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Symptoms of acute myocardial infarction: A correlational study of the discrepancy between patients’ expectations and experiences
International Journal of Nursing Studies 52 (2015) 1591–1599
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Symptoms of acute myocardial infarction: A correlational study of the discrepancy between patients’ expectations and experiences Mona A. Abed a,*, Raeda M. Abu Ali b, Motaz M. Abu Ras c, Faten O. Hamdallah a, Amani A. Khalil d, Debra K. Moser e,f a
Hashemite University College of Nursing, Zarqa, Jordan Albalqa Applied University College of Nursing, Amman, Jordan Jordan University Hospital, Amman, Jordan d The University of Jordan College of Nursing, Amman, Jordan e University of Kentucky College of Nursing, KY, USA f University of Ulster, Newtownabbey, United Kingdom b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 September 2014 Received in revised form 2 June 2015 Accepted 13 June 2015
Background: Patients’ responses to acute myocardial infarction symptoms are affected by symptom incongruence, which is the difference between the symptoms they expect to experience and the symptoms they actually experienced during an acute myocardial infarction. Objective: To examine the relationship of patients’ demographics, clinical characteristics and sources of information about acute myocardial infarction with their symptom expectations, actual experiences and symptom incongruence. Design: Descriptive correlational study. Setting: Patients were recruited from ten hospitals in the two most populated cities in Jordan (Amman and Al Zarqa). Participants: Jordanian patients with acute myocardial infarction were recruited. Inclusion criteria were age 18 years or older, diagnosis of acute myocardial infarction, oriented, mentally competent and fluent in Arabic. Exclusion criteria were experiencing acute myocardial infarction during a hospitalization or having severe psychiatric illnesses. Methods: The Morgan Incongruence of Heart Attack Symptoms Index was used to quantify symptom incongruence and identify patients’ expected and experienced acute myocardial infarction symptoms. Patients’ information sources about acute myocardial infarction and demographic and clinical characteristics were collected by interview and medical chart review. Results: Patients (N = 299) were mostly males (80%) and married (92%). The average age was 56 12.3 years. Patients expected a limited number of acute myocardial infarction symptoms and these expectations were largely confined to typical symptoms and matched their experiences. Patients who were female, elderly, nonsmokers, poorly educated, with low income, and those who were normolipidemic, had no personal or family cardiac history, and were informed about acute myocardial infarction by relatives expected fewer symptoms (mostly typical and atypical) than their counterparts. Elderly patients and those with hyperlipidemia experienced fewer typical symptoms than their counterparts. Patients with
Keywords: Acute myocardial infarction Information resources Prehospital delay Symptoms
* Corresponding author at: Hashemite University College of Nursing, Zarqa 13115, Jordan. Tel.: +962 5 390 3333x5520; fax: +962 5 390 3337. E-mail address: [email protected] (M.A. Abed). http://dx.doi.org/10.1016/j.ijnurstu.2015.06.003 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
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ST-elevation myocardial infarction or previous myocardial infarction experienced more symptoms than their counterparts, yet only the former had more typical complaints. Characteristics that improved patients’ awareness of AMI symptoms were mostly similar to those that decreased symptom incongruence. Conclusions: Patients’ expected and experienced acute myocardial infarction symptoms and symptom incongruence varied according to their demographic and clinical characteristics. Information sources that patients used to learn about acute myocardial infarction may contribute to symptom incongruence. ß 2015 Elsevier Ltd. All rights reserved.
What is already known about the topic? Patients are often aware of the typical symptoms of acute myocardial infarction but are less knowledgeable of the atypical symptoms. The mismatch between expected and experienced acute myocardial infarction symptoms complicates patients’ interpretation of symptoms and prolongs their prehospital delay. What this paper adds Patients’ demographic and clinical characteristics are linked with experienced and expected myocardial infarction symptoms and symptom incongruence. Patients relied on their relatives more than other information sources for their knowledge about myocardial infarction symptoms. Reliance on relatives as a main information source is associated with an increase in the gap between expected and experienced symptoms of myocardial infarction. 1. Introduction Jordan, as did other countries in the Middle East, witnessed a shift in disease burden in the past two decades from infectious diseases to non-communicable diseases. Currently, the highest mortality rate (36%) for all diseases is associated with conditions of the circulatory system, mainly acute myocardial infarction (AMI) (Jordan Ministry of Health, 2013). Quick initiation of reperfusion therapy after the onset of AMI symptoms is crucial for improving survival rates and reducing infarct size. Prehospital delay, the time that has elapsed between the onset of AMI symptoms and the patients’ arrival to the hospital, reduces the opportunity for early reperfusion of ischemic myocardial tissue (De Luca et al., 2008). The delay in seeking treatment for AMI becomes significantly longer when patients develop symptom incongruence or the discordance between the symptoms they expect and the symptoms they actually experience during AMI (Abed et al., 2015b). Between 42% and 74% of patients with AMI experienced symptom incongruence (Chareonthaitawee et al., 2000; Song et al., 2010). During AMI, patients commonly expect a symptom experience similar to that seen on the media or that is highlighted by other information sources (i.e., internet, health care providers and significant others like relatives). This experience consists of typical symptoms with a sudden and relatively unremitting nature. Although complete
consensus is lacking, typical manifestations of AMI are chest pain or discomfort, jaw pain or discomfort, pain radiation to jaw or shoulders, and dyspnea, in addition to symptoms being sudden, continuous, and severe. However, AMI may present with atypical manifestations that many patients do not expect (Henriksson et al., 2007). These atypical manifestations include, but are not limited to, abdominal pain, headache, palpitation, nausea and vomiting, in addition to symptoms being gradual, intermittent, or mild. Experienced symptoms in AMI may vary according to patients’ demographic (e.g., age, gender) and clinical characteristics (e.g., co-morbidities, smoking, AMI type; Arslanian-Engoren et al., 2006; Ryan et al., 2007). Elderly individuals, for example, tend to have intermittent chest pain that gradually increases in intensity while young patients commonly experience severe, radiating chest pain (Ryan et al., 2007). Men frequently complain of typical symptoms while women commonly describe atypical symptoms (Albarran et al., 2007; Arslanian-Engoren et al., 2006; Thuresson et al., 2005). Patients with comorbidities, such as diabetes mellitus (DM), are more likely to develop silent or asymptomatic AMI than their correspondants (MacInnes, 2005). Patients commonly expect a specific AMI symptoms (i.e., the typical symptoms), and AMI presentation differs based on their demographic and clinical characteristics. These two factors suggest a potential relationship between patients’ characteristics and symptom incongruence. This relationship, however, has not been investigated in the litrature. Further, the contributions of information sources about AMI to patients’ expected AMI symptoms and subsequently to symptom incongruence are unexplored. Therefore, the purpose of the current investigation was to study symptom incongruence among Jordanian patients with AMI. Our specific aims were to examine the relationship of Jordanian patients’ demographics (i.e., age, marital status, education, income, insurance, having spouse with cardiac history, having relative with cardiac history), clinical characteristics (i.e., smoking, HTN, DM, hyperlipidemia, cardiac history, AMI type), and information sources about AMI (i.e., mass media, internet, nurses or physicians, relatives, others or no source) with patients’ expectations and actual experiences of AMI symptoms and with symptom incongruence. 2. Design This, and other studies (Abed et al., 2015a,b) were derived from a large descriptive correlational study. It was
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carried out in Jordan between May 2012 and July 2013 to examine factors linked with the experience of AMI among Jordanian patients. 2.1. Sample and setting Inclusion criteria were the following: (1) diagnosis of AMI (as documented in medical records and verified by elevated cardiac enzymes); (2) 18 years or older; (3) oriented and mentally competent; and (4) fluent in Arabic. Exclusion criteria were AMI that developed during hospitalization or having psychiatric illnesses that might make the interview difficult. Recruitment of patients was from government (n = 6), private (n = 2) and military (n = 2) hospitals in the two most populated cities in Jordan (Amman and Al Zarqa). A convenience sample of 299 Jordanian patients with AMI was recruited. With at least 270 patients and an alpha level of .01, the power of the analysis of variance F test to detect a medium effect will be at least 95% for each of two main effects and an interaction effect. Even if the effect size is small, the power of the F test will be at least 85% to detect significant main effect and interaction effects. Analysis of preliminary data for the current study revealed that most effect sizes were in the medium range, thus our sample size of 299 was more than sufficient for subgroup comparisons. 2.2. Data collection Data were collected using self-report and medical records review. The interview with patients was done during their hospitalization for AMI within 96 h of their admission to the hospital. The Morgan Incongruence of Heart Attack Symptoms Index (MIHASI) (Morgan, 2005) was used to quantify symptom incongruence and identify patients’ expected and experienced AMI symptoms. The MIHASI includes (1) a five-point Likert question ‘‘over all, how did the symptoms of your heart attack match what you expected the symptoms of a heart attack would be?’’ with response options ranging from 1 ‘‘my symptoms matched completely what I expected’’ to 5 ‘‘my symptoms did not match at all,’’ and (2) a table that includes 20 possible symptoms (or descriptors) of AMI, and columns A and B which are headed with ‘‘expected to have’’ and ‘‘actually had,’’ respectively. Patients were asked to respond to each listed manifestation by marking (if yes) columns A and B. In scoring, a manifestation that is experienced and expected, or not expected and not experienced, receives a value of zero, otherwise it receives a value of one. The total score is the sum of all individual scores; a higher score indicates a higher degree of symptom incongruence. For the current study, the MIHASI table was modified by (1) removing one symptom; ‘‘light headiness or feeling faint,’’ as it was close in meaning to another listed symptom, ‘‘dizziness,’’ and (2) adding other possible AMI manifestations from the literature. These modifications increased the range of the MIHASI table to 24. Seven of the symptoms were considered typical in
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the current study: two cardinal symptoms (chest pain or discomfort, dyspnea), two common areas of AMI pain radiation (jaw, upper extremities or shoulders) and three descriptions of acute health problem (sudden, continuous and severe). The remaining 17 nonspecific manifestations of AMI were described as atypical in this study and included loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation and dyspepsia. In addition, there were three descriptors of atypical AMI presentation (of gradual onset, intermittent or mild). The content validity of the original MIHASI was evaluated by PhD nursing students and a critical care nurse with a master degree in nursing (Morgan, 2005). The MIHASI was correlated positively with Morgan’s Likert single question about symptom incongruence (r = 0.278, p = 0.05). To use the MIHASI among Arabic patients, translation and back translation techniques, as recommended for adaptation of instruments (WHO, n.d.), were carried out by bilingual experts in nursing. Pilot testing revealed that the Arabic version of the MIHASI was clear to patients and had significant 24-h test-retest correlations (Likert-scale question: 0.90; table of AMI symptoms: 0.80). To measure patients’ sources of information about AMI, patients were asked to focus on the period prior to their AMI. We asked patients to choose from a list of all information sources from which they obtained knowledge about heart attack (general sources) and then indicate their primary source of information. The list included internet, nurses or physicians, mass media (books, magazines, TV, radio), relatives, other sources and no source. Demographic and clinical characteristics were collected by interview and medical records review. These data included age, gender, marital status, education, income, insurance, current smoking, history of hypertension (HTN), DM, hyperlipidemia, angina, coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), previous AMI, and AMI type (ST-elevation myocardial infarction [STEMI] versus non ST-elevation myocardial infarction [NSTEMI]). Collected data also included queries about having first-degree relatives (i.e., parents, siblings) and spouse with cardiac health conditions, including previous AMI. 2.3. Data analysis SPSS version 19.0 was used for analysis. Data accuracy and assumptions of tests (such as normality, linearity and homoscedasticity) were verified prior to analysis. After being dichotomized according to demographic and clinical characteristics, patients were compared on the number of their expected (all, typical, atypical) and experienced AMI manifestations (all, typical, atypical) and level of symptom incongruence by independent samples t-test. Patients were also compared on the number of expected symptoms (all, typical, atypical) and level of symptom incongruence according to their primary information source about AMI (mass media, internet, nurses or physicians, relatives, others and no source) by one-way analysis of variance (ANOVA) and, if needed, post hoc test LSD.
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n (%)
Variable Demographics Male Married High school education Income 350 JOD (495 USD)/month With medical insurance Comorbidities Current smoker With hypertension With diabetes mellitus With hyperlipidemia Past history History of myocardial infarction History of angina Previous percutaneous coronary intervention Previous coronary artery bypass graft Current diagnosis ST-elevation myocardial infarction
239 274 204 166 202
(80) (92) (68) (56) (68)
126 180 142 106
(42) (60) (48) (36)
66 90 116 13
(22) (30) (39) (4)
201 (67)
3. Results 3.1. Sample characteristics Of the recruited patients (N = 299), more than threequarters were male and married. The average age was 56 12.3 (range = 23–93) years. More than one-half of patients were smokers, with no more than a high school education, and had HTN and a diagnosis of STEMI. Less than one-half of patients had low income, DM, hyperlipidemia, history of AMI, angina, CABG, or PCI (Table 1). The percentage of patients with a spouse or a first-degree relative(s) who had
a cardiac ailment was 15% and 63%, respectively. One-fifth of the patients (n = 59) reported that they received no information about AMI from any information source. Of those with some knowledge about AMI, relatives were the most frequent general (81%) and primary (55%) information source. Less than one-fifth and one-tenth of patients cited nurses or physicians and mass media or internet as their primary information sources, respectively (Fig. 1). 3.2. Expected versus experienced AMI manifestations Patients expected on average 7.1 5.0 (range = 0–24, P25 = 3, P75 = 11) of the 24 listed AMI manifestations; including 3.4 2.1 (range = 0–7, P25 = 2, P75 = 5) of the seven typical and 3.7 3.3 (range = 0–17, P25 = 1, P75 = 6) of the 17 atypical (Figs. 2 and 3). Of recruited patients, 23% had no prior expectation of how AMI would present, while 8% did not expect any other symptom than chest pain. Pain or discomfort in the chest and sweating were the most commonly expected typical (83%) and atypical (54%) symptoms, respectively. Classic AMI descriptors (i.e., severe, sudden and continuous) were more often expected (53–63%) than atypical ones (i.e., mild, gradual and intermittent; 8–16%). In terms of symptoms experienced, patients generally had 10.4 3.1 (range = 3–21, P25 = 8, P75 = 12) AMI manifestations, including 4.8 1.4 typical (range = 1–7, P25 = 4, P75 = 6) and 5.6 2.5 (range = 1–15, P25 = 4, P75 = 7) atypical symptoms. Chest pain or discomfort and sweating were the most commonly experienced typical (95%) and atypical (77%) symptom, respectively. Except for collapse or loss of consciousness, all AMI manifestations were more often experienced than expected (Figs. 2 and 3).
Fig. 1. Information sources about heart attack among patients with background about myocardial infarction (n = 240).
M.A. Abed et al. / International Journal of Nursing Studies 52 (2015) 1591–1599
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100
Percentage
80 60 40 20 0
Dyspnea
Jaw pain or discomfort
Arm or shoulder pain or discomfort
Chest pain or discomfort
Experienced
Sudden
Continuous
Severe
Expected
Fig. 2. Expected versus experienced typical acute myocardial infarction manifestations among patients (n = 299).
3.3. Expected versus experienced AMI manifestations and patients’ characteristics and information sources
Percentage
In general, expectations of all symptoms were significantly lower among patients who were females, elderly, unmarried, with less than a high school education, nonsmokers, with low income, with no history of hyperlipidemia, AMI, angina, CABG or PCI, and having no relative(s) with cardiac heath conditions but carrying a diagnosis of NSTEMI (Table 2). All patients with these characteristics expected fewer typical and atypical manifestations than their counterparts, except for females and patients without hyperlipidemia or with NSTEMI who anticipated only fewer atypical symptoms (Table 2). The number and type (typical, atypical) of expected AMI manifestations were significantly related to patients’ primary information sources about heart attack: (1) patients with no source of information expected fewer typical and atypical symptoms than those with information from any source; and (2) patients who were informed by relatives expected fewer symptoms than those who received their information from nurses or physicians and they expected fewer atypical symptoms than those whose information source was mainly mass media (Table 3). The AMI symptoms experienced differed significantly according to patients’ age, AMI type, reported history of AMI and hyperlipidemia (Table 4). Older patients and
those with no hyperlipidemia had fewer typical symptoms, without having fewer total manifestations, than their respective counterparts. Patients with STEMI and previous AMI had more symptoms than their counterparts, however patients with STEMI had more typical complaints. 3.4. Symptom incongruence and patients’ characteristics The mean symptom incongruence score was 6.8 3.1 (range = 0–18). Among patients who expected at least one symptom (n = 262), the match, as measured by the 5-point Likert scale, was ‘‘complete’’ by 20%, ‘‘most’’ by 22%, and ‘‘some’’ by 37% whereas 12% and 10% of patients selected ‘‘most’’ and ‘‘complete’’ mismatch, respectively. The two measures (i.e., the MIHASI table and Likert scale) were significantly correlated (r = 0.36, p < 0.001). When compared to patients’ primary information sources about heart attack, symptom incongruence was significantly higher among (1) patients with no information source than ‘‘any other source’’ and (2) patients informed by relatives more than those educated by nurses or physicians (Table 3). Elderly, unmarried individuals, patients with low income, poor education or with spouse with pre-existing cardiac health conditions, and those with no prior personal history of AMI, angina or PCI had higher levels of symptom incongruence than their counterparts (Table 5).
100 80 60 40 20 0
Experienced
Expected
Fig. 3. Expected versus experienced atypical acute myocardial infarction manifestations among patients (n = 299).
M.A. Abed et al. / International Journal of Nursing Studies 52 (2015) 1591–1599
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Table 2 Number of expected and experienced acute myocardial infarction manifestations based on patients’ characteristics (n = 299). Characteristic
Expected symptoms (M SD) All
Gender Male 7.4 5.1* Female 5.9 4.8 Age 7.9 4.9* <55 years 55 years 6.4 5.1 Marital status Married 7.6 5.0*** Not married 2.6 3.4 Education High school 6.7 4.9* >High school 8.1 5.1 Income 350 JOD/month 5.8 4.9*** 351 JOD/month 8.1 5.1 Smoker Yes 7.9 5.1** No 6.2 4.9 Hyperlipidemia Yes 8.0 4.8* No 6.6 5.1 History of AMI Yes 10.1 5.0*** No 6.3 4.8 History of CABG Yes 11.6 5.0** No 6.9 3.7 History of angina Yes 9.0 5.0*** No 6.3 5.0 Previous PCI Yes 9.5 4.9*** No 6.4 4.9 Having relative(s) with cardiac problems Yes 7.7 5.2** No 6.3 4.8 Type of AMI STEMI 7.6 5.3* NSTEMI 6.2 4.4
Typical
Atypical
3.5 2.1 2.9 2.1
3.9 3.4* 2.9 3.4
3.7 2.1* 3.1 2.1
4.2 3.2* 3.3 3.4
3.6 2.0*** 1.2 1.8
4.0 3.4*** 1.2 1.7
3.2 2.3* 3.8 2.0
3.4 3.2* 4.3 3.4
2.9 2.2** 3.7 2.0
2.9 3.1*** 4.3 3.4
3.7 2.1* 3.1 2.1
4.2 3.4** 3.1 3.2
3.7 2.0 3.2 2.2
4.2 3.3* 3.1 3.3
4.6 1.9*** 3.1 2.1
5.5 3.5*** 3.2 3.1
5.2 1.1** 3.3 2.1
6.5 3.1** 3.6 3.3
4.2 2.0*** 3.1 2.1
4.8 3.3*** 3.3 3.3
4.3 2.0*** 3.1 2.1
5.2 3.3*** 3.3 3.3
3.7 2.1** 3.0 2.1
4.0 3.5* 3.3 3.1
3.5 2.2 3.1 2.0
4.1 3.5* 3.1 3.0
Note: Total number examined symptoms = 24; 7 typical (chest pain or discomfort, jaw pain or discomfort, dyspnea, arm or shoulder pain or discomfort and symptoms being sudden, continuous and severe) and 17 atypical (loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, diarrhea, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation, dyspepsia, and symptoms being intermittent, mild and gradual). AMI, acute myocardial infarction; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; NSTEMI, non ST-elevation myocardial infarction. Patients were compared by independent samples t-test; variables with non significant results at all columns were not presented. * p < 0.05. ** p < 0.01. *** p < 0.001.
4. Discussion The current study revealed that among Jordanian patients with AMI, the expected and, to a lesser degree, the experienced symptoms varied according to patients’ demographic and clinical characteristics. Patients’ information sources and relatives played a significant role in symptom expectation and interpretation. Also, characteristics of patients who demonstrated low symptoms
awareness mostly resembled those with high symptom incongruence. The Jordanian culture, which is mostly derived from Islam, emphasizes an individual’s responsibility for maintaining health. Hadith (saying) of Prophet Muhammad ‘‘your body has a right over you’’ is one of several tenets that foster such beliefs. Thus, one would expect that Jordanians be actively involved in learning about their most common killer, AMI, and demonstrate good awareness about its manifestations. However, our results revealed that Jordanian patients were unfamiliar with AMI symptoms. Around 20% of patients in this study could not identify a sources of AMI information, 31% expected zero to one AMI symptom, and almost all AMI manifestations were anticipated less often than they were experienced. Awareness of AMI symptoms and having at least one information source about AMI are important for accurate symptom attribution to a cardiac etiology (Henriksson et al., 2007; Meischke et al., 1999). Public and individual awareness about AMI symptoms are better in developed countries as only 8% of examined individuals had no prior anticipation of how AMI could present (Mata et al., 2014) and at least one-half of the AMI symptoms studied were expected more often than actually suffered by patients with AMI (Horne et al., 2000; Perry et al., 2001; Ratner et al., 2008). A Swedish investigation revealed that more than onehalf of patients with AMI learned about AMI symptoms from health care providers and the mass media (Thuresson et al., 2007). In contrast, over 50% of our patients learned about AMI from their relatives. Dependence on relatives to learn about AMI resulted in low awareness of AMI symptoms, and high symptom incongruence among our patients. The failure of relatives to provide appropriate information is explained by previous findings that the public, relatives, and patients in general share the same low level of knowledge about AMI manifestations (Henriksson et al., 2011, 2012). Patients who consult their relatives during AMI have long prehospital delay times (Perry et al., 2001). Added to our results, these findings suggest that relatives play a negative role in patients’ prehospital delay prior to AMI by negatively influencing interpretation of symptoms. Consistent with previous research (Goff et al., 2004; Ratner et al., 2008), awareness of AMI symptoms is linked with patients’ characteristics. In our study, accurate symptom knowledge was favorably linked with patients’ gender (male), marital status (married), indicators of good health literacy (i.e., young age, good income and educational level), previous exposure to cardiovascular conditions (either personally or by interaction with relatives), and having AMI risk factors. Most of these characteristics equally affected patients’ awareness of both typical and atypical AMI symptoms. Our findings further revealed that characteristics that improved patients’ awareness of AMI symptoms were mostly those that decreased symptom incongruence (i.e., indicators of good health literacy, having a cardiac history). These characteristics were correlates of short prehospital delay for AMI symptoms in several studies (Fox-Wasylyshyn et al., 2010; Khraim et al., 2009; Moser et al., 2006).
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Table 3 Number of expected acute myocardial infarction symptoms and level of symptom incongruence according to patients’ primary information sources about heart attacks (n = 299). Primary information source
All manifestations (M SD)
Typical manifestations (M SD)
Atypical manifestations (M SD)
Expected
Incongruence
Expected
Incongruence
Expected
Incongruence
A Mass media (n = 41) B Internet (n = 14) C Nurses, physicians (n = 45) D Relatives (n = 132) E Other (n = 8) F None (n = 59) p value Post hoc test by LSD:
9.4 4.6
6.4 3.3
4.0 1.8
1.9 1.3
5.4 3.4
4.5 2.5
9.1 4.3
5.9 2.5
4.1 1.7
1.9 1.3
5.0 3.0
4.1 1.7
10.5 4.4
5.9 3.5
4.6 1.7
1.6 1.5
5.8 3.1
4.3 2.5
7.5 4.3
7.3 3.0
3.7 1.8
2.3 15
3.8 3.0
5.0 2.2
10.8 4.1
5.7 2.1
4.9 1.1
1.6 1.2
6.0 3.1
4.1 1.4
1.1 1.9
10.5 3.9
0.8 1.2
4.5 1.7
0.2 0.8
6.0 3.1
<0.001 F < A, B, C, D, E D < A, C, E
<0.001 F > A, B, C, D, E D>C
<0.001 F < A, B, C, D, E D
<0.001 F > A, B, C, D, E D>C
<0.001 F < A, B, C, D, E D < A, C, E
0.004 F > A, B, C, D, E
Note: Total number examined symptoms = 24; 7 typical (chest pain or discomfort, jaw pain or discomfort, dyspnea, arm or shoulder pain or discomfort and symptoms being sudden, continuous and severe) and 17 atypical (loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, diarrhea, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation, dyspepsia, and symptoms being intermittent, mild and gradual). Patients were compared by one-way analysis of variance (ANOVA).
Previous reports indicated that female gender, advanced age, and history of diabetes may more commonly result in an atypical AMI presentation while male gender or STEMI are associated with a typical presentation (Canto et al., 2007; Coventry et al., 2011; DeVon et al., 2008; MacInnes, 2005; Morgan, 2005). Nevertheless, this was not completely reflected in our study nor in some previous investigations (Milner et al., 2002; Thuresson et al., 2005).
We found that gender was not related to the type of presenting symptoms. In addition, the elderly and those with hyperlipidemia suffered fewer typical symptoms and patients with previous AMI had more typical and atypical Table 5 Level of symptom incongruence according to patients’ characteristics (n = 299). Variable
Table 4 Number of experienced acute myocardial infarction manifestations based on patients’ characteristics (n = 299). Characteristic
Age <55 years 55 years Hyperlipidemia Yes No History of AMI Yes No Type of AMI STEMI NSTEMI
Experienced symptoms (M SD) All
Typical
Atypical
10.7 2.9 10.2 3.2
5.0 1.3** 4.5 1.5
5.6 2.4 5.6 2.6
9.9 2.8* 10.7 3.1
4.6 1.4* 4.9 1.3
5.5 2.3 5.8 2.6
11.4 3.0** 10.2 3.0
5.1 1.2* 4.7 1.4
6.3 2.6* 5.5 2.5
10.9 3.1*** 9.5 2.9
5.1 1.3*** 4.2 1.3
5.8 2.5 5.3 2.5
Note: Total number examined symptoms = 24; 7 typical (chest pain or discomfort, jaw pain or discomfort, dyspnea, arm or shoulder pain or discomfort and symptoms being sudden, continuous and severe) and 17 atypical (loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, diarrhea, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation, dyspepsia, and symptoms being intermittent, mild and gradual). AMI, acute myocardial infarction; STEMI, ST-elevation myocardial infarction; NSTEMI, non ST-elevation myocardial infarction. Patients were compared by independent samples t-test; Variables with non significant results at all columns were not presented. * p < 0.05. ** p < 0.01. *** p < 0.001.
Age <55 years 55 years Marital status Married Not married Education High school education or less More than high school education Income 350 JOD (495 USD)/month 351 JOD/month Insurance Yes No History of myocardial infarction Yes No History of angina Yes No History of percutaneous coronary intervention Yes No Having spouse with cardiac health conditions Yes No
Level of symptom incongruence (M SD)
p value
0.008 6.9 3.6 8.0 3.6 <0.001 7.2 3.5 10.2 3.7 0.002 8.3 3.4 7.2 3.5 0.004 8.2 3.7 7.0 3.5 0.018 7.1 3.7 8.2 3.5 0.001 6.2 3.3 7.9 3.7 0.026 6.8 3.2 7.8 3.8 0.009 6.5 3.1 7.8 3.7 0.007 8.8 3.5 7.2 3.6
Note: Patients were compared by independent samples t-test; variables with non significant results were not presented.
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symptoms than their counterparts. These variations among research studies may be related to several factors including differences in both the proportions of subgroups that represented various patients’ characteristics and the endpoints compared. In the current study, we focused on the total number of symptoms and not on individual symptoms, as is frequently done in the literature. The limited diversity of both the expected and experienced symptoms among the examined patients resulted in low symptom incongruence. Yet, as we previously reported, this low incongruence was sufficient to make our patients less apprehensive about their AMI symptoms, more confused regarding their symptoms origin, and consequently more reluctant to seek for immediate medical help (Abed et al., 2015b). Enhancing patients’ awareness of AMI symptoms is the only way to reduce symptom incongruence given that the expectation, and not the experience, of symptoms is the amenable factor to improvement. Unfortunately, health education and public awareness programs are not well integrated in Jordan health care sector (WHO, 2009). Outpatient clinics are mainly used for curative purposes such as prescribing medications. Prehospital discharge education is mostly inactive. A recent study indicated that up to 50% of Jordanian cardiac patients were not questioned nor advised about their behavioral risk factors during their hospitalization period (Mosleh and Darawad, 2014). Mass media is only focused on specific health topics, such as family planning and vaccines. Cardiac rehabilitation centers are also unavailable. Faulty beliefs and socio-cultural factors may also contribute to Jordanians limited knowledge about AMI, as they lessen their motivation to seek for health information. For example, the belief that a health threat is more likely to occur when one is actively involved in learning about it is not uncommon among Jordanians. Also, Jordanians in general are optimistic in their assessment of their risk for heart attacks (Abed et al., 2015a). The dialog between health care providers and patients is still conducted in a manner where health professions are dominant while patients, or their caregivers, are passive and avoid asking questions. Our findings are a call for action. We need to educate Jordanians patients and their significant others about AMI and its typical and atypical symptoms. To achieve this goal, Jordanians must first recognize that they need to learn about AMI. Disease prevention and health knowledge dissemination programs should be fostered in the Jordan health care system. Heath care providers must embrace their role as health educators, otherwise patients’ reliance on less credible sources of information will continue. The relationship of information sources to prehospital delay needs examination because, to date, it has not yet been explored in the literature. We also need studies that examine factors that motivate Jordanians to learn about AMI. 5. Limitations There are several limitations of the current investigation. First, awareness of AMI symptoms was assessed
based on patients’ retrospective recalls of their expectations of AMI symptoms. Second, stratifying patients according to one characteristic and then comparing between them may underestimate their complex attributes. Third, the use of a non-random sample which affects generalization of results. Finally, measurement of the study’s main outcomes relied mainly on a relatively new scale that was not previously translated or validated for the Jordanian patients. 6. Conclusion In conclusion, Jordanian patients’ unfamiliarity with, and misinterpretation of, AMI symptoms was common. Patients gleaned information about AMI from different sources even though they mostly depended on relatives. The expected and experienced AMI symptoms and symptom incongruence were linked with patients’ demographic and clinical characteristics and their information sources about heart attack. Conflict of interest: Authors declared no conflict of interest. Funding: This study was funded by the Hashemite University in Jordan. Ethical approval: Institutional review board approval for conducting the current study was obtained from the Hashemite University and all hospitals involved in the study. After orienting patients to the study aims and subjects’ rights, a consent form was signed by participant patients. References Abed, M.A., Khalil, A.A., Moser, D.K., 2015a. Awareness of modifiable acute myocardial infarction risk factors has little impact on risk perception for heart attack among vulnerable patients. Heart Lung 44, 183–188. Abed, M.A., Khalil, A.A., Moser, D.K., 2015b. The contribution of symptom incongruence to prehospital delay for acute myocardial infarction symptoms among Jordanian patients. Res. Nurs. Health 38 (3), 213–221. Albarran, J.W., Clarke, B.A., Crawford, J., 2007. ‘It was not chest pain really I can’t explain it!’ An exploratory study on the nature of symptoms experienced by women during their myocardial infarction J. Clin. Nurs. 16 (7), 1292–1301. Arslanian-Engoren, C., Patel, A., Fang, J., Armstrong, D., Kline-Rogers, E., Duvernoy, C.S., Eagle, K.A., 2006. Symptoms of men and women presenting with acute coronary syndromes. Am. J. Cardiol. 98 (9), 1177–1181. Canto, J.G., Goldberg, R.J., Hand, M.M., Bonow, R.O., Sopko, G., Pepine, C.J., Long, T., 2007. Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch. Intern. Med. 167 (22), 2405–2413. Chareonthaitawee, P., Gibbons, R.J., Roberts, R.S., Christian, T.F., Burns, R., Yusuf, S., 2000. The impact of time to thrombolytic treatment on outcome in patients with acute myocardial infarction For the CORE investigators (Collaborative Organization for RheothRx Evaluation). Heart 84 (2), 142–148. Coventry, L.L., Finn, J., Bremner, A.P., 2011. Sex differences in symptom presentation in acute myocardial infarction: a systematic review and meta-analysis. Heart Lung 40 (6), 477–491. De Luca, G., Suryapranata, H., Marino, P., 2008. Reperfusion strategies in acute ST-elevation myocardial infarction: an overview of current status. Prog. Cardiovasc. Dis. 50 (5), 352–382. DeVon, H.A., Penckofer, S., Larimer, K., 2008. The association of diabetes and older age with the absence of chest pain during acute coronary syndromes. West J. Nurs. Res. 30 (1), 130–144. Fox-Wasylyshyn, S.M., El-Masri, M., Artinian, N.T., 2010. Testing a model of delayed care-seeking for acute myocardial infarction. Clin. Nurs. Res. 19 (1), 38–54. Goff Jr., D.C., Mitchell, P., Finnegan, J., Pandey, D., Bittner, V., Feldman, H., Meischke, H., Goldberg, R.J., Luepker, R.V., Raczynski, J.M., Cooper, L.,
M.A. Abed et al. / International Journal of Nursing Studies 52 (2015) 1591–1599 Mann, C., 2004. Knowledge of heart attack symptoms in 20 US communities. Results from the Rapid Early Action for Coronary Treatment Community Trial. Prev. Med. 38 (1), 85–93. Henriksson, C., Larsson, M., Arnetz, J., Berglin-Jarlov, M., Herlitz, J., Karlsson, J.E., Svensson, L., Thuresson, M., Zedigh, C., Wernroth, L., Lindahl, B., 2011. Knowledge and attitudes toward seeking medical care for AMI-symptoms. Int. J. Cardiol. 147 (2), 224–227. Henriksson, C., Larsson, M., Arnetz, J., Herlitz, J., Karlsson, J.-E., Svensson, L., Thuresson, M., Zedigh, C., Wernroth, L., Lindahl, B., 2012. Knowledge about acute myocardial infarction (AMI) and attitudes to medical care seeking—a comparison between patients and the general public. Open J. Nurs. 2 (4), 372–378. Henriksson, C., Lindahl, B., Larsson, M., 2007. Patients’ and relatives’ thoughts and actions during and after symptom presentation for an acute myocardial infarction. Eur. J. Cardiovasc. Nurs. 6 (4), 280–286. Horne, R., James, D., Petrie, K., Weinman, J., Vincent, R., 2000. Patients’ interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction. Heart 83 (4), 388–393. Jordan Ministry of Health, 2013. Mortality data in Jordan, 2010. www. moh.gov.jo/AR/Pages/Periodic-Newsletters.aspx (accessed 10.12.13). Khraim, F.M., Scherer, Y.K., Dorn, J.M., Carey, M.G., 2009. Predictors of decision delay to seeking health care among Jordanians with acute myocardial infarction. J. Nurs. Scholarsh. 41 (3), 260–267. MacInnes, J.D., 2005. The illness perceptions of women following acute myocardial infarction: implications for behavior change and attendance at cardiac rehabilitation. Women Health 42 (4), 105–121. Mata, J., Frank, R., Gigerenzer, G., 2014. Symptom recognition of heart attack and stroke in nine European countries: a representative survey. Health Expect. 17 (3), 376–387. Meischke, H., Yasui, Y., Kuniyuki, A., Bowen, D.J., Andersen, R., Urban, N., 1999. How women label and respond to symptoms of acute myocardial infarction: responses to hypothetical symptom scenarios. Heart Lung 28 (4), 261–269. Milner, K.A., Funk, M., Arnold, A., Vaccarino, V., 2002. Typical symptoms are predictive of acute coronary syndromes in women. Am. Heart J. 143 (2), 283–288. Morgan, D.M., 2005. Effect of incongruence of acute myocardial infarction symptoms on the decision to seek treatment in a rural population. J. Cardiovasc. Nurs. 20 (5), 365–371.
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Moser, D.K., Kimble, L.P., Alberts, M.J., Alonzo, A., Croft, J.B., Dracup, K., Evenson, K.R., Go, A.S., Hand, M.M., Kothari, R.U., Mensah, G.A., Morris, D.L., Pancioli, A.M., Riegel, B., Zerwic, J.J., 2006. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council. Circulation 114 (2), 168–182. Mosleh, S.M., Darawad, M., 2014. Patients’ adherence to healthy behavior in coronary heart disease: risk factor management among Jordanian patients. J. Cardiovasc. Nurs., http://dx.doi.org/10.1097/ JCN.0000000000000189 (Advance online publication). Perry, K., Petrie, K.J., Ellis, C.J., Horne, R., Moss-Morris, R., 2001. Symptom expectations and delay in acute myocardial infarction patients. Heart 86 (1), 91–93. Ratner, P.A., Johnson, J.L., Mackay, M., Tu, A.W., Hossain, S., 2008. Knowledge of ‘‘heart attack’’ symptoms in a Canadian urban community. Clin. Med. Cardiol. 2, 201–213. Ryan, C.J., DeVon, H.A., Horne, R., King, K.B., Milner, K., Moser, D.K., Quinn, J.R., Rosenfeld, A., Hwang, S.Y., Zerwic, J.J., 2007. Symptom clusters in acute myocardial infarction: a secondary data analysis. Nurs. Res. 56 (2), 72–81. Song, L., Yan, H.B., Yang, J.G., Sun, Y.H., Hu, D.Y., 2010. Impact of patients’ symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chin. Med. J. 123 (14), 1840–1845. Thuresson, M., Jarlov, M.B., Lindahl, B., Svensson, L., Zedigh, C., Herlitz, J., 2005. Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes. Am. Heart J. 150 (2), 234–242. Thuresson, M., Jarlov, M.B., Lindahl, B., Svensson, L., Zedigh, C., Herlitz, J., 2007. Thoughts, actions, and factors associated with prehospital delay in patients with acute coronary syndrome. Heart Lung 36 (6), 398–409. World Health Organization, 2009. Country Cooperation Strategy for WHO and Jordan 2008–2013. http://www.who.int/countryfocus/ cooperation_strategy/ccs_jor_en.pdf (accessed 10.05.15). World Health Organization, n.d. Process of translation and adaptation of instruments. http://www.who.int/substance_abuse/research_tools/ translation/en/ (accessed 10.04.12).
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Symptoms of acute myocardial infarction: A correlational study of the discrepancy between patients’ expectations and experiences Mona A. Abed a,*, Raeda M. Abu Ali b, Motaz M. Abu Ras c, Faten O. Hamdallah a, Amani A. Khalil d, Debra K. Moser e,f a
Hashemite University College of Nursing, Zarqa, Jordan Albalqa Applied University College of Nursing, Amman, Jordan Jordan University Hospital, Amman, Jordan d The University of Jordan College of Nursing, Amman, Jordan e University of Kentucky College of Nursing, KY, USA f University of Ulster, Newtownabbey, United Kingdom b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 September 2014 Received in revised form 2 June 2015 Accepted 13 June 2015
Background: Patients’ responses to acute myocardial infarction symptoms are affected by symptom incongruence, which is the difference between the symptoms they expect to experience and the symptoms they actually experienced during an acute myocardial infarction. Objective: To examine the relationship of patients’ demographics, clinical characteristics and sources of information about acute myocardial infarction with their symptom expectations, actual experiences and symptom incongruence. Design: Descriptive correlational study. Setting: Patients were recruited from ten hospitals in the two most populated cities in Jordan (Amman and Al Zarqa). Participants: Jordanian patients with acute myocardial infarction were recruited. Inclusion criteria were age 18 years or older, diagnosis of acute myocardial infarction, oriented, mentally competent and fluent in Arabic. Exclusion criteria were experiencing acute myocardial infarction during a hospitalization or having severe psychiatric illnesses. Methods: The Morgan Incongruence of Heart Attack Symptoms Index was used to quantify symptom incongruence and identify patients’ expected and experienced acute myocardial infarction symptoms. Patients’ information sources about acute myocardial infarction and demographic and clinical characteristics were collected by interview and medical chart review. Results: Patients (N = 299) were mostly males (80%) and married (92%). The average age was 56 12.3 years. Patients expected a limited number of acute myocardial infarction symptoms and these expectations were largely confined to typical symptoms and matched their experiences. Patients who were female, elderly, nonsmokers, poorly educated, with low income, and those who were normolipidemic, had no personal or family cardiac history, and were informed about acute myocardial infarction by relatives expected fewer symptoms (mostly typical and atypical) than their counterparts. Elderly patients and those with hyperlipidemia experienced fewer typical symptoms than their counterparts. Patients with
Keywords: Acute myocardial infarction Information resources Prehospital delay Symptoms
* Corresponding author at: Hashemite University College of Nursing, Zarqa 13115, Jordan. Tel.: +962 5 390 3333x5520; fax: +962 5 390 3337. E-mail address: [email protected] (M.A. Abed). http://dx.doi.org/10.1016/j.ijnurstu.2015.06.003 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
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ST-elevation myocardial infarction or previous myocardial infarction experienced more symptoms than their counterparts, yet only the former had more typical complaints. Characteristics that improved patients’ awareness of AMI symptoms were mostly similar to those that decreased symptom incongruence. Conclusions: Patients’ expected and experienced acute myocardial infarction symptoms and symptom incongruence varied according to their demographic and clinical characteristics. Information sources that patients used to learn about acute myocardial infarction may contribute to symptom incongruence. ß 2015 Elsevier Ltd. All rights reserved.
What is already known about the topic? Patients are often aware of the typical symptoms of acute myocardial infarction but are less knowledgeable of the atypical symptoms. The mismatch between expected and experienced acute myocardial infarction symptoms complicates patients’ interpretation of symptoms and prolongs their prehospital delay. What this paper adds Patients’ demographic and clinical characteristics are linked with experienced and expected myocardial infarction symptoms and symptom incongruence. Patients relied on their relatives more than other information sources for their knowledge about myocardial infarction symptoms. Reliance on relatives as a main information source is associated with an increase in the gap between expected and experienced symptoms of myocardial infarction. 1. Introduction Jordan, as did other countries in the Middle East, witnessed a shift in disease burden in the past two decades from infectious diseases to non-communicable diseases. Currently, the highest mortality rate (36%) for all diseases is associated with conditions of the circulatory system, mainly acute myocardial infarction (AMI) (Jordan Ministry of Health, 2013). Quick initiation of reperfusion therapy after the onset of AMI symptoms is crucial for improving survival rates and reducing infarct size. Prehospital delay, the time that has elapsed between the onset of AMI symptoms and the patients’ arrival to the hospital, reduces the opportunity for early reperfusion of ischemic myocardial tissue (De Luca et al., 2008). The delay in seeking treatment for AMI becomes significantly longer when patients develop symptom incongruence or the discordance between the symptoms they expect and the symptoms they actually experience during AMI (Abed et al., 2015b). Between 42% and 74% of patients with AMI experienced symptom incongruence (Chareonthaitawee et al., 2000; Song et al., 2010). During AMI, patients commonly expect a symptom experience similar to that seen on the media or that is highlighted by other information sources (i.e., internet, health care providers and significant others like relatives). This experience consists of typical symptoms with a sudden and relatively unremitting nature. Although complete
consensus is lacking, typical manifestations of AMI are chest pain or discomfort, jaw pain or discomfort, pain radiation to jaw or shoulders, and dyspnea, in addition to symptoms being sudden, continuous, and severe. However, AMI may present with atypical manifestations that many patients do not expect (Henriksson et al., 2007). These atypical manifestations include, but are not limited to, abdominal pain, headache, palpitation, nausea and vomiting, in addition to symptoms being gradual, intermittent, or mild. Experienced symptoms in AMI may vary according to patients’ demographic (e.g., age, gender) and clinical characteristics (e.g., co-morbidities, smoking, AMI type; Arslanian-Engoren et al., 2006; Ryan et al., 2007). Elderly individuals, for example, tend to have intermittent chest pain that gradually increases in intensity while young patients commonly experience severe, radiating chest pain (Ryan et al., 2007). Men frequently complain of typical symptoms while women commonly describe atypical symptoms (Albarran et al., 2007; Arslanian-Engoren et al., 2006; Thuresson et al., 2005). Patients with comorbidities, such as diabetes mellitus (DM), are more likely to develop silent or asymptomatic AMI than their correspondants (MacInnes, 2005). Patients commonly expect a specific AMI symptoms (i.e., the typical symptoms), and AMI presentation differs based on their demographic and clinical characteristics. These two factors suggest a potential relationship between patients’ characteristics and symptom incongruence. This relationship, however, has not been investigated in the litrature. Further, the contributions of information sources about AMI to patients’ expected AMI symptoms and subsequently to symptom incongruence are unexplored. Therefore, the purpose of the current investigation was to study symptom incongruence among Jordanian patients with AMI. Our specific aims were to examine the relationship of Jordanian patients’ demographics (i.e., age, marital status, education, income, insurance, having spouse with cardiac history, having relative with cardiac history), clinical characteristics (i.e., smoking, HTN, DM, hyperlipidemia, cardiac history, AMI type), and information sources about AMI (i.e., mass media, internet, nurses or physicians, relatives, others or no source) with patients’ expectations and actual experiences of AMI symptoms and with symptom incongruence. 2. Design This, and other studies (Abed et al., 2015a,b) were derived from a large descriptive correlational study. It was
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carried out in Jordan between May 2012 and July 2013 to examine factors linked with the experience of AMI among Jordanian patients. 2.1. Sample and setting Inclusion criteria were the following: (1) diagnosis of AMI (as documented in medical records and verified by elevated cardiac enzymes); (2) 18 years or older; (3) oriented and mentally competent; and (4) fluent in Arabic. Exclusion criteria were AMI that developed during hospitalization or having psychiatric illnesses that might make the interview difficult. Recruitment of patients was from government (n = 6), private (n = 2) and military (n = 2) hospitals in the two most populated cities in Jordan (Amman and Al Zarqa). A convenience sample of 299 Jordanian patients with AMI was recruited. With at least 270 patients and an alpha level of .01, the power of the analysis of variance F test to detect a medium effect will be at least 95% for each of two main effects and an interaction effect. Even if the effect size is small, the power of the F test will be at least 85% to detect significant main effect and interaction effects. Analysis of preliminary data for the current study revealed that most effect sizes were in the medium range, thus our sample size of 299 was more than sufficient for subgroup comparisons. 2.2. Data collection Data were collected using self-report and medical records review. The interview with patients was done during their hospitalization for AMI within 96 h of their admission to the hospital. The Morgan Incongruence of Heart Attack Symptoms Index (MIHASI) (Morgan, 2005) was used to quantify symptom incongruence and identify patients’ expected and experienced AMI symptoms. The MIHASI includes (1) a five-point Likert question ‘‘over all, how did the symptoms of your heart attack match what you expected the symptoms of a heart attack would be?’’ with response options ranging from 1 ‘‘my symptoms matched completely what I expected’’ to 5 ‘‘my symptoms did not match at all,’’ and (2) a table that includes 20 possible symptoms (or descriptors) of AMI, and columns A and B which are headed with ‘‘expected to have’’ and ‘‘actually had,’’ respectively. Patients were asked to respond to each listed manifestation by marking (if yes) columns A and B. In scoring, a manifestation that is experienced and expected, or not expected and not experienced, receives a value of zero, otherwise it receives a value of one. The total score is the sum of all individual scores; a higher score indicates a higher degree of symptom incongruence. For the current study, the MIHASI table was modified by (1) removing one symptom; ‘‘light headiness or feeling faint,’’ as it was close in meaning to another listed symptom, ‘‘dizziness,’’ and (2) adding other possible AMI manifestations from the literature. These modifications increased the range of the MIHASI table to 24. Seven of the symptoms were considered typical in
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the current study: two cardinal symptoms (chest pain or discomfort, dyspnea), two common areas of AMI pain radiation (jaw, upper extremities or shoulders) and three descriptions of acute health problem (sudden, continuous and severe). The remaining 17 nonspecific manifestations of AMI were described as atypical in this study and included loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation and dyspepsia. In addition, there were three descriptors of atypical AMI presentation (of gradual onset, intermittent or mild). The content validity of the original MIHASI was evaluated by PhD nursing students and a critical care nurse with a master degree in nursing (Morgan, 2005). The MIHASI was correlated positively with Morgan’s Likert single question about symptom incongruence (r = 0.278, p = 0.05). To use the MIHASI among Arabic patients, translation and back translation techniques, as recommended for adaptation of instruments (WHO, n.d.), were carried out by bilingual experts in nursing. Pilot testing revealed that the Arabic version of the MIHASI was clear to patients and had significant 24-h test-retest correlations (Likert-scale question: 0.90; table of AMI symptoms: 0.80). To measure patients’ sources of information about AMI, patients were asked to focus on the period prior to their AMI. We asked patients to choose from a list of all information sources from which they obtained knowledge about heart attack (general sources) and then indicate their primary source of information. The list included internet, nurses or physicians, mass media (books, magazines, TV, radio), relatives, other sources and no source. Demographic and clinical characteristics were collected by interview and medical records review. These data included age, gender, marital status, education, income, insurance, current smoking, history of hypertension (HTN), DM, hyperlipidemia, angina, coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), previous AMI, and AMI type (ST-elevation myocardial infarction [STEMI] versus non ST-elevation myocardial infarction [NSTEMI]). Collected data also included queries about having first-degree relatives (i.e., parents, siblings) and spouse with cardiac health conditions, including previous AMI. 2.3. Data analysis SPSS version 19.0 was used for analysis. Data accuracy and assumptions of tests (such as normality, linearity and homoscedasticity) were verified prior to analysis. After being dichotomized according to demographic and clinical characteristics, patients were compared on the number of their expected (all, typical, atypical) and experienced AMI manifestations (all, typical, atypical) and level of symptom incongruence by independent samples t-test. Patients were also compared on the number of expected symptoms (all, typical, atypical) and level of symptom incongruence according to their primary information source about AMI (mass media, internet, nurses or physicians, relatives, others and no source) by one-way analysis of variance (ANOVA) and, if needed, post hoc test LSD.
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1594 Table 1 Sample characteristics (n = 299).
n (%)
Variable Demographics Male Married High school education Income 350 JOD (495 USD)/month With medical insurance Comorbidities Current smoker With hypertension With diabetes mellitus With hyperlipidemia Past history History of myocardial infarction History of angina Previous percutaneous coronary intervention Previous coronary artery bypass graft Current diagnosis ST-elevation myocardial infarction
239 274 204 166 202
(80) (92) (68) (56) (68)
126 180 142 106
(42) (60) (48) (36)
66 90 116 13
(22) (30) (39) (4)
201 (67)
3. Results 3.1. Sample characteristics Of the recruited patients (N = 299), more than threequarters were male and married. The average age was 56 12.3 (range = 23–93) years. More than one-half of patients were smokers, with no more than a high school education, and had HTN and a diagnosis of STEMI. Less than one-half of patients had low income, DM, hyperlipidemia, history of AMI, angina, CABG, or PCI (Table 1). The percentage of patients with a spouse or a first-degree relative(s) who had
a cardiac ailment was 15% and 63%, respectively. One-fifth of the patients (n = 59) reported that they received no information about AMI from any information source. Of those with some knowledge about AMI, relatives were the most frequent general (81%) and primary (55%) information source. Less than one-fifth and one-tenth of patients cited nurses or physicians and mass media or internet as their primary information sources, respectively (Fig. 1). 3.2. Expected versus experienced AMI manifestations Patients expected on average 7.1 5.0 (range = 0–24, P25 = 3, P75 = 11) of the 24 listed AMI manifestations; including 3.4 2.1 (range = 0–7, P25 = 2, P75 = 5) of the seven typical and 3.7 3.3 (range = 0–17, P25 = 1, P75 = 6) of the 17 atypical (Figs. 2 and 3). Of recruited patients, 23% had no prior expectation of how AMI would present, while 8% did not expect any other symptom than chest pain. Pain or discomfort in the chest and sweating were the most commonly expected typical (83%) and atypical (54%) symptoms, respectively. Classic AMI descriptors (i.e., severe, sudden and continuous) were more often expected (53–63%) than atypical ones (i.e., mild, gradual and intermittent; 8–16%). In terms of symptoms experienced, patients generally had 10.4 3.1 (range = 3–21, P25 = 8, P75 = 12) AMI manifestations, including 4.8 1.4 typical (range = 1–7, P25 = 4, P75 = 6) and 5.6 2.5 (range = 1–15, P25 = 4, P75 = 7) atypical symptoms. Chest pain or discomfort and sweating were the most commonly experienced typical (95%) and atypical (77%) symptom, respectively. Except for collapse or loss of consciousness, all AMI manifestations were more often experienced than expected (Figs. 2 and 3).
Fig. 1. Information sources about heart attack among patients with background about myocardial infarction (n = 240).
M.A. Abed et al. / International Journal of Nursing Studies 52 (2015) 1591–1599
1595
100
Percentage
80 60 40 20 0
Dyspnea
Jaw pain or discomfort
Arm or shoulder pain or discomfort
Chest pain or discomfort
Experienced
Sudden
Continuous
Severe
Expected
Fig. 2. Expected versus experienced typical acute myocardial infarction manifestations among patients (n = 299).
3.3. Expected versus experienced AMI manifestations and patients’ characteristics and information sources
Percentage
In general, expectations of all symptoms were significantly lower among patients who were females, elderly, unmarried, with less than a high school education, nonsmokers, with low income, with no history of hyperlipidemia, AMI, angina, CABG or PCI, and having no relative(s) with cardiac heath conditions but carrying a diagnosis of NSTEMI (Table 2). All patients with these characteristics expected fewer typical and atypical manifestations than their counterparts, except for females and patients without hyperlipidemia or with NSTEMI who anticipated only fewer atypical symptoms (Table 2). The number and type (typical, atypical) of expected AMI manifestations were significantly related to patients’ primary information sources about heart attack: (1) patients with no source of information expected fewer typical and atypical symptoms than those with information from any source; and (2) patients who were informed by relatives expected fewer symptoms than those who received their information from nurses or physicians and they expected fewer atypical symptoms than those whose information source was mainly mass media (Table 3). The AMI symptoms experienced differed significantly according to patients’ age, AMI type, reported history of AMI and hyperlipidemia (Table 4). Older patients and
those with no hyperlipidemia had fewer typical symptoms, without having fewer total manifestations, than their respective counterparts. Patients with STEMI and previous AMI had more symptoms than their counterparts, however patients with STEMI had more typical complaints. 3.4. Symptom incongruence and patients’ characteristics The mean symptom incongruence score was 6.8 3.1 (range = 0–18). Among patients who expected at least one symptom (n = 262), the match, as measured by the 5-point Likert scale, was ‘‘complete’’ by 20%, ‘‘most’’ by 22%, and ‘‘some’’ by 37% whereas 12% and 10% of patients selected ‘‘most’’ and ‘‘complete’’ mismatch, respectively. The two measures (i.e., the MIHASI table and Likert scale) were significantly correlated (r = 0.36, p < 0.001). When compared to patients’ primary information sources about heart attack, symptom incongruence was significantly higher among (1) patients with no information source than ‘‘any other source’’ and (2) patients informed by relatives more than those educated by nurses or physicians (Table 3). Elderly, unmarried individuals, patients with low income, poor education or with spouse with pre-existing cardiac health conditions, and those with no prior personal history of AMI, angina or PCI had higher levels of symptom incongruence than their counterparts (Table 5).
100 80 60 40 20 0
Experienced
Expected
Fig. 3. Expected versus experienced atypical acute myocardial infarction manifestations among patients (n = 299).
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Table 2 Number of expected and experienced acute myocardial infarction manifestations based on patients’ characteristics (n = 299). Characteristic
Expected symptoms (M SD) All
Gender Male 7.4 5.1* Female 5.9 4.8 Age 7.9 4.9* <55 years 55 years 6.4 5.1 Marital status Married 7.6 5.0*** Not married 2.6 3.4 Education High school 6.7 4.9* >High school 8.1 5.1 Income 350 JOD/month 5.8 4.9*** 351 JOD/month 8.1 5.1 Smoker Yes 7.9 5.1** No 6.2 4.9 Hyperlipidemia Yes 8.0 4.8* No 6.6 5.1 History of AMI Yes 10.1 5.0*** No 6.3 4.8 History of CABG Yes 11.6 5.0** No 6.9 3.7 History of angina Yes 9.0 5.0*** No 6.3 5.0 Previous PCI Yes 9.5 4.9*** No 6.4 4.9 Having relative(s) with cardiac problems Yes 7.7 5.2** No 6.3 4.8 Type of AMI STEMI 7.6 5.3* NSTEMI 6.2 4.4
Typical
Atypical
3.5 2.1 2.9 2.1
3.9 3.4* 2.9 3.4
3.7 2.1* 3.1 2.1
4.2 3.2* 3.3 3.4
3.6 2.0*** 1.2 1.8
4.0 3.4*** 1.2 1.7
3.2 2.3* 3.8 2.0
3.4 3.2* 4.3 3.4
2.9 2.2** 3.7 2.0
2.9 3.1*** 4.3 3.4
3.7 2.1* 3.1 2.1
4.2 3.4** 3.1 3.2
3.7 2.0 3.2 2.2
4.2 3.3* 3.1 3.3
4.6 1.9*** 3.1 2.1
5.5 3.5*** 3.2 3.1
5.2 1.1** 3.3 2.1
6.5 3.1** 3.6 3.3
4.2 2.0*** 3.1 2.1
4.8 3.3*** 3.3 3.3
4.3 2.0*** 3.1 2.1
5.2 3.3*** 3.3 3.3
3.7 2.1** 3.0 2.1
4.0 3.5* 3.3 3.1
3.5 2.2 3.1 2.0
4.1 3.5* 3.1 3.0
Note: Total number examined symptoms = 24; 7 typical (chest pain or discomfort, jaw pain or discomfort, dyspnea, arm or shoulder pain or discomfort and symptoms being sudden, continuous and severe) and 17 atypical (loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, diarrhea, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation, dyspepsia, and symptoms being intermittent, mild and gradual). AMI, acute myocardial infarction; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; NSTEMI, non ST-elevation myocardial infarction. Patients were compared by independent samples t-test; variables with non significant results at all columns were not presented. * p < 0.05. ** p < 0.01. *** p < 0.001.
4. Discussion The current study revealed that among Jordanian patients with AMI, the expected and, to a lesser degree, the experienced symptoms varied according to patients’ demographic and clinical characteristics. Patients’ information sources and relatives played a significant role in symptom expectation and interpretation. Also, characteristics of patients who demonstrated low symptoms
awareness mostly resembled those with high symptom incongruence. The Jordanian culture, which is mostly derived from Islam, emphasizes an individual’s responsibility for maintaining health. Hadith (saying) of Prophet Muhammad ‘‘your body has a right over you’’ is one of several tenets that foster such beliefs. Thus, one would expect that Jordanians be actively involved in learning about their most common killer, AMI, and demonstrate good awareness about its manifestations. However, our results revealed that Jordanian patients were unfamiliar with AMI symptoms. Around 20% of patients in this study could not identify a sources of AMI information, 31% expected zero to one AMI symptom, and almost all AMI manifestations were anticipated less often than they were experienced. Awareness of AMI symptoms and having at least one information source about AMI are important for accurate symptom attribution to a cardiac etiology (Henriksson et al., 2007; Meischke et al., 1999). Public and individual awareness about AMI symptoms are better in developed countries as only 8% of examined individuals had no prior anticipation of how AMI could present (Mata et al., 2014) and at least one-half of the AMI symptoms studied were expected more often than actually suffered by patients with AMI (Horne et al., 2000; Perry et al., 2001; Ratner et al., 2008). A Swedish investigation revealed that more than onehalf of patients with AMI learned about AMI symptoms from health care providers and the mass media (Thuresson et al., 2007). In contrast, over 50% of our patients learned about AMI from their relatives. Dependence on relatives to learn about AMI resulted in low awareness of AMI symptoms, and high symptom incongruence among our patients. The failure of relatives to provide appropriate information is explained by previous findings that the public, relatives, and patients in general share the same low level of knowledge about AMI manifestations (Henriksson et al., 2011, 2012). Patients who consult their relatives during AMI have long prehospital delay times (Perry et al., 2001). Added to our results, these findings suggest that relatives play a negative role in patients’ prehospital delay prior to AMI by negatively influencing interpretation of symptoms. Consistent with previous research (Goff et al., 2004; Ratner et al., 2008), awareness of AMI symptoms is linked with patients’ characteristics. In our study, accurate symptom knowledge was favorably linked with patients’ gender (male), marital status (married), indicators of good health literacy (i.e., young age, good income and educational level), previous exposure to cardiovascular conditions (either personally or by interaction with relatives), and having AMI risk factors. Most of these characteristics equally affected patients’ awareness of both typical and atypical AMI symptoms. Our findings further revealed that characteristics that improved patients’ awareness of AMI symptoms were mostly those that decreased symptom incongruence (i.e., indicators of good health literacy, having a cardiac history). These characteristics were correlates of short prehospital delay for AMI symptoms in several studies (Fox-Wasylyshyn et al., 2010; Khraim et al., 2009; Moser et al., 2006).
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Table 3 Number of expected acute myocardial infarction symptoms and level of symptom incongruence according to patients’ primary information sources about heart attacks (n = 299). Primary information source
All manifestations (M SD)
Typical manifestations (M SD)
Atypical manifestations (M SD)
Expected
Incongruence
Expected
Incongruence
Expected
Incongruence
A Mass media (n = 41) B Internet (n = 14) C Nurses, physicians (n = 45) D Relatives (n = 132) E Other (n = 8) F None (n = 59) p value Post hoc test by LSD:
9.4 4.6
6.4 3.3
4.0 1.8
1.9 1.3
5.4 3.4
4.5 2.5
9.1 4.3
5.9 2.5
4.1 1.7
1.9 1.3
5.0 3.0
4.1 1.7
10.5 4.4
5.9 3.5
4.6 1.7
1.6 1.5
5.8 3.1
4.3 2.5
7.5 4.3
7.3 3.0
3.7 1.8
2.3 15
3.8 3.0
5.0 2.2
10.8 4.1
5.7 2.1
4.9 1.1
1.6 1.2
6.0 3.1
4.1 1.4
1.1 1.9
10.5 3.9
0.8 1.2
4.5 1.7
0.2 0.8
6.0 3.1
<0.001 F < A, B, C, D, E D < A, C, E
<0.001 F > A, B, C, D, E D>C
<0.001 F < A, B, C, D, E D
<0.001 F > A, B, C, D, E D>C
<0.001 F < A, B, C, D, E D < A, C, E
0.004 F > A, B, C, D, E
Note: Total number examined symptoms = 24; 7 typical (chest pain or discomfort, jaw pain or discomfort, dyspnea, arm or shoulder pain or discomfort and symptoms being sudden, continuous and severe) and 17 atypical (loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, diarrhea, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation, dyspepsia, and symptoms being intermittent, mild and gradual). Patients were compared by one-way analysis of variance (ANOVA).
Previous reports indicated that female gender, advanced age, and history of diabetes may more commonly result in an atypical AMI presentation while male gender or STEMI are associated with a typical presentation (Canto et al., 2007; Coventry et al., 2011; DeVon et al., 2008; MacInnes, 2005; Morgan, 2005). Nevertheless, this was not completely reflected in our study nor in some previous investigations (Milner et al., 2002; Thuresson et al., 2005).
We found that gender was not related to the type of presenting symptoms. In addition, the elderly and those with hyperlipidemia suffered fewer typical symptoms and patients with previous AMI had more typical and atypical Table 5 Level of symptom incongruence according to patients’ characteristics (n = 299). Variable
Table 4 Number of experienced acute myocardial infarction manifestations based on patients’ characteristics (n = 299). Characteristic
Age <55 years 55 years Hyperlipidemia Yes No History of AMI Yes No Type of AMI STEMI NSTEMI
Experienced symptoms (M SD) All
Typical
Atypical
10.7 2.9 10.2 3.2
5.0 1.3** 4.5 1.5
5.6 2.4 5.6 2.6
9.9 2.8* 10.7 3.1
4.6 1.4* 4.9 1.3
5.5 2.3 5.8 2.6
11.4 3.0** 10.2 3.0
5.1 1.2* 4.7 1.4
6.3 2.6* 5.5 2.5
10.9 3.1*** 9.5 2.9
5.1 1.3*** 4.2 1.3
5.8 2.5 5.3 2.5
Note: Total number examined symptoms = 24; 7 typical (chest pain or discomfort, jaw pain or discomfort, dyspnea, arm or shoulder pain or discomfort and symptoms being sudden, continuous and severe) and 17 atypical (loss of consciousness, leg pain, abdominal pain, fatigue, nausea or vomiting, diarrhea, numbness in arms, dizziness, headache, sweating, fever, cough, palpitation, dyspepsia, and symptoms being intermittent, mild and gradual). AMI, acute myocardial infarction; STEMI, ST-elevation myocardial infarction; NSTEMI, non ST-elevation myocardial infarction. Patients were compared by independent samples t-test; Variables with non significant results at all columns were not presented. * p < 0.05. ** p < 0.01. *** p < 0.001.
Age <55 years 55 years Marital status Married Not married Education High school education or less More than high school education Income 350 JOD (495 USD)/month 351 JOD/month Insurance Yes No History of myocardial infarction Yes No History of angina Yes No History of percutaneous coronary intervention Yes No Having spouse with cardiac health conditions Yes No
Level of symptom incongruence (M SD)
p value
0.008 6.9 3.6 8.0 3.6 <0.001 7.2 3.5 10.2 3.7 0.002 8.3 3.4 7.2 3.5 0.004 8.2 3.7 7.0 3.5 0.018 7.1 3.7 8.2 3.5 0.001 6.2 3.3 7.9 3.7 0.026 6.8 3.2 7.8 3.8 0.009 6.5 3.1 7.8 3.7 0.007 8.8 3.5 7.2 3.6
Note: Patients were compared by independent samples t-test; variables with non significant results were not presented.
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symptoms than their counterparts. These variations among research studies may be related to several factors including differences in both the proportions of subgroups that represented various patients’ characteristics and the endpoints compared. In the current study, we focused on the total number of symptoms and not on individual symptoms, as is frequently done in the literature. The limited diversity of both the expected and experienced symptoms among the examined patients resulted in low symptom incongruence. Yet, as we previously reported, this low incongruence was sufficient to make our patients less apprehensive about their AMI symptoms, more confused regarding their symptoms origin, and consequently more reluctant to seek for immediate medical help (Abed et al., 2015b). Enhancing patients’ awareness of AMI symptoms is the only way to reduce symptom incongruence given that the expectation, and not the experience, of symptoms is the amenable factor to improvement. Unfortunately, health education and public awareness programs are not well integrated in Jordan health care sector (WHO, 2009). Outpatient clinics are mainly used for curative purposes such as prescribing medications. Prehospital discharge education is mostly inactive. A recent study indicated that up to 50% of Jordanian cardiac patients were not questioned nor advised about their behavioral risk factors during their hospitalization period (Mosleh and Darawad, 2014). Mass media is only focused on specific health topics, such as family planning and vaccines. Cardiac rehabilitation centers are also unavailable. Faulty beliefs and socio-cultural factors may also contribute to Jordanians limited knowledge about AMI, as they lessen their motivation to seek for health information. For example, the belief that a health threat is more likely to occur when one is actively involved in learning about it is not uncommon among Jordanians. Also, Jordanians in general are optimistic in their assessment of their risk for heart attacks (Abed et al., 2015a). The dialog between health care providers and patients is still conducted in a manner where health professions are dominant while patients, or their caregivers, are passive and avoid asking questions. Our findings are a call for action. We need to educate Jordanians patients and their significant others about AMI and its typical and atypical symptoms. To achieve this goal, Jordanians must first recognize that they need to learn about AMI. Disease prevention and health knowledge dissemination programs should be fostered in the Jordan health care system. Heath care providers must embrace their role as health educators, otherwise patients’ reliance on less credible sources of information will continue. The relationship of information sources to prehospital delay needs examination because, to date, it has not yet been explored in the literature. We also need studies that examine factors that motivate Jordanians to learn about AMI. 5. Limitations There are several limitations of the current investigation. First, awareness of AMI symptoms was assessed
based on patients’ retrospective recalls of their expectations of AMI symptoms. Second, stratifying patients according to one characteristic and then comparing between them may underestimate their complex attributes. Third, the use of a non-random sample which affects generalization of results. Finally, measurement of the study’s main outcomes relied mainly on a relatively new scale that was not previously translated or validated for the Jordanian patients. 6. Conclusion In conclusion, Jordanian patients’ unfamiliarity with, and misinterpretation of, AMI symptoms was common. Patients gleaned information about AMI from different sources even though they mostly depended on relatives. The expected and experienced AMI symptoms and symptom incongruence were linked with patients’ demographic and clinical characteristics and their information sources about heart attack. Conflict of interest: Authors declared no conflict of interest. Funding: This study was funded by the Hashemite University in Jordan. Ethical approval: Institutional review board approval for conducting the current study was obtained from the Hashemite University and all hospitals involved in the study. After orienting patients to the study aims and subjects’ rights, a consent form was signed by participant patients. References Abed, M.A., Khalil, A.A., Moser, D.K., 2015a. Awareness of modifiable acute myocardial infarction risk factors has little impact on risk perception for heart attack among vulnerable patients. Heart Lung 44, 183–188. Abed, M.A., Khalil, A.A., Moser, D.K., 2015b. The contribution of symptom incongruence to prehospital delay for acute myocardial infarction symptoms among Jordanian patients. Res. Nurs. Health 38 (3), 213–221. Albarran, J.W., Clarke, B.A., Crawford, J., 2007. ‘It was not chest pain really I can’t explain it!’ An exploratory study on the nature of symptoms experienced by women during their myocardial infarction J. Clin. Nurs. 16 (7), 1292–1301. Arslanian-Engoren, C., Patel, A., Fang, J., Armstrong, D., Kline-Rogers, E., Duvernoy, C.S., Eagle, K.A., 2006. Symptoms of men and women presenting with acute coronary syndromes. Am. J. Cardiol. 98 (9), 1177–1181. Canto, J.G., Goldberg, R.J., Hand, M.M., Bonow, R.O., Sopko, G., Pepine, C.J., Long, T., 2007. Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch. Intern. Med. 167 (22), 2405–2413. Chareonthaitawee, P., Gibbons, R.J., Roberts, R.S., Christian, T.F., Burns, R., Yusuf, S., 2000. The impact of time to thrombolytic treatment on outcome in patients with acute myocardial infarction For the CORE investigators (Collaborative Organization for RheothRx Evaluation). Heart 84 (2), 142–148. Coventry, L.L., Finn, J., Bremner, A.P., 2011. Sex differences in symptom presentation in acute myocardial infarction: a systematic review and meta-analysis. Heart Lung 40 (6), 477–491. De Luca, G., Suryapranata, H., Marino, P., 2008. Reperfusion strategies in acute ST-elevation myocardial infarction: an overview of current status. Prog. Cardiovasc. Dis. 50 (5), 352–382. DeVon, H.A., Penckofer, S., Larimer, K., 2008. The association of diabetes and older age with the absence of chest pain during acute coronary syndromes. West J. Nurs. Res. 30 (1), 130–144. Fox-Wasylyshyn, S.M., El-Masri, M., Artinian, N.T., 2010. Testing a model of delayed care-seeking for acute myocardial infarction. Clin. Nurs. Res. 19 (1), 38–54. Goff Jr., D.C., Mitchell, P., Finnegan, J., Pandey, D., Bittner, V., Feldman, H., Meischke, H., Goldberg, R.J., Luepker, R.V., Raczynski, J.M., Cooper, L.,
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