk candidate for AMI, the educational message will have some negative components. To counter this, pharmacists should discuss the efficacy of pharmacologic thrombolysis and other interventions for AMI, and strongly emphasize the reward of acting quickly and getting definitive treatment before irreversible myocardial damage occurs. Providing positive messages about the salvage of cardiac muscle and urvival when treatment is started rapidly is potentially more effective than the negative messages about delay and the possibility of sudden death. Social Factors
Most individuals will contact a relative or friend about their symptoms before seeking treatment. Therefore, family members and significant others should be included in any education and counseling provided. The pharmacist should ensure that these individuals understand the nature and the urgency of AMI symptoms and know the importance of calling EMS quickly. If a patient with acute symptoms contacts the pharmacist for consultation, the pharmacist needs to understand the importance of activating EMS on behalf of the patient or of ensuring that the patient or family member does so immediately. Family members and significant others, if interested, can be referred to a class on cardiopulmonary resuscitation, where much of the information will be reinforced. Finally,
756
Journal of the American Pharmaceutical Association
they hould be helped to under tand that individual will typicall want to ascribe their symptoms to a noncardiac cau e and that bystander often mu t take re pon ibility for calling EMS.
VVhen and Where to Educate The fIrst and most important place for an educational intervention is the primary care physician's office. However, as mentioned above, multiple interventions in different environments are necessary to effectively change behavior in high-risk patients, and pharmacists in various practice settings have the opportunity to reiterate and support the initial intervention. For example, during discharge counseling for take-home medications, pharmacists could also discuss the potential for future AMI and the necessary actions to be taken. Pharmacists could speak on AMI to community senior citizens groups or other groups that include a high percentage of these high-risk individuals. Finally, pharmacists can provide this counseling to their customers as a value-added service in their pharmacies. The task before pharmacists should not be the decision to intervene or not, but when and where to educate high-risk patients and how best to convey these potentially lifesaving messages.
How: Techniques for Conveying the Message For the pharmacist, one-on-one counseling with the high-risk patient is the best means of delivering the message. Verbal instruction should be accompanied by written information that addresses symptom recognition, appropriate steps to take, the I emergency telephone number (if not 911), and the location of the emergency department nearest the patient's home and work. I Written material should be at a sixth-grade reading leve1. 39 In addition to the Patient Advisory Form (Figure 1), pamphlets and wallet cards addressing AMI are available from the American Heart Association. Additional information and other tools may be I found at the NHAAP page of the National Heart, Lung, and Blood Institute Web site (http://www.nhlbi.nih.gov/about/ nhaap/index.htm) or at the REACT trial Web site (http://epihub. epi. umn.edu/reactlwelcome.html).
Summary The most common reason for delay in treatment of an AMI is the patient's failure to seek care promptly.40 Individuals diagnosed with CHD, including those who have experienced an AMI, are considered to be at high risk for an AMI. These patients have the same or greater delay times as individuals without prior AMI or CHD. Pharmacists interact with these high-risk individuals and their families frequently in person or by telephone. During these interventions, they have the opportunity, through education and coun-
November!December 1999
Vol. 39, No.6
Reducing AMI Treatment Delay
eling, to improve their patients' understanding of early symp-
I
tolUS of AMI and the need for and benefits of prompt evaluation and treatment. Hearing this message from their pharmacist and from other health care providers in other settings will hopefully lead the high-risk individual to seek care promptly when needed. Successfully conveying this message could effectively reduce the morbidity and mortality associated with CHD.
M. Ray Holt, PharmD, FAPhA, is a pharmacist with the Eckerd Corporation in Chesapeake, Va. Mary M. Hand, MPH, RN, is coordinator, National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md.
17. Alonzo AA. The impact of the family and lay others on care-seeking during life-threatening episodes of suspected coronary artery disease. Soc Sci Med. 1986;22(12):1297-311 . 18. Clark LT, Bellam SV, Shah AH, et al. Analysis of prehospital delay among inner-city patients with symptoms of myocardial infarction: implications for therapeutic intervention. J Natl Med Assoc. 1992;84(11):931- 7. 19. Cunningham MA, Lee TH, Cooke EF, et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group. J Gen Intern Med 1989;4(5):392-8. 20.
Schmidt SB, Borsch MA. The prehospital phase of acute myocardial infarction in the era ofthrombolysis. Am J Cardiol. 1990,65(22):1411-5.
21.
Cooper RS, Simmons B, Castaner A, et al. Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol.1986;57:208-11 .
22.
Ghali JK, Cooper RS, Kowatly I, et al. Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients. J Natl Med Assoc. 1993;85(3):180-4.
23.
Ell K, Haywood LJ, Sobel E, et al. Acute chest pain in African Americans: factors in the delay in seeking emergency care. Am J Public Health. 1994;84(6):965-70.
24.
Moss AJ, Goldstein S. The pre-hospital phase of acute myocardial infarction. Circulation. 1970;41 (5):737-42.
25.
Simon AB, Feinleib M, Thompson HK Jr. Components of delay in the pre-hospital phase of acute myocardial infarction. Am J Cardiol. 1972;30:476-82.
26.
Schroeder JS, Lamb IH, Hu M. The prehospital course of patients with chest pain: analysis of the prodromal, symptomatic, decision-making, transportation and emergency room periods. Am J Med. 1978;64:742-48
27.
Dracup K, Moser DK. Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction. Heart Lung. 1991;20(5 Pt 2):570-75.
28.
Gillum RF, Fortmann SP, Prineas RJ, et al. International diagnostic criteria for acute myocardial infarction and stroke. Am Heart J. 1984;108(1):150-8.
29.
Raczynski JM, Taylor H, Cutter G, et al. Diagnosis, symptoms, andattribution of symptoms among black and white inpatients admitted for coronary heart disease. Am J Public Health. 1994;84(6):951-6.
aln October 1998, FDA recommended for suspected acute MI, aspirin 160 to 162.5 mg be administered as an initial dose as soon as an MI is sus-
pected and continued for at least 30 days postinfarction.
References 1. Heart and Stroke Facts: 1998 Statistical Supplement. Washington, DC: American Heart Association; 1998.
2. Dracup K, Moser DK, Eisenberg M, et al. Causes of delay in seeking treatment for heart attack symptoms. Soc Sci Med. 1995;40:379-92.
3. Criqui MH, Langer RD, Gronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326(6):381-6. 4. Pekkanen J, Linn S, Heiss G, et al. Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med. 1990;322(24),1700-7.
5. Salonen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb. 1991;11(5): 1245-9.
6. Rankin SH. Going it alone: female managing recovery from acute MI. Fam Community Health. 1995;17(4): 50-62.
7. White SK. Educational strategies to prevent prehospital delay in patients at high risk for acute myocardial infarction. Proceedings from the Second National Congress of Chest Pain Centers in Emergency Departments. Clinician. 1996;14(4):36-40.
30. Johnson JA, King KB. The influence of expectations about symptoms on delay in seeking treatment during myocardial infarction. Am J Crit Care. 1995;4(1):29-35. 31.
Braunwald, Mark DB, Jones RH, et al. Unstable Angina: Diagnosis and Management. Clinical Practice Guideline Number 10. Rockville, Md: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, U.S. Department of Health and Human Services; March 1994. AHCPR Publication 94-0602.
32.
Second International Study of Infarct Survival Collaborative Group (lSIS-2). Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Am Call Cardiol. 1988;12(6 Suppl A):3A-13A.
8. Lee H. Typical and atypical clinical signs and symptoms of myocardial infarction and delayed seeking of professional care among blacks. Am J Critical Care. 1997;6:7-13. 9. Joos SK, Hickman DH. How health professionals influence health behavior: patient-provider interaction and health care outcomes. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education. San Francisco: Jossey-Bass Publishers; 1990. 10. Mullen PD, Mains DA, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Couns. 1992;19:143-62.
11. National Heart, Lung, and Blood Institute. Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Bethesda, Md: National Institutes of Health; 1997. NIH Publication 97-3787.
12. Yarzebski J, Goldberg RJ, Gore JM, et al. Temporal trends and factors associated with extent of delay to hospital arrival in patients with acute myocardial infarction: the Worcester Heart Attack Study. Am Heart J. 1994; 128:255-63.
33. Weaver WO, Kennedy JW. Myocardial infarction-thrombolytic therapy in the prehospital setting. In: Fuster V, Varstraete M, eds. Thrombosis in Cardiovascular Disorders. Philadelphia, Pa: WB Saunders Co; 1992:275-87. 34.
36.
Kereiakes DJ, Weaver D, Anderson JL, et al. Time delays in the diagnosis and treatment of acute myocardial infarction: a tale of eight cities. Report from the Pre-Hospital Study Group and the Cincinnati Heart Project. Am Heart J. 1990;120:773-80.
37.
Reilly A, Dracup K, Dattolo J. Factors influencing prehospital delay in patients experiencing chest pain. Am J Crit Care. 1994;3(4):300-6.
38.
Meishchke H, Ho MT, Eisenberg MS, et al. Reasons patients with chest pain delay or do not call 911. Ann Emerg Med. 1995 Feb;25(2):193-7.
39.
Estey A, Musseau A, Keehn L. Comprehension levels of patients reading health information. Patient Educ Counseling. 1991 ;18:165-9.
40.
Dracup K, Moser DK. Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction. Heart Lung. 1991;20(5 Pt2):570-5.
5. Meischke H, Eisenberg MS, Larsen MP. Prehospital delay interval for patients who use emergency medical services: the effect of heart related medical conditions and demographic variables. Ann Emerg Med.1993;22(1):1597-601.
6. Turi ZG, Stone PH, Muller JE, et al. Implications for acute intervention related to time of hospital arrival in acute myocardial infarction. Am J Cardiol. 1986;58(3):203-9.
.1. 39, No.6
NovemberlDecember 1999
Dracup K, McKinley S, Moser OK. Australian patients' delay in response to heart attack symptoms. Med J Aust. 1997;166:233-6.
35. Weaver WD, Cerqueira M, Hallstrom AP, et al. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA. 1993;270(10):1211-6.
13. Maynard C, Althouse R, Olsufka M, et al. Early versus late hospital arrival for acute myocardial infarction in the Western Washington thrombolytic therapy trials. Am J Cardiol. 1989;63(18):1296-300. 4. Weaver WD, Litwin PE, Martin JS, et al. Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Call Cardiol. 1991;18(3):657-62.
FEATURE
Journal of the American Pharmaceutical Association
757
The Pharmacist's Role in Reducing Patient Delay in Seeking Treatment for Acute Myocardial Infarction M. Ray Holt and Mary M. Hand
The key to achieving behavioral change is to deliver a simple, consistent message repeatedly in a variety of settings. In 1997 a working group of the National Heart Attack Alert 'rogram (NHAAP) Coordinating Committee published a report for health care providers highlighting the increased future risk of an acute myocardial infarction (AMI) in individuals with preexisting coronary heart disease, peripheral vascular disease, or cerebrovascular disease. In addition, the working group cautioned that this patient group has the same or greater delay times in seeking care as those without prior cardiovascular disease. Given the importance of early reperfusion treatment for acute MI in general, coupled with the high-risk status of this group and their tendency to delay timely evaluation in particular, the NHAAP has continued to emphasize the ongoing need for health care providers to educate their high-risk patients and their family members about early symptom recognition and appropriate response. Accordingly, in this article, M. Ray Holt, PharmD, representing the American Pharmaceutical Association on the NHAAP Coordinating Committee, and Mary Hand, MSPH, RN, program coordinator, describe the pivotal role of the community pharmacist as a key intermediary for reaching these high-risk patients with this important and potentially lifesaving information. Coronary heart disease (CHD) continues to be the leading cause of death among Americans. About every 29 seconds, someone in the United States experiences a new or recurrent acute myocardial infarction (AMI), and every 60 seconds a death occurs as a result of an AMI. l Innovations in reperfusion therapies (e.g., thrombolysis, percutaneous transluminal coronary angioplasty) have the potential to reduce CHD morbidity and mortality associated with AMI if treatment is begun within the first few hours of the onset of symptoms. However, delays in accessing and receiving care are a continuing problem, threatening the effectiveness of these therapies. 2 Patients diagnosed with CHD, including patients who have experienced an AMI, have the same or greater delay times as
752
Journal of the American Phannaceutical Association
those without prior AMI or CHD.2 Because of the high-risk status of these patients, along with the problem of delay in seeking care, a Working Group of the National Heart Attack Alert Program (NHAAP) (see text box) advises physicians and other health care providers of their important role in reducing delays in treatment. The working group recommends that these patients and their family members and significant others be counseled about actions to take in response to symptoms of an AMI. Although the NHAAP recognizes universal education about the symptoms and signs of AMI and the need to seek treatment as a long-term goal, the current recommendations focus attention
National Heart Attack Alert Program The National Heart Attack Alert Program (NHAAP) is a national education program initiated by the National Heart, Lung, and Blood Institute in 1991 to educate health care providers, patients, and the public about the importance of rapid identification and treatment of individuals with symptoms and signs of acute myocardial infarction (AMI), including sudden cardiac arrest. By educating these groups, the NHAAP hopes to achieve its primary goal of reducing the morbidity and mortality associated with AMI. The program's coordinating committee, a main component of the NHAAP, consists of individuals from more than 40 multidisciplinary national professional, voluntary, and government liaison organizations. The American Pharmaceutical Association is a member of this committee and is the sole representative for the pharmacy profession. Learn more about the NHAAP by visiting the program's Web site at http://www.nhlbi.nih.gov/aboutlnhaap/index.htm.
NovemberlDecember 1999
Vol. 39, No.6
Reducing AMI Treatment Delay
on individuals who have the greatest potential benefit. Therefore, education and counseling should be aimed at reducing treatmenteeking delay for patients at high risk for a future AMI. This would include patients with established CHD, clinical atherosclerotic disease of the aorta or peripheral arteries, or clinical cerebrovascular disease. 3- 5 The risk for subsequent AMI and death in patients with established CHD (or other atherosclerotic disease) is fivefo ld to sevenfold higher than for the general population. 3 It is particularly important to focus within this high-risk patient group on women, African Americans, and elderly patients; these populations have longer reported delay times in seeking care in I response to AMI symptoms.6-8 No single intervention, no matter how carefully designed, will be sufficient to alter a high-risk individual's propensity to delay seeking treatment for a potential AMI. Multiple interventions are necessary throughout the entire course of treatment. The key to achieving behavioral change is to deliver a simple, consistent message repeatedly in a variety of settings. 9,10 The primary care physician should provide the initial educational intervention, addressing the early recognition of heart attack symptoms and the appropriate steps to take to ensure rapid evaluation and treatment. Additional education and counseling would be appropriate during hospitalization for CHD, and the message should be reiterated at discharge. Ambulatory care settings, including pharmacies, are appropriate settings for further reinforcement of the educational message (e.g., by the cardiac rehabilitation nurse or community pharmacist). The community pharmacist is an excellent resource for reinforcing the physician's initial intervention for two reasons. First, the pharmacist is readily accessible to high-risk patients. The community pharmacist is only a telephone call away, or more importantly, he or she is available for face-to-face consultation during pharmacy visits. Second, patients' trust in their pharmacist has been well documented. Several Gallup Polls, including the most recent, have identified pharmacists as the most trusted professionals in America. People are more likely to accept and act on information provided from a source they trust. Some of the information on AMI provided during a consultation may be difficult for the patient to accept or understand. Hearing this information again from someone they trust and respect makes it less likely that the individual will disregard or not act on what is presented to them. Therefore, the availability of and the confidence placed in community pharmacists makes them a logical resource for providing the additional educational interventions needed to effect behavioral change in this high-risk group. The NHAAP has issued recommendations about a health care providers preparing to educate high-risk patients for potential AMI evenL II Pharmacists and other health care providers should consider whom to educate, what to tell them, when and where to deliver the information, and how best to present the message about early recognition and response to AMI symptoms. These recommendations are summarized in Table 1 and in the text below.
Vol. 39, No.6
NovemberlDecember 1999
FEATURE
Whom to Educate It is important for pharmacists to focus their educational efforts on patients with established CHD, peripheral arterial disease, or substantial carotid atherosclerosis. Particular attention should be given to patients who are likely to delay--elderly patients, 12-14 women,IS-20 minorities,17,18,21 those of low socioeconomic status,22,23 patients with a history of angina or diabetes,15,16,24-26 and patients with known CHD including heart failure or prior MI. 12,27
What to Tell High-Risk Patients The message to high-risk patients should focus on three areas: information, emotional issues, and social factors. Individuals need to be given information about the typical symptoms of AMI and the actions to take if they experience those symptoms. Emotional issues surrounding the AMI experience may contribute to delay behaviors. Social factors surrounding the decision to seek treatment should be discussed, as well. Information
The symptoms of AMI can be atypical; however, the majority of patients will present with chest pain/discomfort, left arm painiheaviness, shortness of breath, or a feeling of dread. 28 Differences in presentation profiles between individuals will occur, and counseling should take into account significant generational or cultural differences that might affect a patient's receptiveness. Pharmacists should keep in mind that presenting symptoms of AMI in elderly patients might be vague. The elderly more often have a history of hypertension, congestive heart failure, and MI, as well as longer delay times than younger patients. I4 Minority patients appear to have lower levels of symptom recognition and belief in treatability.1 8 Raczynski et a1. 29 found that black inpatients admitted for CHD reported fewer painful symptoms and were more likely to attribute symptoms to noncardiac origins (i.e., gastrointestinal tract). Because many believe an AMI is accompanied by sudden, crushing chest pain and unconsciousness,30 patients need to be told that the symptoms may come on gradually or may be intermittent. Thus, to the extent possible, the pharmacist should tailor the message to the individual's history of symptom presentation. For instance, counseling might emphasize jaw discomfort if this symptom occurred in the past as part of the individual's ischemic presentation. However, all of the more frequent presenting symptoms also need to be discussed, because a second heart attack may not involve the same symptoms as the first. Pharmacists must ensure that patients are clear about the actions they should take if AMI symptoms occur, including taking nitroglycerin (if prescribed) or aspirin, and calling emergency medical services (EMS). Counseling should reinforce prior instructions given by the physician. Pharmacists can tailor advice about medications to the needs of the individual. The guideline for the use of nitrates for anginal pain published by the Agency
Journal of the American Pharmaceutical Association
753
FEATURE
Reducing AMI Treatment Delay
Table 1. Counseling Plan for High-Risk Patients
Who 1. Patients with a diagnosis of coronary heart disease (CHD); patients with clinical atherosclerotic disease of the aorta, arteries to the limbs, or carotid arteries (includes patients with previous myocardial infarction [MI] or angina; patients who have had coronary angioplasty or coronary artery bypass surgery); patients with clinical symptoms and signs of peripheral vascular disease; patients with transient ischemic attacks or past stroke or demonstrated carotid atherosclerosis. 2. Elderly patients, women, minorities, low- income patients, those with a history of angina/CHD, diabetes, and heart failure.
What to Discuss 1. Typical symptoms of an acute myocardial infarction (AMI) a. Chest discomfort/pain, possibly radiating to the arm, neck, or jaw b. Shortness of breath c. Sweating and gastrointestinal complaints (nausea) 2. Expectations about symptoms a. Symptoms may come on gradually or may be intermittent b. A heart attack is not necessarily accompanied by sudden, crushing chest pain and unconsciousness c. Symptoms mayor may not resemble prior symptoms 3. Steps to take if experiencing symptoms a. Take appropriate medications i. Nitroglycerin (if prescribed) ii. Aspirin (chew one 325 mg adult uncoated tablet) b . Call emergency medical services (EMS) if symptoms continue for more than 15 minutes c. Know the location of the hospital with 24-hour emergency services closest to home or work d. Identify and address potential health care system barriers 4. Emotional aspects a. Emphasize the big reward for acting quickly and getting definitive treatment before irreversible myocardial damage occurs b. Denial of the serious nature of symptoms contributes to treatment delay c. Attribution of symptoms to a system other than cardiac is common, but contributes to delay d. Prior negative experiences in seeking care need to be reconciled 5. Social aspects a. Family members/significant others should be included in all education and counseling and have a good understanding of the nature of AMI symptoms and importance of calling EMS quickly b. Family members/significant others should consider taking a cardiopulmonary resuscitation (CPR) class c. 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 1. Physician office/clinic, inpatient hospital setting, and cardiac rehabilitation programs 2. Community setting such as pharmacy or a home health nurse
How to Educate 1. One-on-one instruction a. Keep message simple and consistent b. Repeat message in variety of settings 2. Use supplementary means of reinforcing your message about symptoms and action steps a. Written materials (at approximately sixth-grade reading level) b. Patient Advisory Form c. Videos 3. Encourage individuals to have a plan and to review/rehearse it periodically (Patient Advisory Form) Adapted from : Reference 11 .
for Health Care Policy and Research Guideline PanePl would be appropriate for nitroglycerin dosing. Patients are directed to take one nitroglycerin tablet as soon as they feel discomfort, take a second tablet if the discomfort does not disappear 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 call EMS and go to the hospital immediately. Because of aspirin's demonstrated benefit in treating an AMI,32 pharmacists should advise high-risk individuals to chew an adult-strength (325 mg),a noncoated aspirin tablet when symptoms are experienced. Immediately contacting EMS shortens the delay in treatment
754
Journal of the American Pharmaceutical Association
for most patients with suspected AMI. 33 Pharmacists should, therefore, tell high-risk individuals and their families to call 911 or their 7-digit emergency number if 911 is not available when AMI symptoms occur. Pharmacists should stress that patients should never drive themselves because of the potential for cardiac arrest. It is also inadvisable for a family member or friend to drive the patient to the hospital, because the person driving cannot provide any care and may not be able to safely communicate with the hospital while in transit. Arrival at the emergency department by private vehicle has been shown to delay triage and assessment of AMI patients compared with patients conveyed by EMS.34
NovemberlDecember 1999
Vol. 39, No.6
Reducing AMI Treatment Delay
FEATURE
........
-
Figure 1. Patient Advisory Form What to Do If You Have One or More Heart Attack Warning Signs Name: _________________________________________________________________________________ Physicians now have treatments that can stop heart attacks and lessen damage to the heart. To make sure you can benefit from these treatments, you need to act promptly if you begin to experience symptoms that might signal a heart attack. 1. You may feel: • Chest pain, discomfort, or pressure • Left arm pain or discomfort • Pain radiating to neck or jaw • Shortness of breath • Sweating • Upset stomach • Discomfort in the area between breastbone and navel • A sense of dread • Other:
2. Medication instructions: • Chew one 325 mg tablet of uncoated adult aspirin • Place 1 tablet of nitroglycerin under your tongue as soon as you feel discomfort. Take a second tablet if the discomfort does not go away in 5 minutes. Take a third tablet after 5 more minutes if the discomfort does not go away. • Other:
3. If the symptoms stop, call your physician at: 4. If symptoms continue for more than 15 minutes, call the emergency medical services phone number below immediately. (Often this is 911, but you should check to make sure.) Never wait longer than 15 minutes. • At home, the emergency phone number is: • At work, the emergency phone number is: • At
, the emergency phone number is:
5. Know the location of the nearest 24-hour emergency department. • At home, the closest emergency department is: • At wo rk, the closest emergency depa rtme nt is: _________________________________________ • At
, the closest emergency department is:
Place this form next to the phone, near your other emergency numbers! Adapted from: Reference 11.
Table 2. Patient Advisory Form: Instructions for Use Background: This form is designed for health care providers to use or adapt when teaching high-risk patients about heart attack symptoms and the appropriate steps for rapid action. Identified "high-risk" patients have a five to seven times greater risk of subsequent myocardial infarction and sudden death than the general population. Note about use: This form is not copyrighted. You may duplicate as many copies as you need. Instructions: Review the form with your high-risk patients, filling in the blanks so that it is tailored for them. Address the emotional and social barriers that may contribute to patient delay in the event of a heart attack. These include: •
The tendency to attribute heart attack symptoms to less serious, noncardiac causes (e.g., indigestion).
•
The tendency to wait and see if symptoms will go away.
•
The tendency to self-medicate (e.g., to take an antacid).
•
The tendency to seek advice from family, friends, and coworkers.
•
The tendency to call one's physician (in preference to emergency medical services).
•
A reluctance to use the emergency medical services system.
Advise your patients that, in the event of heart attack symptoms, they should wait no longer than 15 minutes before calling the emergency medical services system ( 911 in most cases). Emphasize the reward of acting quickly and getting definitive treatment before irreversible myocardial damage occurs. Suggest that your patients keep the completed form on their refrigerator or with their other emergency numbers, as well as keep a copy at work. Adapted from: Reference 11.
Vol. 39, No.6
NovemberlDecember 1999
Journal of the American Pharmaceutical Association
755
FEATURE
Reducing AMI Treatment Delay
Preadrni i n identification of an AMI by EMS per onnel by hi t ry or ele tr cardiogram ha been hown to decrea e time to treatm nt in the emergency department. 35 ,36 A mple patient advi ory form (Figure 1) i provided to a i t the pharmaci t in c un eling patient at high ri k for AMI. The form may be individualized to include any unu ual symptoms an individual may experience ugge ting an evolving AMI, instruction for any pecial medication uch a nitrates or aspirin, the EMS telephone number in the community, and the location of the ho pital with 24-hour emergency department ervice closest to the patient' home and work. Patients should be asked to post the form on their refrigerator or keep it with their other emergency number , and to keep a copy at work. Emotional Issues
Much of the delay in seeking treatment for a potential AMI can be attributed to the belief that one's symptoms are not serious and not due to cardiac causes. 29,34,37,38 It is natural for an individual to alleviate his or her anxiety about cardiac symptoms by attributing a cause that is less threatening than an AMI. Therefore, patients and their families need to anticipate this defense and recognize that denial of cardiac symptoms contributes to treatment delay and its consequences. The pharmacist should also determine whether patients, their family members or significant others have had a prior negative experience related to seeking care for a potential acute health problem, especially if it was cardiac in nature. Such an experience could cause an individual to delay seeking treatment, and this should be noted and addressed. When counseling a high-risk candidate for AMI, the educational message will have some negative components. To counter this, pharmacists should discuss the efficacy of pharmacologic thrombolysis and other interventions for AMI, and strongly emphasize the reward of acting quickly and getting definitive treatment before irreversible myocardial damage occurs. Providing positive messages about the salvage of cardiac muscle and urvival when treatment is started rapidly is potentially more effective than the negative messages about delay and the possibility of sudden death. Social Factors
Most individuals will contact a relative or friend about their symptoms before seeking treatment. Therefore, family members and significant others should be included in any education and counseling provided. The pharmacist should ensure that these individuals understand the nature and the urgency of AMI symptoms and know the importance of calling EMS quickly. If a patient with acute symptoms contacts the pharmacist for consultation, the pharmacist needs to understand the importance of activating EMS on behalf of the patient or of ensuring that the patient or family member does so immediately. Family members and significant others, if interested, can be referred to a class on cardiopulmonary resuscitation, where much of the information will be reinforced. Finally,
756
Journal of the American Pharmaceutical Association
they hould be helped to under tand that individual will typicall want to ascribe their symptoms to a noncardiac cau e and that bystander often mu t take re pon ibility for calling EMS.
VVhen and Where to Educate The fIrst and most important place for an educational intervention is the primary care physician's office. However, as mentioned above, multiple interventions in different environments are necessary to effectively change behavior in high-risk patients, and pharmacists in various practice settings have the opportunity to reiterate and support the initial intervention. For example, during discharge counseling for take-home medications, pharmacists could also discuss the potential for future AMI and the necessary actions to be taken. Pharmacists could speak on AMI to community senior citizens groups or other groups that include a high percentage of these high-risk individuals. Finally, pharmacists can provide this counseling to their customers as a value-added service in their pharmacies. The task before pharmacists should not be the decision to intervene or not, but when and where to educate high-risk patients and how best to convey these potentially lifesaving messages.
How: Techniques for Conveying the Message For the pharmacist, one-on-one counseling with the high-risk patient is the best means of delivering the message. Verbal instruction should be accompanied by written information that addresses symptom recognition, appropriate steps to take, the I emergency telephone number (if not 911), and the location of the emergency department nearest the patient's home and work. I Written material should be at a sixth-grade reading leve1. 39 In addition to the Patient Advisory Form (Figure 1), pamphlets and wallet cards addressing AMI are available from the American Heart Association. Additional information and other tools may be I found at the NHAAP page of the National Heart, Lung, and Blood Institute Web site (http://www.nhlbi.nih.gov/about/ nhaap/index.htm) or at the REACT trial Web site (http://epihub. epi. umn.edu/reactlwelcome.html).
Summary The most common reason for delay in treatment of an AMI is the patient's failure to seek care promptly.40 Individuals diagnosed with CHD, including those who have experienced an AMI, are considered to be at high risk for an AMI. These patients have the same or greater delay times as individuals without prior AMI or CHD. Pharmacists interact with these high-risk individuals and their families frequently in person or by telephone. During these interventions, they have the opportunity, through education and coun-
November!December 1999
Vol. 39, No.6
Reducing AMI Treatment Delay
eling, to improve their patients' understanding of early symp-
I
tolUS of AMI and the need for and benefits of prompt evaluation and treatment. Hearing this message from their pharmacist and from other health care providers in other settings will hopefully lead the high-risk individual to seek care promptly when needed. Successfully conveying this message could effectively reduce the morbidity and mortality associated with CHD.
M. Ray Holt, PharmD, FAPhA, is a pharmacist with the Eckerd Corporation in Chesapeake, Va. Mary M. Hand, MPH, RN, is coordinator, National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md.
17. Alonzo AA. The impact of the family and lay others on care-seeking during life-threatening episodes of suspected coronary artery disease. Soc Sci Med. 1986;22(12):1297-311 . 18. Clark LT, Bellam SV, Shah AH, et al. Analysis of prehospital delay among inner-city patients with symptoms of myocardial infarction: implications for therapeutic intervention. J Natl Med Assoc. 1992;84(11):931- 7. 19. Cunningham MA, Lee TH, Cooke EF, et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group. J Gen Intern Med 1989;4(5):392-8. 20.
Schmidt SB, Borsch MA. The prehospital phase of acute myocardial infarction in the era ofthrombolysis. Am J Cardiol. 1990,65(22):1411-5.
21.
Cooper RS, Simmons B, Castaner A, et al. Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol.1986;57:208-11 .
22.
Ghali JK, Cooper RS, Kowatly I, et al. Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients. J Natl Med Assoc. 1993;85(3):180-4.
23.
Ell K, Haywood LJ, Sobel E, et al. Acute chest pain in African Americans: factors in the delay in seeking emergency care. Am J Public Health. 1994;84(6):965-70.
24.
Moss AJ, Goldstein S. The pre-hospital phase of acute myocardial infarction. Circulation. 1970;41 (5):737-42.
25.
Simon AB, Feinleib M, Thompson HK Jr. Components of delay in the pre-hospital phase of acute myocardial infarction. Am J Cardiol. 1972;30:476-82.
26.
Schroeder JS, Lamb IH, Hu M. The prehospital course of patients with chest pain: analysis of the prodromal, symptomatic, decision-making, transportation and emergency room periods. Am J Med. 1978;64:742-48
27.
Dracup K, Moser DK. Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction. Heart Lung. 1991;20(5 Pt 2):570-75.
28.
Gillum RF, Fortmann SP, Prineas RJ, et al. International diagnostic criteria for acute myocardial infarction and stroke. Am Heart J. 1984;108(1):150-8.
29.
Raczynski JM, Taylor H, Cutter G, et al. Diagnosis, symptoms, andattribution of symptoms among black and white inpatients admitted for coronary heart disease. Am J Public Health. 1994;84(6):951-6.
aln October 1998, FDA recommended for suspected acute MI, aspirin 160 to 162.5 mg be administered as an initial dose as soon as an MI is sus-
pected and continued for at least 30 days postinfarction.
References 1. Heart and Stroke Facts: 1998 Statistical Supplement. Washington, DC: American Heart Association; 1998.
2. Dracup K, Moser DK, Eisenberg M, et al. Causes of delay in seeking treatment for heart attack symptoms. Soc Sci Med. 1995;40:379-92.
3. Criqui MH, Langer RD, Gronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326(6):381-6. 4. Pekkanen J, Linn S, Heiss G, et al. Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med. 1990;322(24),1700-7.
5. Salonen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb. 1991;11(5): 1245-9.
6. Rankin SH. Going it alone: female managing recovery from acute MI. Fam Community Health. 1995;17(4): 50-62.
7. White SK. Educational strategies to prevent prehospital delay in patients at high risk for acute myocardial infarction. Proceedings from the Second National Congress of Chest Pain Centers in Emergency Departments. Clinician. 1996;14(4):36-40.
30. Johnson JA, King KB. The influence of expectations about symptoms on delay in seeking treatment during myocardial infarction. Am J Crit Care. 1995;4(1):29-35. 31.
Braunwald, Mark DB, Jones RH, et al. Unstable Angina: Diagnosis and Management. Clinical Practice Guideline Number 10. Rockville, Md: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, U.S. Department of Health and Human Services; March 1994. AHCPR Publication 94-0602.
32.
Second International Study of Infarct Survival Collaborative Group (lSIS-2). Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Am Call Cardiol. 1988;12(6 Suppl A):3A-13A.
8. Lee H. Typical and atypical clinical signs and symptoms of myocardial infarction and delayed seeking of professional care among blacks. Am J Critical Care. 1997;6:7-13. 9. Joos SK, Hickman DH. How health professionals influence health behavior: patient-provider interaction and health care outcomes. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education. San Francisco: Jossey-Bass Publishers; 1990. 10. Mullen PD, Mains DA, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Couns. 1992;19:143-62.
11. National Heart, Lung, and Blood Institute. Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Bethesda, Md: National Institutes of Health; 1997. NIH Publication 97-3787.
12. Yarzebski J, Goldberg RJ, Gore JM, et al. Temporal trends and factors associated with extent of delay to hospital arrival in patients with acute myocardial infarction: the Worcester Heart Attack Study. Am Heart J. 1994; 128:255-63.
33. Weaver WO, Kennedy JW. Myocardial infarction-thrombolytic therapy in the prehospital setting. In: Fuster V, Varstraete M, eds. Thrombosis in Cardiovascular Disorders. Philadelphia, Pa: WB Saunders Co; 1992:275-87. 34.
36.
Kereiakes DJ, Weaver D, Anderson JL, et al. Time delays in the diagnosis and treatment of acute myocardial infarction: a tale of eight cities. Report from the Pre-Hospital Study Group and the Cincinnati Heart Project. Am Heart J. 1990;120:773-80.
37.
Reilly A, Dracup K, Dattolo J. Factors influencing prehospital delay in patients experiencing chest pain. Am J Crit Care. 1994;3(4):300-6.
38.
Meishchke H, Ho MT, Eisenberg MS, et al. Reasons patients with chest pain delay or do not call 911. Ann Emerg Med. 1995 Feb;25(2):193-7.
39.
Estey A, Musseau A, Keehn L. Comprehension levels of patients reading health information. Patient Educ Counseling. 1991 ;18:165-9.
40.
Dracup K, Moser DK. Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction. Heart Lung. 1991;20(5 Pt2):570-5.
5. Meischke H, Eisenberg MS, Larsen MP. Prehospital delay interval for patients who use emergency medical services: the effect of heart related medical conditions and demographic variables. Ann Emerg Med.1993;22(1):1597-601.
6. Turi ZG, Stone PH, Muller JE, et al. Implications for acute intervention related to time of hospital arrival in acute myocardial infarction. Am J Cardiol. 1986;58(3):203-9.
.1. 39, No.6
NovemberlDecember 1999
Dracup K, McKinley S, Moser OK. Australian patients' delay in response to heart attack symptoms. Med J Aust. 1997;166:233-6.
35. Weaver WD, Cerqueira M, Hallstrom AP, et al. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA. 1993;270(10):1211-6.
13. Maynard C, Althouse R, Olsufka M, et al. Early versus late hospital arrival for acute myocardial infarction in the Western Washington thrombolytic therapy trials. Am J Cardiol. 1989;63(18):1296-300. 4. Weaver WD, Litwin PE, Martin JS, et al. Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Call Cardiol. 1991;18(3):657-62.
FEATURE
Journal of the American Pharmaceutical Association
757