- Email: [email protected]
Ethnic Variation in Acute Myocardial Infarction Presentation and Access to Care
Ethnic Variation in Acute Myocardial Infarction Presentation and Access to Care Kathryn M. King, RN, PhDa,b,*, Nadia A. Khan, MD, MScc, and Hude Quan, MD, PhDb Given the growing ethnic diversity in Canada, it is essential to recognize potential ethnic variability in acute myocardial infarction (AMI) symptoms to increase timely and effective treatment. We thus examined ethnic variation in symptom presentation and access to care of patients presenting to the emergency department (ED) with AMI. A random sample of 406 health records of Caucasian, Chinese, South Asian, Southeast Asian, and First Nations patients discharged from hospitals in the Calgary Health Region (Alberta, Canada) was audited. Measured variables were compared across ethnic groups and associations with classic AMI symptom profile and timely presentation to a hospital were examined. Chinese, South Asian, and Southeast Asian patients were 64% to 69% less likely than Caucasian patients to have a classic symptom profile reported and were less likely to speak English than their Caucasian and First Nations counterparts (p <0.001). Thirty-nine percent of patients who had a reported distinct time of symptom onset waited >12 hours to present to the ED; even in patients who presented with a classic symptom profile, South Asians were 70% less likely than Caucasians to report to the ED within 3 hours of symptom onset. Caucasians were significantly more likely to undergo angiography within 3 hours of presentation to the ED (42%, p ⴝ 0.001). In conclusion, explanatory variables associated with variability in symptom presentation and access to care associated with ethnicity require further exploration to ultimately develop effective strategies aimed at increasing timely presentation and care access. © 2009 Elsevier Inc. (Am J Cardiol 2009;103:1368 –1373)
We compared the acute myocardial infarction (AMI) symptom presentation and care pathways in European (Caucasian), Chinese (from mainland China, Hong Kong, Macau), South Asian (from India, Pakistan, Bangladesh, Sri Lanka), and Southeast Asian (from Philippines, Vietnam, Cambodia, Malaysia, Fiji), and First Nations (North American Indian) patients admitted to tertiary care centers in Calgary, Alberta, Canada. These ethnic groups are among the largest and fastest growing minority ethnic populations in Canada.1 Given the coronary heart disease risk for these ethnic groups,2,3 identifying variability in symptom presentation and access to care will provide essential information for patients and clinicians to enable sooner identification of symptoms/cases, diagnostic evaluation, and timely management.
a Faculty of Nursing and bDepartment of Community Health Sciences, University of Calgary, Calgary, Alberta, and cDepartment of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Manuscript received November 18, 2008; revised manuscript received and accepted January 17, 2009. Dr. King holds a Health Scholar Award from the Alberta Heritage Foundation for Medical Research, Alberta, Canada. Dr. Khan holds a New Investigator Award from the Canadian Institutes of Health Research and a GENESIS Scholar Award, Quebec, Canada. Dr. Quan holds a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research and a New Investigator Award from the Canadian Institutes of Health Research. *Corresponding author: Tel: 403-210-3953; fax: 403-210-3818. E-mail address: [email protected] (K.M. King).
0002-9149/09/$ – see front matter © 2009 Elsevier Inc. doi:10.1016/j.amjcard.2009.01.344
Methods After approval from the health research ethics board, patients with AMI were identified from Calgary Health Region hospital discharge abstract data from 2002 through 2006 fiscal years. This administrative database was coded in the International Statistical Classification of Diseases, 10th Revision. To identify patients with AMI, we used health records in which the most responsible diagnosis field was coded as I21.x or I22.x in the International Statistical Classification of Diseases, 10th Revision. Ethnicity of patients with AMI was categorized as European, Chinese, South Asian, Southeast Asian, and First Nations using the surname method, a relatively reliable and valid mechanism to identify ethnicity.4,5 All inpatient health records of Chinese, South Asian, Southeast Asian, and First Nations patients with AMI and a random sample of European patients with AMI were then identified using a unique personal health number, admission date, and location found in the discharge abstract. Later, to enhance the accuracy of a patient’s ethnic categorization, we identified the ethnicity documented in the health record. If there was a disparity between the surname method and that identified in the health record, the health record indication was used (this included ensuring that all European patients were Caucasian). Data were collected from 406 health records of European (Caucasian, n ⫽ 117), Chinese (n ⫽ 92), South Asian (n ⫽ 101), Southeast Asian (n ⫽ 57), and First Nations (n ⫽ 39) patients with AMI. Demographic (i.e., gender, age, body mass index), clinical (i.e., co-morbid conditions, type of infarction), sympwww.AJConline.org
Coronary Artery Disease/Ethnicity and AMI Presentation
1369
Table 1 Characteristics of study sample Demographic and Clinical Characteristics Age (yrs), mean ⫾ SD Body mass index (kg/m2), mean ⫾ SD Men Fluent in English language Co-morbid conditions Old MI Congestive heart failure Peripheral vascular disease Cerebrovascular disease Dementia Chronic lung disease Diabetes mellitus Chronic renal disease Any malignancy Previous cardiac testing Angiography Noninvasive imaging Previous revascularization Percutaneous coronary intervention Coronary artery bypass graft surgery Documented cardiac risk factors Current smoker Ever smoker Dyslipidemia* Hypertension Excessive alcohol consumption Sedentary lifestyle Obesity Abdominal obesity None listed Type of MI Non-ST elevation
European (Caucasian) (n ⫽ 117)
Chinese (n ⫽ 92)
South Asian (n ⫽ 101)
Southeast Asian (n ⫽ 57)
First Nations (n ⫽ 39)
p Value
63.9 ⫾ 14.35 27.95 ⫾ 5.51 78% (91) 99% (116)
71.58 ⫾ 13.90 24.73 ⫾ 4.25 63% (58) 34% (31)
66.84 ⫾ 11.47 25.60 ⫾ 3.86 66% (67) 46% (46)
65.51 ⫾ 16.85 25.06 ⫾ 4.44 74% (42) 51% (29)
55.56 ⫾ 12.73 28.94 ⫾ 4.41 80% (31) 92% (36)
⬍0.001 ⬍0.001 0.088 ⬍0.001
27% (31) 2.6% (3) 1.7% (2) 2.6% (3) 1.7% (2) 0.9% (1) 25% (29) 6.0% (7) 5.1% (6)
20% (18) 5.4% (5) 2.2% (2) 3.3% (3) 1.1% (1) 2.2% (2) 30% (28) 11% (10) 4.3% (4)
15% (15) 2.0% (2) 2.0% (2) 1.0% (1) 2.0% (2) 1.0% (1) 38% (38) 8.9% (9) 0.0% (0)
18% (10) 0.0% (0) 0.0% (0) 0.0% (0) 5.3% (3) 3.5% (2) 27% (15) 3.5% (2) 0.0% (0)
36% (14) 2.6% (1) 13% (5) 0.0% (0) 0.0% (0) 7.7% (3) 39% (15) 16% (6) 0.0% (0)
0.043 0.355 0.002 0.437 0.355 0.110 0.214 0.206 0.044
15% (18) 3.4% (4)
11% (10) 2.2% (2)
14% (14) 5.0% (5)
14.0% (8) 5.3% (3)
33% (13) 5.1% (2)
0.024 0.822
10% (12) 8.5% (10)
7.6% (7) 2.2% (2)
6.9% (7) 4.0% (4)
8.8% (5) 5.3% (3)
26% (10) 7.7% (3)
0.016 0.294
40% (47) 33% (39) 44% (52) 47% (55) 12% (14) 1.7% (2) 10% (12) 2.6% (3) 6.8% (8)
21% (19) 25% (23) 38% (35) 70% (64) 0.0% (0) 2.2% (2) 3.3% (3) 0.0% (0) 11% (10)
7.9% (8) 12% (12) 48% (48) 70% (71) 5.0% (5) 2.0% (2) 11% (11) 1.0% (1) 14.9% (15)
23% (13) 25% (14) 51% (29) 63% (36) 1.8% (1) 0.0% (0) 1.8% (1) 0.0% (0) 3.5% (2)
62% (24) 18% (7) 49% (19) 51% (20) 10% (4) 0.0% (0) 7.7% (3) 2.6% (1) 2.6% (1)
⬍0.001 0.005 0.544 0.001 0.002 0.742 0.086 0.382 0.050
46% (52)
60% (52)
54% (54)
66% (36)
56% (22)
0.137
* Increased low-density lipoprotein cholesterol or triglycerides or low high-density lipoprotein cholesterol as documented in the health record.
Table 2 Symptoms presentation Reported Symptoms Distinct time of symptom onset Symptom Midsternal pain Midsternal pressure Shortness of breath Nausea or vomiting Throat/neck pain Shoulder pain Abdominal discomfort Back pain Confusion Heart palpitations Syncope Diaphoresis Arm pain Dizziness Fatigue Heart burn Body weakness Classic symptom profile*
European (Caucasian) (n ⫽ 117)
Chinese (n ⫽ 92)
South Asian (n ⫽ 101)
Southeast Asian (n ⫽ 57)
First Nations (n ⫽ 39)
93% (109)
76% (70)
91% (92)
88% (50)
90% (35)
0.003
87% (102) 39% (46) 43% (50) 25% (29) 15% (17) 18% (21) 2.6% (3) 15% (17) 0.0% (0) 0.9% (1) 0.9% (1) 46% (54) 44% (52) 7.7% (9) 5.1% (6) 6.8% (8) 6.8% (8) 93% (109)
69% (63) 28% (26) 54% (50) 17% (16) 119% (10) 3.3% (3) 3.3% (3) 7.6% (7) 0.0% (0) 3.3% (3) 1.1% (1) 27% (25) 14% (13) 15% (14) 5.4% (5) 5.4% (5) 3.3% (3) 77% (71)
79% (80) 16% (17) 42% (42) 29% (29) 9.9% (10) 12% (12) 11% (11) 6.9% (7) 1.0% (1) 5.0% (5) 2.0% (2) 25% (25) 24% (24) 6.9% (7) 3.0% (3) 6.9% (7) 6.9% (7) 79% (80)
75% (43) 26% (15) 58% (33) 23% (13) 12% (7) 8.8% (5) 5.3% (3) 11% (6) 5.3% (3) 1.8% (1) 0.0% (0) 12% (7) 26% (15) 11% (6) 7.0% (4) 7.0% (4) 8.8% (5) 83% (47)
77% (30) 28% (11) 56% (22) 36% (14) 18% (7) 10% (4) 7.7% (3) 5.1% (2) 5.1% (2) 2.6% (1) 7.7% (3) 23% (9) 36% (14) 10% (4) 5.1% (2) 15% (6) 2.6% (1) 85% (33)
0.026 0.009 0.102 0.183 0.674 0.020 0.073 0.242 0.014 0.440 0.041 ⬍0.001 ⬍0.001 0.330 0.840 0.373 0.686 0.016
* Classic symptom profile ⫽ (midsternal pain and/or midsternal pressure) ⫾ throat/neck pain ⫾ shoulder pain ⫾ arm pain.6
p Value
1370
The American Journal of Cardiology (www.AJConline.org)
Table 3 Access to care Factors Related to Care Access If distinct onset of pain, time to ED presentation (h) ⬍1 1–2 3–6 7–12 13–24 Saw provider ⱕ72 h to ED presentation If yes, where/what provider? Same ED Different ED Family physician Emergency clinic Cardiologist Other physician Alternative provider Method of transport to ED Ambulance Private vehicle Taxi Other Unknown Accompanying person(s) fluent in English? Time from ED presentation to cardiac catheterization/angiography (h) ⬍3 3–6 ⬎6–24 ⬎24 Not done Percutaneous coronary intervention performed this admission Coronary artery bypass graft surgery performed this admission
European (Caucasian) (n ⫽ 117)
Chinese (n ⫽ 92)
South Asian (n ⫽ 101)
Southeast Asian (n ⫽ 57)
First Nations (n ⫽ 39)
20% (22/109) 25% (27/109) 27% (297/109) 1.8% (2/109) 27% (29/109) 12% (14)
21% (8/70) 14% (10/70) 16% (11/70) 5.7% (4/70) 53% (37/70) 9.3% (27)
8.7% (8/92) 13% (12/92) 24% (22/92) 7.6% (7/92) 47% (43/92) 37% (37)
20% (10/50) 18% (9/50) 16% (8/50) 8.0% (4/50) 38% (19/50) 18% (10)
23% (8/35) 26% (9/35) 11% (4/35) 5.7% (2/35) 34% (12/35) 21% (8)
5.4% (2) 0.0% (0) 35% (13) 8.1% (3) 2.7% (1) 49% (18) 0.0% (0)
0.0% (0) 0.0% (0) 30% (3) 10% (1) 0.0% (0) 60% (6) 0.0% (0)
11% (1) 11% (1) 11% (1) 44% (4) 0.0% (0) 11% (1) 0.0% (0)
p Value 0.015
0.0% (0) 29% (4) 57% (8) 7.1% (1) 0.0% (0) 7.1% (1) 0.0% (0)
3.7% (1) 3.7% (1) 33% (9) 14.8% (4) 0.0% (0) 33% (9) 3.7% (1)
0.002 0.002
⬍0.001 64% (75) 1.7% (2) 0.0% (0) 1.7% (2) 33% (38) 93% (13/14)
59% (54) 4.3% (4) 0.0% (0) 26% (24) 11% (10) 97% (59/61)
55% (55) 1.0% (1) 0.0% (0) 32% (32) 13% (13) 98% (47/48)
46% (26) 0.0% (0) 1.8% (1) 42% (24) 11% (6) 6.4% (27/28)
56% (22) 2.6% (1) 0.0% (0) 28% (11) 13% (5) 100% (8/8)
42% (49) 5.1% (6) 9.4% (11) 27% (32) 16% (19) 63% (74)
22% (20) 3.3% (3) 5.4% (5) 33% (30) 37% (34) 40% (37)
21% (21) 3.0% (3) 7.9% (8) 35% (35) 34% (34) 47% (47)
16% (9) 3.5% (2) 5.3% (3) 33% (19) 42% (24) 33% (19)
18% (7) 7.7% (3) 0.0% (0) 46% (18) 28% (11) 62% (24)
6.0% (7)
9.8% (9)
3.0% (3)
3.5% (2)
2.6% (1)
tom (including “classic,” i.e., midsternal chest pain/pressure, and “atypical,” i.e., nausea, fatigue, confusion, weakness, abdominal discomfort6), and processes-of-care (i.e., time to presentation, if patient saw another health care provider before emergency department [ED] presentation, those accompanying a patient, receipt of investigations) data were abstracted and recorded on a data form developed for this study. Research assistants were specially trained to undertake the audits and maintained high (ⱖ95%) interrater reliabilities. Demographic, clinical, and symptom characteristics and process-of-care data were characterized for each of the 5 ethnic groups using descriptive statistics. Continuous variables were presented using means ⫾ SDs. Categorical variables were presented using proportions and percentages. Differences between groups were examined using chisquare test for categorical variables and analysis of variance for continuous variables. We conducted logistic regression models to examine the association between ethnicity compared with Caucasian and (1) having classic symptoms and (2) time to ED presentation in those who had classic symptoms after adjustment for age (⬍65 years) and male sex (factors known to be associated with symptom presenta-
0.940 0.001
⬍0.001 0.022
tion7–10). SPSS 15 (SPSS, Inc. Chicago, Illinois) was used to analyze the data. Results Of the 406 health records reviewed, the number of patients representing each ethnic group was consistent with the population of Calgary, Alberta, and the known burden of disease in each group.1,3 As presented in Table 1, most patients were men. First Nations patients were youngest (mean age 56 years) and Chinese patients were oldest (mean age 72 years) when presenting with the index AMI. First Nations and Caucasian patients had significantly greater body mass index than patients in other ethnic groups. Chinese patients were least likely to be fluent in English, followed by South Asian and Southeast Asian patients. First Nations patients were more likely to have had a previous MI and documented previous angiography and percutaneous coronary intervention than their counterparts in the other ethnic groups. First Nations and Caucasian patients were most likely to be current smokers. South Asian, Chinese, and Southeast Asian patients were more likely to be hypertensive. There was no difference between groups in type (ST, non-ST elevation) of AMI.
Coronary Artery Disease/Ethnicity and AMI Presentation
Compared with other ethnic groups, Chinese patients least frequently reported a distinct time of symptom onset (Table 2). There were significant differences between groups in reporting midsternal chest pain and pressure. Caucasians were most likely to have had midsternal chest pain or pressure reported. Caucasian patients also had the greatest likelihood of reporting shoulder pain, diaphoresis, and arm pain. Southeast Asian and First Nations patients were more likely than other ethnic groups to report confusion and First Nations patients were most likely to report syncope compared with the other ethnic groups. Caucasian patients most frequently and Chinese patients least frequently presented with a classic symptom profile (i.e., midsternal pain and/or midsternal pressure with/without throat/ neck pain with/without shoulder pain with/without arm pain6). In logistic regression modeling, patients who were ⬍65 years of age were more likely than patients ⱖ65 years of age to present with reported classic symptoms (adjusted odds ratio (AOR) 2.99, 95% confidence interval (CI) 1.52 to 5.91). Conversely, Chinese (AOR 0.31, 95% CI 0.13 to 0.76), South Asian (AOR 0.35, 95% CI 0.14 to 0.84), and Southeast Asian (AOR 0.36, 95% CI 0.13 to 0.97) patients were less likely and First Nations patients tended to be less likely (OR 0.33, 95% CI 0.13 to 1.05) than Caucasian patients to have reported classic symptoms. Of those who reported a distinct time of onset, a larger proportion of Chinese and South Asian patients waited ⬎12 hours to seek care at the ED (Table 3). Even in patients who had reported classic symptoms, South Asians were significantly less likely (AOR 0.30, 95% CI 0.15 to 0.61) than Caucasians to report to the ED within 3 hours of symptom onset after adjustment for age and gender. Also, as presented in Table 3, South Asian and Chinese patients were most likely to have seen a health care provider within 72 hours of presenting in the index ED visit. Caucasian patients were most likely to be transported to the ED by ambulance. Although there were language barriers for the Chinese, South Asian, and Southeast Asian patients, a large proportion of documented “accompanying persons” for each ethnic group spoke English (⬎96% for Chinese, South Asian, and Southeast Asian patients). In unadjusted analyses, Caucasian patients received cardiac catheterization/angiography within 3 hours of presentation to the ED more frequently than other ethnic groups and Caucasian and First Nations patients underwent percutaneous coronary interventions more frequently compared with the others (p ⬍0.001). Discussion We examined variations in AMI symptom presentation and access to care by studying 406 health records of patients of Caucasian, Chinese, South Asian, Southeast Asian, and First Nations ethnicities and found ethnic differences in symptom presentation, including differences in reporting distinct onset of “symptoms” and the care pathway. A significant proportion of ethnic-minority patients in this study did not present with classic cardiac symptoms. Other investigators have reported ethnic variations in coronary heart disease symptoms. For example, Lee et al11 found that a significantly larger proportion of Korean pa-
1371
tients reported chest pain; shoulder, neck, and jaw pain; dyspnea; and diaphoresis compared with their AfricanAmerican and Caucasian counterparts. Gupta et al12 found that Caucasians were more likely to present with only chest pain (vs other atypical symptoms) than their ethnic counterparts (African-American, Hispanic, and Asian). In a study of 604 South Asian (primarily of Indian origin) and 2,301 European (Caucasian) patients, Teoh et al13 found that some symptoms differed significantly between these ethnic groups. South Asian patients reported their symptoms over a larger area of their body and had more frequent discomfort over the rear of their upper thorax compared with Caucasian patients. Given a lack of consistent definition regarding ethnicity (i.e., Asian, South Asian, Southeast Asian) and a focus on ethnic groups of interest to particular countries (i.e., African-Americans and Hispanics for researchers in the United States and South Asians [from India] for researchers in the United Kingdom), more generalizable investigation needs to be done. Although most patients reported classic symptoms, up to 37% saw a health care provider within 72 hours before reporting to the ED. Indeed, South Asian patients were most likely to seek the advice of a health care provider before presenting to the ED. Further, 27% to 53% of patients who reported having a distinct time of symptom onset presented to the ED ⬎12 hours later; well beyond the time that thrombolytics could be offered. There are compelling data to suggest that ethnic-minority patients remain less aware of heart disease and its symptoms. Although 95% of patients in an American survey of 61,018 recognized chest pain/discomfort as a symptom of a heart attack, awareness was lower in visible minority groups (African-American, Hispanic, Asian, First Nations, Hawaiian) than in Caucasians. Further, non-Caucasians were less likely than Caucasians to recognize “other” (i.e., shoulder pain; shortness of breath; jaw, neck, or back pain; or dizziness) cardiac symptoms.14 In a population-based telephone survey of 976 Canadian respondents, Ratner et al15 offered a case scenario to participants and asked them to identify the most likely cause of the symptoms and what action they would recommend. The majority (78%) of respondents recognized the symptoms as cardiac in nature. However, South Asian and Chinese participants were less likely than those “born in Canada” to identify classic symptoms as heart related (p ⬍0.05). Ratner et al16 asked this same sample to spontaneously identify heart attack symptoms. Chinese and South Asian participants identified fewer correct symptoms than their born-inCanada counterparts (p ⬍0.001). Being non-English speaking is a barrier to receipt of care in the ED.17 In our study, Chinese patients were least likely to speak English, representing a potential barrier to receipt of care. The majority of those who accompanied patients to the ED spoke English and could presumably act as interpreters. However, language variations and interpretation can pose barriers to identifying symptoms for patients. In unadjusted analyses Caucasian patients were significantly more likely to undergo angiography within 3 hours of presentation to the ED than their counterparts in other ethnic groups. A landmark cardiac care study by Venkat et al18 revealed that non-Caucasians with chest pain were less likely to receive necessary investigations and those with
1372
The American Journal of Cardiology (www.AJConline.org)
AMI underwent cardiac catheterization less frequently than Caucasians. Similarly, LaVeist et al19 found that AfricanAmericans were significantly less likely than Caucasians (even after controlling for known barriers such as income, insurance, and geography) to receive cardiac care (i.e., angiography, coronary artery bypass graft surgery, percutaneous coronary intervention). Further, Correa-de-Araujo et al20 showed that Hispanics and African-Americans were less likely than Caucasians to receive appropriate medications after AMI. A study from the United Kingdom revealed that South Asians were less likely than Caucasians (hazard ratio 0.48 95% CI 0.34 to 0.67) to undergo angiography for potential stable angina.21 Patients need to be aware of classic and atypical presentations of AMI to best make decisions to seek the most appropriate (i.e., ED) care. Indeed, once patients arrive at the ED, it is imperative that clinicians recognize potential ethnic variation in symptoms and act accordingly. Systems in busy triage areas are often challenged to manage patients who are non-English speaking. Potential barriers to healthservices access lay with the patient, provider (clinician), and health system.22 To prevent unnecessary delays in treatment, increase receipt of evidence-based therapies, and decrease in-hospital morbidity and mortality,7,23,24 a broadbased approach to education will be necessary. There were some limitations to undertaking this retrospective work. First, we studied only patients who accessed the ED and had been discharged with a diagnosis of AMI. Thus, patients who did not present to the ED or those whose diagnosis was “missed” and sent home were not included in this study. Health records contained only observations and interpretations of those entering data and may not necessarily have reflected all or exact symptoms of the patient or the prehospital care pathways (i.e., previous contact with health care provider, accompanying persons, mechanism of transport); and information regarding the social context in which these study findings occurred are not available. There may be a number of other variables that also influence symptom presentation, such as education, health literacy, and socioeconomic status, that are not available from a health record. Chinese patients in this study were significantly older than patients of other ethnic groups when presenting to the ED with AMI and were least likely to report symptoms in keeping with a classic symptom profile. Reporting of atypical symptoms increases with age7–9 and may be more likely in women8,9 and patients with diabetes.7,24 –26 It is imperative that in future studies other potential associated variables are measured and samples are sufficient to enable appropriate multivariate adjustment to be made. We did not collect data regarding severity of disease (e.g., angiographic findings). Our findings regarding differences in access to care are observational and unadjusted. Thus they should be interpreted with caution. This study was undertaken in 1 health region. Although this health region supports the city with the third largest visible minority population in Canada and has a population in excess of 1 million,1 it is indeed possible that findings lack generalizability. We did not explore outcomes (i.e., long-term morbidity or mortality) associated with the symptom presentation of the index AMI. Thus the direct clinical
significance of these findings may be limited. This 1 region study provided basic descriptive information and raised research questions. Undertaking a prospective study in which more detailed data were collected and enabling more multivariate analyses would attend to our study limitations. Acknowledgment: The investigators acknowledge Mrs. Pamela LeBlanc and Rebekah Spencer for their assistance with data abstraction. 1. Canada. Statistics Canada. 2006 Census directory. Ottawa, Canada: Statistics Canada, 2006. Available at: http://www.statcan.ca/english/ census06/data/highlights. Accessed July 10, 2008. 2. Anand SS, Yusuf S, Vuksan V, Devanesen S, Teo KK, Montague PA, Kelemen L, Yi C, Lonn E, Gerstein H, Hegele RA, McQueen M, for the SHARE Investigators. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada; the study of health assessment and risk in ethnic groups (SHARE). Lancet 2000;356:279 –285. 3. Yusuf S, Reddy S, Ôunpuu S, Anand S. Global burden of cardiovascular diseases Part II. Variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001;104:2855–2864. 4. Quan H, Wang FL, Schopflocher D, Norris C, Galbraith PD, Faris P, Graham M, Knudtson M, Ghali WA. Development and validation of a surname list to define Chinese ethnicity. Med Care 2006;44:328 –333. 5. Mcfarlane GJ, Lunt M, Palmer B, Afzal C, Silman AJ, Esmail A. Determining aspects of ethnicity amongst persons of South Asian origin: the use of a surname-classification programme (Nam Pehchan). Pub Health 2007;121:231–236. 6. Théroux P, Fuster V. Acute coronary syndromes. Unstable angina and non–Q-wave myocardial infarction. Circulation 1998;97:1195–1206. 7. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT, Ornato JP, Barron HV, Kiefe CI. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–3229. 8. Goldberg R, Goff D, Cooper L, Lawton C, Luepker RD, Zapka JA, Bittner VE, Osganian SA, Lessard DA, Cornell CE, et al. Age and gender differences in presentation of symptoms among patients with acute coronary disease: the REACT trial. Coron Artery Dis 2000;11: 399 – 407. 9. Milner KA, Vaccarino V, Arnold AL, Funk M, Goldberg RJ. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol 2004;93:606 – 608. 10. Canto JG, Goldberg RJ, Hand MM, Bonow RO, Sopko G, Pepine CJ, Long T. Symptom presentation of women with acute coronary syndromes. Myth vs reality. Arch Intern Med 2007;167:2405–2413. 11. Lee H, Bahler R, Park OJ, Kim CJ, Lee HY, Kim YJ. Typical and atypical symptoms of myocardial infarction among African Americans, Whites, and Koreans. Crit Care Nurs Clin North Am 2001;13: 531–539. 12. Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban public hospital emergency department. Ann Emerg Med 2002;40:180 –186. 13. Teoh M, Lalondrelle S, Roughton M, Grocott-Mason R, Dubrey SW. Acute coronary syndromes and their presentation in Asian and Caucasian patients in Britain. Heart 2007;93:183–188. 14. Greenlund KJ, Keenan NL, Giles WH, Zheng ZJ, Neff LJ, Croft JB, Mensah JA. Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2005;147:1010 –1016. 15. Ratner PA, Johnson JL, Mackay M, Tu AW. Knowledge of ‘heart attack’ symptoms in a Canadian urban community. Clin Med Cardiol 2008;2:201–213. 16. Ranter PA, Tzianetas R, Tu AW, Johnson JL, Mackay M, Buller CE, Rowlands M, Reime B. Myocardial infarction symptom recognition by the lay public: the role of gender and ethnicity. J Epidemiol Community Health 2006;60:606 – 615.
Coronary Artery Disease/Ethnicity and AMI Presentation 17. Heron SL, Stettner E, Haley LL Jr. Racial and ethnic disparities in the emergency department: a public health perspective. Emerg Med Clin North Am 2006;24:905–923. 18. Venkat A, Hoekstra J, Lindsell C, Prall D, Hollander JE, Pollack CV Jr, Diercks D, Kirk JD, Tiffany B, Peacock F, Storrow AB, Gibler WB. The impact of race on acute management of chest pain. Acad Emerg Med 2003;10:1199 –1208. 19. LaVeist TA, Arthur M, Morgan A, Rubinstein M, Kinder J, Kinney LM, Plantholt S. The cardiac access longitudinal study. A study of access to invasive cardiology among African American and White patients. J Am Coll Cardiol 2003;41:1159 –1166. 20. Correa-de-Araujo R, Stevens B, Moy E, Nilasena D, Chesley F, McDermott K. Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities. Womens Health Issues 2006;16: 44 – 45. 21. Sekhri N, Timmis A, Chen R, Junghans C, Walsh N, Zaman J, Eldridge S, Hemingway H, Feder G. Inequity of access to investigation and effect on clinical outcomes: Prognostic study of coronary
22. 23.
24.
25. 26.
1373
angiography for suspected stable angina pectoris. BMJ 2008;336: 1058 –1061. Scheppers E, VanDongen E, Dekker J, Geertzen J, Dekker J. Potential barriers to use of health services among ethnic minorities: a review. Fam Pract 2006;23:325–248. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, Selker HP. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163–1170. Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, Montalescot G, for the GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated highrisk group. Chest 2004;126:461– 469. Stephen SA, Darney BG, Rosenfeld AG. Symptoms of acute coronary syndrome in women with diabetes: an integrative review of the literature. Heart Lung 2008;37:179 –189. DeVon HA, Penckofer S, Larimer K. The association of diabetes and older age with the absence of chest pain during acute coronary syndromes. West J Nurs Res 2008;30:130 –144.
We compared the acute myocardial infarction (AMI) symptom presentation and care pathways in European (Caucasian), Chinese (from mainland China, Hong Kong, Macau), South Asian (from India, Pakistan, Bangladesh, Sri Lanka), and Southeast Asian (from Philippines, Vietnam, Cambodia, Malaysia, Fiji), and First Nations (North American Indian) patients admitted to tertiary care centers in Calgary, Alberta, Canada. These ethnic groups are among the largest and fastest growing minority ethnic populations in Canada.1 Given the coronary heart disease risk for these ethnic groups,2,3 identifying variability in symptom presentation and access to care will provide essential information for patients and clinicians to enable sooner identification of symptoms/cases, diagnostic evaluation, and timely management.
a Faculty of Nursing and bDepartment of Community Health Sciences, University of Calgary, Calgary, Alberta, and cDepartment of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Manuscript received November 18, 2008; revised manuscript received and accepted January 17, 2009. Dr. King holds a Health Scholar Award from the Alberta Heritage Foundation for Medical Research, Alberta, Canada. Dr. Khan holds a New Investigator Award from the Canadian Institutes of Health Research and a GENESIS Scholar Award, Quebec, Canada. Dr. Quan holds a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research and a New Investigator Award from the Canadian Institutes of Health Research. *Corresponding author: Tel: 403-210-3953; fax: 403-210-3818. E-mail address: [email protected] (K.M. King).
0002-9149/09/$ – see front matter © 2009 Elsevier Inc. doi:10.1016/j.amjcard.2009.01.344
Methods After approval from the health research ethics board, patients with AMI were identified from Calgary Health Region hospital discharge abstract data from 2002 through 2006 fiscal years. This administrative database was coded in the International Statistical Classification of Diseases, 10th Revision. To identify patients with AMI, we used health records in which the most responsible diagnosis field was coded as I21.x or I22.x in the International Statistical Classification of Diseases, 10th Revision. Ethnicity of patients with AMI was categorized as European, Chinese, South Asian, Southeast Asian, and First Nations using the surname method, a relatively reliable and valid mechanism to identify ethnicity.4,5 All inpatient health records of Chinese, South Asian, Southeast Asian, and First Nations patients with AMI and a random sample of European patients with AMI were then identified using a unique personal health number, admission date, and location found in the discharge abstract. Later, to enhance the accuracy of a patient’s ethnic categorization, we identified the ethnicity documented in the health record. If there was a disparity between the surname method and that identified in the health record, the health record indication was used (this included ensuring that all European patients were Caucasian). Data were collected from 406 health records of European (Caucasian, n ⫽ 117), Chinese (n ⫽ 92), South Asian (n ⫽ 101), Southeast Asian (n ⫽ 57), and First Nations (n ⫽ 39) patients with AMI. Demographic (i.e., gender, age, body mass index), clinical (i.e., co-morbid conditions, type of infarction), sympwww.AJConline.org
Coronary Artery Disease/Ethnicity and AMI Presentation
1369
Table 1 Characteristics of study sample Demographic and Clinical Characteristics Age (yrs), mean ⫾ SD Body mass index (kg/m2), mean ⫾ SD Men Fluent in English language Co-morbid conditions Old MI Congestive heart failure Peripheral vascular disease Cerebrovascular disease Dementia Chronic lung disease Diabetes mellitus Chronic renal disease Any malignancy Previous cardiac testing Angiography Noninvasive imaging Previous revascularization Percutaneous coronary intervention Coronary artery bypass graft surgery Documented cardiac risk factors Current smoker Ever smoker Dyslipidemia* Hypertension Excessive alcohol consumption Sedentary lifestyle Obesity Abdominal obesity None listed Type of MI Non-ST elevation
European (Caucasian) (n ⫽ 117)
Chinese (n ⫽ 92)
South Asian (n ⫽ 101)
Southeast Asian (n ⫽ 57)
First Nations (n ⫽ 39)
p Value
63.9 ⫾ 14.35 27.95 ⫾ 5.51 78% (91) 99% (116)
71.58 ⫾ 13.90 24.73 ⫾ 4.25 63% (58) 34% (31)
66.84 ⫾ 11.47 25.60 ⫾ 3.86 66% (67) 46% (46)
65.51 ⫾ 16.85 25.06 ⫾ 4.44 74% (42) 51% (29)
55.56 ⫾ 12.73 28.94 ⫾ 4.41 80% (31) 92% (36)
⬍0.001 ⬍0.001 0.088 ⬍0.001
27% (31) 2.6% (3) 1.7% (2) 2.6% (3) 1.7% (2) 0.9% (1) 25% (29) 6.0% (7) 5.1% (6)
20% (18) 5.4% (5) 2.2% (2) 3.3% (3) 1.1% (1) 2.2% (2) 30% (28) 11% (10) 4.3% (4)
15% (15) 2.0% (2) 2.0% (2) 1.0% (1) 2.0% (2) 1.0% (1) 38% (38) 8.9% (9) 0.0% (0)
18% (10) 0.0% (0) 0.0% (0) 0.0% (0) 5.3% (3) 3.5% (2) 27% (15) 3.5% (2) 0.0% (0)
36% (14) 2.6% (1) 13% (5) 0.0% (0) 0.0% (0) 7.7% (3) 39% (15) 16% (6) 0.0% (0)
0.043 0.355 0.002 0.437 0.355 0.110 0.214 0.206 0.044
15% (18) 3.4% (4)
11% (10) 2.2% (2)
14% (14) 5.0% (5)
14.0% (8) 5.3% (3)
33% (13) 5.1% (2)
0.024 0.822
10% (12) 8.5% (10)
7.6% (7) 2.2% (2)
6.9% (7) 4.0% (4)
8.8% (5) 5.3% (3)
26% (10) 7.7% (3)
0.016 0.294
40% (47) 33% (39) 44% (52) 47% (55) 12% (14) 1.7% (2) 10% (12) 2.6% (3) 6.8% (8)
21% (19) 25% (23) 38% (35) 70% (64) 0.0% (0) 2.2% (2) 3.3% (3) 0.0% (0) 11% (10)
7.9% (8) 12% (12) 48% (48) 70% (71) 5.0% (5) 2.0% (2) 11% (11) 1.0% (1) 14.9% (15)
23% (13) 25% (14) 51% (29) 63% (36) 1.8% (1) 0.0% (0) 1.8% (1) 0.0% (0) 3.5% (2)
62% (24) 18% (7) 49% (19) 51% (20) 10% (4) 0.0% (0) 7.7% (3) 2.6% (1) 2.6% (1)
⬍0.001 0.005 0.544 0.001 0.002 0.742 0.086 0.382 0.050
46% (52)
60% (52)
54% (54)
66% (36)
56% (22)
0.137
* Increased low-density lipoprotein cholesterol or triglycerides or low high-density lipoprotein cholesterol as documented in the health record.
Table 2 Symptoms presentation Reported Symptoms Distinct time of symptom onset Symptom Midsternal pain Midsternal pressure Shortness of breath Nausea or vomiting Throat/neck pain Shoulder pain Abdominal discomfort Back pain Confusion Heart palpitations Syncope Diaphoresis Arm pain Dizziness Fatigue Heart burn Body weakness Classic symptom profile*
European (Caucasian) (n ⫽ 117)
Chinese (n ⫽ 92)
South Asian (n ⫽ 101)
Southeast Asian (n ⫽ 57)
First Nations (n ⫽ 39)
93% (109)
76% (70)
91% (92)
88% (50)
90% (35)
0.003
87% (102) 39% (46) 43% (50) 25% (29) 15% (17) 18% (21) 2.6% (3) 15% (17) 0.0% (0) 0.9% (1) 0.9% (1) 46% (54) 44% (52) 7.7% (9) 5.1% (6) 6.8% (8) 6.8% (8) 93% (109)
69% (63) 28% (26) 54% (50) 17% (16) 119% (10) 3.3% (3) 3.3% (3) 7.6% (7) 0.0% (0) 3.3% (3) 1.1% (1) 27% (25) 14% (13) 15% (14) 5.4% (5) 5.4% (5) 3.3% (3) 77% (71)
79% (80) 16% (17) 42% (42) 29% (29) 9.9% (10) 12% (12) 11% (11) 6.9% (7) 1.0% (1) 5.0% (5) 2.0% (2) 25% (25) 24% (24) 6.9% (7) 3.0% (3) 6.9% (7) 6.9% (7) 79% (80)
75% (43) 26% (15) 58% (33) 23% (13) 12% (7) 8.8% (5) 5.3% (3) 11% (6) 5.3% (3) 1.8% (1) 0.0% (0) 12% (7) 26% (15) 11% (6) 7.0% (4) 7.0% (4) 8.8% (5) 83% (47)
77% (30) 28% (11) 56% (22) 36% (14) 18% (7) 10% (4) 7.7% (3) 5.1% (2) 5.1% (2) 2.6% (1) 7.7% (3) 23% (9) 36% (14) 10% (4) 5.1% (2) 15% (6) 2.6% (1) 85% (33)
0.026 0.009 0.102 0.183 0.674 0.020 0.073 0.242 0.014 0.440 0.041 ⬍0.001 ⬍0.001 0.330 0.840 0.373 0.686 0.016
* Classic symptom profile ⫽ (midsternal pain and/or midsternal pressure) ⫾ throat/neck pain ⫾ shoulder pain ⫾ arm pain.6
p Value
1370
The American Journal of Cardiology (www.AJConline.org)
Table 3 Access to care Factors Related to Care Access If distinct onset of pain, time to ED presentation (h) ⬍1 1–2 3–6 7–12 13–24 Saw provider ⱕ72 h to ED presentation If yes, where/what provider? Same ED Different ED Family physician Emergency clinic Cardiologist Other physician Alternative provider Method of transport to ED Ambulance Private vehicle Taxi Other Unknown Accompanying person(s) fluent in English? Time from ED presentation to cardiac catheterization/angiography (h) ⬍3 3–6 ⬎6–24 ⬎24 Not done Percutaneous coronary intervention performed this admission Coronary artery bypass graft surgery performed this admission
European (Caucasian) (n ⫽ 117)
Chinese (n ⫽ 92)
South Asian (n ⫽ 101)
Southeast Asian (n ⫽ 57)
First Nations (n ⫽ 39)
20% (22/109) 25% (27/109) 27% (297/109) 1.8% (2/109) 27% (29/109) 12% (14)
21% (8/70) 14% (10/70) 16% (11/70) 5.7% (4/70) 53% (37/70) 9.3% (27)
8.7% (8/92) 13% (12/92) 24% (22/92) 7.6% (7/92) 47% (43/92) 37% (37)
20% (10/50) 18% (9/50) 16% (8/50) 8.0% (4/50) 38% (19/50) 18% (10)
23% (8/35) 26% (9/35) 11% (4/35) 5.7% (2/35) 34% (12/35) 21% (8)
5.4% (2) 0.0% (0) 35% (13) 8.1% (3) 2.7% (1) 49% (18) 0.0% (0)
0.0% (0) 0.0% (0) 30% (3) 10% (1) 0.0% (0) 60% (6) 0.0% (0)
11% (1) 11% (1) 11% (1) 44% (4) 0.0% (0) 11% (1) 0.0% (0)
p Value 0.015
0.0% (0) 29% (4) 57% (8) 7.1% (1) 0.0% (0) 7.1% (1) 0.0% (0)
3.7% (1) 3.7% (1) 33% (9) 14.8% (4) 0.0% (0) 33% (9) 3.7% (1)
0.002 0.002
⬍0.001 64% (75) 1.7% (2) 0.0% (0) 1.7% (2) 33% (38) 93% (13/14)
59% (54) 4.3% (4) 0.0% (0) 26% (24) 11% (10) 97% (59/61)
55% (55) 1.0% (1) 0.0% (0) 32% (32) 13% (13) 98% (47/48)
46% (26) 0.0% (0) 1.8% (1) 42% (24) 11% (6) 6.4% (27/28)
56% (22) 2.6% (1) 0.0% (0) 28% (11) 13% (5) 100% (8/8)
42% (49) 5.1% (6) 9.4% (11) 27% (32) 16% (19) 63% (74)
22% (20) 3.3% (3) 5.4% (5) 33% (30) 37% (34) 40% (37)
21% (21) 3.0% (3) 7.9% (8) 35% (35) 34% (34) 47% (47)
16% (9) 3.5% (2) 5.3% (3) 33% (19) 42% (24) 33% (19)
18% (7) 7.7% (3) 0.0% (0) 46% (18) 28% (11) 62% (24)
6.0% (7)
9.8% (9)
3.0% (3)
3.5% (2)
2.6% (1)
tom (including “classic,” i.e., midsternal chest pain/pressure, and “atypical,” i.e., nausea, fatigue, confusion, weakness, abdominal discomfort6), and processes-of-care (i.e., time to presentation, if patient saw another health care provider before emergency department [ED] presentation, those accompanying a patient, receipt of investigations) data were abstracted and recorded on a data form developed for this study. Research assistants were specially trained to undertake the audits and maintained high (ⱖ95%) interrater reliabilities. Demographic, clinical, and symptom characteristics and process-of-care data were characterized for each of the 5 ethnic groups using descriptive statistics. Continuous variables were presented using means ⫾ SDs. Categorical variables were presented using proportions and percentages. Differences between groups were examined using chisquare test for categorical variables and analysis of variance for continuous variables. We conducted logistic regression models to examine the association between ethnicity compared with Caucasian and (1) having classic symptoms and (2) time to ED presentation in those who had classic symptoms after adjustment for age (⬍65 years) and male sex (factors known to be associated with symptom presenta-
0.940 0.001
⬍0.001 0.022
tion7–10). SPSS 15 (SPSS, Inc. Chicago, Illinois) was used to analyze the data. Results Of the 406 health records reviewed, the number of patients representing each ethnic group was consistent with the population of Calgary, Alberta, and the known burden of disease in each group.1,3 As presented in Table 1, most patients were men. First Nations patients were youngest (mean age 56 years) and Chinese patients were oldest (mean age 72 years) when presenting with the index AMI. First Nations and Caucasian patients had significantly greater body mass index than patients in other ethnic groups. Chinese patients were least likely to be fluent in English, followed by South Asian and Southeast Asian patients. First Nations patients were more likely to have had a previous MI and documented previous angiography and percutaneous coronary intervention than their counterparts in the other ethnic groups. First Nations and Caucasian patients were most likely to be current smokers. South Asian, Chinese, and Southeast Asian patients were more likely to be hypertensive. There was no difference between groups in type (ST, non-ST elevation) of AMI.
Coronary Artery Disease/Ethnicity and AMI Presentation
Compared with other ethnic groups, Chinese patients least frequently reported a distinct time of symptom onset (Table 2). There were significant differences between groups in reporting midsternal chest pain and pressure. Caucasians were most likely to have had midsternal chest pain or pressure reported. Caucasian patients also had the greatest likelihood of reporting shoulder pain, diaphoresis, and arm pain. Southeast Asian and First Nations patients were more likely than other ethnic groups to report confusion and First Nations patients were most likely to report syncope compared with the other ethnic groups. Caucasian patients most frequently and Chinese patients least frequently presented with a classic symptom profile (i.e., midsternal pain and/or midsternal pressure with/without throat/ neck pain with/without shoulder pain with/without arm pain6). In logistic regression modeling, patients who were ⬍65 years of age were more likely than patients ⱖ65 years of age to present with reported classic symptoms (adjusted odds ratio (AOR) 2.99, 95% confidence interval (CI) 1.52 to 5.91). Conversely, Chinese (AOR 0.31, 95% CI 0.13 to 0.76), South Asian (AOR 0.35, 95% CI 0.14 to 0.84), and Southeast Asian (AOR 0.36, 95% CI 0.13 to 0.97) patients were less likely and First Nations patients tended to be less likely (OR 0.33, 95% CI 0.13 to 1.05) than Caucasian patients to have reported classic symptoms. Of those who reported a distinct time of onset, a larger proportion of Chinese and South Asian patients waited ⬎12 hours to seek care at the ED (Table 3). Even in patients who had reported classic symptoms, South Asians were significantly less likely (AOR 0.30, 95% CI 0.15 to 0.61) than Caucasians to report to the ED within 3 hours of symptom onset after adjustment for age and gender. Also, as presented in Table 3, South Asian and Chinese patients were most likely to have seen a health care provider within 72 hours of presenting in the index ED visit. Caucasian patients were most likely to be transported to the ED by ambulance. Although there were language barriers for the Chinese, South Asian, and Southeast Asian patients, a large proportion of documented “accompanying persons” for each ethnic group spoke English (⬎96% for Chinese, South Asian, and Southeast Asian patients). In unadjusted analyses, Caucasian patients received cardiac catheterization/angiography within 3 hours of presentation to the ED more frequently than other ethnic groups and Caucasian and First Nations patients underwent percutaneous coronary interventions more frequently compared with the others (p ⬍0.001). Discussion We examined variations in AMI symptom presentation and access to care by studying 406 health records of patients of Caucasian, Chinese, South Asian, Southeast Asian, and First Nations ethnicities and found ethnic differences in symptom presentation, including differences in reporting distinct onset of “symptoms” and the care pathway. A significant proportion of ethnic-minority patients in this study did not present with classic cardiac symptoms. Other investigators have reported ethnic variations in coronary heart disease symptoms. For example, Lee et al11 found that a significantly larger proportion of Korean pa-
1371
tients reported chest pain; shoulder, neck, and jaw pain; dyspnea; and diaphoresis compared with their AfricanAmerican and Caucasian counterparts. Gupta et al12 found that Caucasians were more likely to present with only chest pain (vs other atypical symptoms) than their ethnic counterparts (African-American, Hispanic, and Asian). In a study of 604 South Asian (primarily of Indian origin) and 2,301 European (Caucasian) patients, Teoh et al13 found that some symptoms differed significantly between these ethnic groups. South Asian patients reported their symptoms over a larger area of their body and had more frequent discomfort over the rear of their upper thorax compared with Caucasian patients. Given a lack of consistent definition regarding ethnicity (i.e., Asian, South Asian, Southeast Asian) and a focus on ethnic groups of interest to particular countries (i.e., African-Americans and Hispanics for researchers in the United States and South Asians [from India] for researchers in the United Kingdom), more generalizable investigation needs to be done. Although most patients reported classic symptoms, up to 37% saw a health care provider within 72 hours before reporting to the ED. Indeed, South Asian patients were most likely to seek the advice of a health care provider before presenting to the ED. Further, 27% to 53% of patients who reported having a distinct time of symptom onset presented to the ED ⬎12 hours later; well beyond the time that thrombolytics could be offered. There are compelling data to suggest that ethnic-minority patients remain less aware of heart disease and its symptoms. Although 95% of patients in an American survey of 61,018 recognized chest pain/discomfort as a symptom of a heart attack, awareness was lower in visible minority groups (African-American, Hispanic, Asian, First Nations, Hawaiian) than in Caucasians. Further, non-Caucasians were less likely than Caucasians to recognize “other” (i.e., shoulder pain; shortness of breath; jaw, neck, or back pain; or dizziness) cardiac symptoms.14 In a population-based telephone survey of 976 Canadian respondents, Ratner et al15 offered a case scenario to participants and asked them to identify the most likely cause of the symptoms and what action they would recommend. The majority (78%) of respondents recognized the symptoms as cardiac in nature. However, South Asian and Chinese participants were less likely than those “born in Canada” to identify classic symptoms as heart related (p ⬍0.05). Ratner et al16 asked this same sample to spontaneously identify heart attack symptoms. Chinese and South Asian participants identified fewer correct symptoms than their born-inCanada counterparts (p ⬍0.001). Being non-English speaking is a barrier to receipt of care in the ED.17 In our study, Chinese patients were least likely to speak English, representing a potential barrier to receipt of care. The majority of those who accompanied patients to the ED spoke English and could presumably act as interpreters. However, language variations and interpretation can pose barriers to identifying symptoms for patients. In unadjusted analyses Caucasian patients were significantly more likely to undergo angiography within 3 hours of presentation to the ED than their counterparts in other ethnic groups. A landmark cardiac care study by Venkat et al18 revealed that non-Caucasians with chest pain were less likely to receive necessary investigations and those with
1372
The American Journal of Cardiology (www.AJConline.org)
AMI underwent cardiac catheterization less frequently than Caucasians. Similarly, LaVeist et al19 found that AfricanAmericans were significantly less likely than Caucasians (even after controlling for known barriers such as income, insurance, and geography) to receive cardiac care (i.e., angiography, coronary artery bypass graft surgery, percutaneous coronary intervention). Further, Correa-de-Araujo et al20 showed that Hispanics and African-Americans were less likely than Caucasians to receive appropriate medications after AMI. A study from the United Kingdom revealed that South Asians were less likely than Caucasians (hazard ratio 0.48 95% CI 0.34 to 0.67) to undergo angiography for potential stable angina.21 Patients need to be aware of classic and atypical presentations of AMI to best make decisions to seek the most appropriate (i.e., ED) care. Indeed, once patients arrive at the ED, it is imperative that clinicians recognize potential ethnic variation in symptoms and act accordingly. Systems in busy triage areas are often challenged to manage patients who are non-English speaking. Potential barriers to healthservices access lay with the patient, provider (clinician), and health system.22 To prevent unnecessary delays in treatment, increase receipt of evidence-based therapies, and decrease in-hospital morbidity and mortality,7,23,24 a broadbased approach to education will be necessary. There were some limitations to undertaking this retrospective work. First, we studied only patients who accessed the ED and had been discharged with a diagnosis of AMI. Thus, patients who did not present to the ED or those whose diagnosis was “missed” and sent home were not included in this study. Health records contained only observations and interpretations of those entering data and may not necessarily have reflected all or exact symptoms of the patient or the prehospital care pathways (i.e., previous contact with health care provider, accompanying persons, mechanism of transport); and information regarding the social context in which these study findings occurred are not available. There may be a number of other variables that also influence symptom presentation, such as education, health literacy, and socioeconomic status, that are not available from a health record. Chinese patients in this study were significantly older than patients of other ethnic groups when presenting to the ED with AMI and were least likely to report symptoms in keeping with a classic symptom profile. Reporting of atypical symptoms increases with age7–9 and may be more likely in women8,9 and patients with diabetes.7,24 –26 It is imperative that in future studies other potential associated variables are measured and samples are sufficient to enable appropriate multivariate adjustment to be made. We did not collect data regarding severity of disease (e.g., angiographic findings). Our findings regarding differences in access to care are observational and unadjusted. Thus they should be interpreted with caution. This study was undertaken in 1 health region. Although this health region supports the city with the third largest visible minority population in Canada and has a population in excess of 1 million,1 it is indeed possible that findings lack generalizability. We did not explore outcomes (i.e., long-term morbidity or mortality) associated with the symptom presentation of the index AMI. Thus the direct clinical
significance of these findings may be limited. This 1 region study provided basic descriptive information and raised research questions. Undertaking a prospective study in which more detailed data were collected and enabling more multivariate analyses would attend to our study limitations. Acknowledgment: The investigators acknowledge Mrs. Pamela LeBlanc and Rebekah Spencer for their assistance with data abstraction. 1. Canada. Statistics Canada. 2006 Census directory. Ottawa, Canada: Statistics Canada, 2006. Available at: http://www.statcan.ca/english/ census06/data/highlights. Accessed July 10, 2008. 2. Anand SS, Yusuf S, Vuksan V, Devanesen S, Teo KK, Montague PA, Kelemen L, Yi C, Lonn E, Gerstein H, Hegele RA, McQueen M, for the SHARE Investigators. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada; the study of health assessment and risk in ethnic groups (SHARE). Lancet 2000;356:279 –285. 3. Yusuf S, Reddy S, Ôunpuu S, Anand S. Global burden of cardiovascular diseases Part II. Variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001;104:2855–2864. 4. Quan H, Wang FL, Schopflocher D, Norris C, Galbraith PD, Faris P, Graham M, Knudtson M, Ghali WA. Development and validation of a surname list to define Chinese ethnicity. Med Care 2006;44:328 –333. 5. Mcfarlane GJ, Lunt M, Palmer B, Afzal C, Silman AJ, Esmail A. Determining aspects of ethnicity amongst persons of South Asian origin: the use of a surname-classification programme (Nam Pehchan). Pub Health 2007;121:231–236. 6. Théroux P, Fuster V. Acute coronary syndromes. Unstable angina and non–Q-wave myocardial infarction. Circulation 1998;97:1195–1206. 7. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT, Ornato JP, Barron HV, Kiefe CI. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–3229. 8. Goldberg R, Goff D, Cooper L, Lawton C, Luepker RD, Zapka JA, Bittner VE, Osganian SA, Lessard DA, Cornell CE, et al. Age and gender differences in presentation of symptoms among patients with acute coronary disease: the REACT trial. Coron Artery Dis 2000;11: 399 – 407. 9. Milner KA, Vaccarino V, Arnold AL, Funk M, Goldberg RJ. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol 2004;93:606 – 608. 10. Canto JG, Goldberg RJ, Hand MM, Bonow RO, Sopko G, Pepine CJ, Long T. Symptom presentation of women with acute coronary syndromes. Myth vs reality. Arch Intern Med 2007;167:2405–2413. 11. Lee H, Bahler R, Park OJ, Kim CJ, Lee HY, Kim YJ. Typical and atypical symptoms of myocardial infarction among African Americans, Whites, and Koreans. Crit Care Nurs Clin North Am 2001;13: 531–539. 12. Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban public hospital emergency department. Ann Emerg Med 2002;40:180 –186. 13. Teoh M, Lalondrelle S, Roughton M, Grocott-Mason R, Dubrey SW. Acute coronary syndromes and their presentation in Asian and Caucasian patients in Britain. Heart 2007;93:183–188. 14. Greenlund KJ, Keenan NL, Giles WH, Zheng ZJ, Neff LJ, Croft JB, Mensah JA. Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2005;147:1010 –1016. 15. Ratner PA, Johnson JL, Mackay M, Tu AW. Knowledge of ‘heart attack’ symptoms in a Canadian urban community. Clin Med Cardiol 2008;2:201–213. 16. Ranter PA, Tzianetas R, Tu AW, Johnson JL, Mackay M, Buller CE, Rowlands M, Reime B. Myocardial infarction symptom recognition by the lay public: the role of gender and ethnicity. J Epidemiol Community Health 2006;60:606 – 615.
Coronary Artery Disease/Ethnicity and AMI Presentation 17. Heron SL, Stettner E, Haley LL Jr. Racial and ethnic disparities in the emergency department: a public health perspective. Emerg Med Clin North Am 2006;24:905–923. 18. Venkat A, Hoekstra J, Lindsell C, Prall D, Hollander JE, Pollack CV Jr, Diercks D, Kirk JD, Tiffany B, Peacock F, Storrow AB, Gibler WB. The impact of race on acute management of chest pain. Acad Emerg Med 2003;10:1199 –1208. 19. LaVeist TA, Arthur M, Morgan A, Rubinstein M, Kinder J, Kinney LM, Plantholt S. The cardiac access longitudinal study. A study of access to invasive cardiology among African American and White patients. J Am Coll Cardiol 2003;41:1159 –1166. 20. Correa-de-Araujo R, Stevens B, Moy E, Nilasena D, Chesley F, McDermott K. Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities. Womens Health Issues 2006;16: 44 – 45. 21. Sekhri N, Timmis A, Chen R, Junghans C, Walsh N, Zaman J, Eldridge S, Hemingway H, Feder G. Inequity of access to investigation and effect on clinical outcomes: Prognostic study of coronary
22. 23.
24.
25. 26.
1373
angiography for suspected stable angina pectoris. BMJ 2008;336: 1058 –1061. Scheppers E, VanDongen E, Dekker J, Geertzen J, Dekker J. Potential barriers to use of health services among ethnic minorities: a review. Fam Pract 2006;23:325–248. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, Selker HP. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163–1170. Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, Montalescot G, for the GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated highrisk group. Chest 2004;126:461– 469. Stephen SA, Darney BG, Rosenfeld AG. Symptoms of acute coronary syndrome in women with diabetes: an integrative review of the literature. Heart Lung 2008;37:179 –189. DeVon HA, Penckofer S, Larimer K. The association of diabetes and older age with the absence of chest pain during acute coronary syndromes. West J Nurs Res 2008;30:130 –144.