Elderly Acute MI Patients Still Waiting Too Long to Seek Medical Care

Elderly men and women are still dragging their feet when it comes to getting to the hospital once symptoms of acute myocardial infarction begin, according to the results of a new study.

Over a recent 10-year period, there has been no improvement in the timeliness of seeking medical attention among individuals 65 years and older, a vexing problem that “remains of considerable clinical and public health concern,” say investigators.

“It’s a very difficult behavior to modify,” senior investigator Robert Goldberg, MD (University of Massachusetts Medical School, Worcester, MA), told TCTMD. “A lot of things come racing into a patient’s head once these symptoms start, including fear, denial, embarrassment, and a whole variety of other reasons. You hear anecdotes—I could tell you several from my family—of people trying to wait things out, hoping it isn’t a heart attack.”

There have been significant advances in the treatment of acute MI, but the full benefits of coronary reperfusion and revascularization procedures depend on the timely presentation of the patient, something that can only be achieved if the extent of prehospital delay is minimized, say researchers.

No Change Over a Decade

Published online April 21, 2016, in the Journal of the American Heart Association, the population-based study is an analysis of 1,542 patients 65 years and older admitted to 11 hospitals in central Massachusetts with a confirmed diagnosis of acute MI between 2001 and 2011.

During the 10-year study period, the mean duration of prehospital delay was 3.7 hours. When stratifying patients by three age categories—65 to 74 years, 75 to 84 years, and 85 years and older—the average delay times were 3.5, 4.0, and 3.4 hours, respectively. Just under half of all patients presented to the hospital within 2 hours of symptom onset while 37% presented between 2 and 6 hours. Another 16% of patients presented more than 6 hours after symptoms started.

The median duration of prehospital delay remained consistent at about 2 hours over the 10-year period. Across the three different age groups, the median duration of delay decreased marginally from 2001-2003 to 2009-2011, although this change was not statistically significant. The mean duration of prehospital delay declined from 3.9 hours in 2001-2003 to 3.2 hours in 2009-2011, but again the reduction was not statistically significant. In the 10 years, the percentage of patients who reached the hospital within 2 hours of symptom onset remained stable, according to investigators.

Individuals who delayed getting to the hospital were more likely to develop acute symptoms in the evening, night, and early morning (between 6 pm and 5:59 am) and were more likely to present with atypical symptoms, such as abdominal pain and palpitations, when compared with those who went to the hospital earlier. Individuals with a STEMI and with less comorbidity were more likely to seek out care earlier.

As to why some patients don’t go to the hospital or call an ambulance when symptoms emerge, Goldberg said the decision to seek medical care is complex, weighted with psychosocial, contextual, and other personal variables. “A lot of people don’t recognize their symptoms and a lot of people attribute them to other conditions,” he said. While some are afraid or embarrassed, other factors, such as having health insurance, also influences the decision to wait or seek medical attention.  

From a research perspective, measuring prehospital delay is difficult, with Goldberg calling the endpoint “somewhat squishy.” In other words, defining exactly how long the patient waited before presenting to the emergency room or calling an ambulance is imprecise. “How does someone clock their symptoms?” he asked. “Is it when they have a little chest pain, a moderate amount, or immense chest pain? Is it a twinge in their back or is it more crippling pain? Most people don’t look down at their watch when this happens either. Also, depending on the provider and their interest, it might not be extensively queried and noted.”

Goldberg told TCTMD the study results suggest more work needs to be done to educate patients about the risks of delaying when symptoms arise and in identifying and eliminating the barriers to seeking medical care. Overall, he suspects the biggest bang for the buck could be in reducing the number of “laggards,” those individuals who wait 6 hours or more before going to the hospital with acute MI symptoms.

“One of the aspects of coronary heart disease is that it can kill you in seconds to minutes,” he said. “If people linger, they can be one of those unfortunate cases of out-of-hospital cardiac deaths, many of which come on suddenly. Some people may die within seconds, while in others there might be slightly more a prolonged course they want to wait out. You don’t want to wind up as one of those statistics.”

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