Delays in Presenting for AMI Linked to Surprising Factors
Ruth SoRelle · Emergency Medicine News · 2002
Patients who are elderly, female, diabetic, or who have low educational or socioeconomic levels are more likely to delay going to the emergency department for treatment for an acute myocardial infarction, according to a study in a recent issue of the Annals of Emergency Medicine (2002;39:123). But a comparison of two studies carried out seven years apart — the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) and Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III) — showed that the wait for treatment once the patients presented to the emergency department decreased although it was still longer than that for younger, male, and white patients of higher socioeconomic and educational levels. Two experts in the field differ on the importance of such delays in getting patients to treatment, although both admit that it would be better if education about the signs and symptoms of heart attack were directed at these groups to alert them when they are suffering a heart attack. W. Brian Gibler, MD, the chairman of emergency medicine University of Cincinnati College of Medicine, said, “If the patient delays too long, he or she is outside the window for thrombolytics.” The reasons behind the delays are enigmatic, Dr. Gibler said. For example, diabetics have changes in their perceptions of pain and symptoms. “They often have silent heart attacks,” he said, adding that he was more surprised at the other groups who delayed going to the hospital. Costs to Avoid Delays Jerome Hoffman, MD, a professor of emergency medicine at the University of California at Los Angeles, said it is certainly true that some people delay getting to the emergency department. “The bigger question is, so what?” he said. Dr. Hoffman concedes that getting patients to the hospital very quickly — within two and a half hours of the onset of symptoms — can result in a therapeutic improvement. Those patients who get there later, however, might subject themselves to more risk than the benefits justify. And then there is the issue of swamping emergency departments with patients who have symptoms but not heart attacks. “In the case of myocardial infarction, which should not be lumped together with stroke, it is useful to get people at risk of having an event get to the emergency department quickly. There are treatments we know to work in myocardial infarction, and some are better given early,” he said. The medical community should consider the cost of getting people to come to the hospital earlier, Dr. Hoffman said. What is the tradeoff in telling people to rush to the emergency department versus the problems presented when people who have nothing rush to get there quickly? “What is the tradeoff in telling people to rush to the emergency department versus the problems presented when people who have nothing rush to get there quickly?” Dr. Jerome Hoffman It is hard to know when you are having a myocardial infarction. Think of the consequences of having a massive community program to encourage people to race to the emergency department. It may mean we are overwhelming our hospitals beds with people who do not have myocardial infarctions. “It is great when you get the right people in earlier,” said Dr. Hoffman. As long as it is hard to tell what is ischemia and what isn't, this will be a problem. “Once patients show up with minor symptoms, in our current status in the world with legal issues and the fear of missing something, many people with trivial symptoms get admitted to a monitored bed,” he said. “Doctors are uncomfortable sending them home.” “If we improve the educational level of everyone about the symptoms of heart attack, they will receive better treatment.” Dr. Brian Gibler Dr. Hoffman said some evidence shows that thrombolytics have value in acute myocardial infarction, but the influence of time is not quite as clear. “In the first hour, minutes count. If you can get thrombolytics in the first half hour or hour, they are tremendously effective,” he said. “If you get them in under two hours, there is enhanced value. After that, it is not clear there is a great difference between two and a half hours, six hours, and nine hours. Unless you get people to get there right away, thrombolytics are not as effective. And that carries the risk of overtriage.” Dr. Hoffman said thrombolytics have less of an impact on the outcome of myocardial infarction than many other interventions such as aspirin or beta-blockers. “While we seem obsessed with thrombolytics and they can have real value, there are other things to do in the case of acute MI.” Educational Programs While Dr. Gibler said delays are troublesome, he said he also was concerned about whose treatment was delayed. “Educational levels of the patients had a tremendous impact on seeking care and for getting care once they were in the emergency department,” he said. “When you put the information as far as what the occupational and educational levels were, things like being members of minority groups dropped out of the model. The fact that patients were members of minority groups did not affect presentation of treatment. If we improve the educational level of everyone about the symptoms of heart attack, they will receive better treatment.” Dr. Gibler said the patient who comes in with a clear idea of what the symptoms of a heart attack are, and says, “I think I'm having a heart attack” gives the health care provider a better idea of what is happening. Dr. Gibler agreed that how to carry out such education is difficult. He said a study that looked at two cities — one with a vigorous educational program and one without — did not bring in more people with acute coronary syndromes. “You got more people coming in, but not more people with problems,” he said. “Are we going about education the wrong way?” he asked. That was one reason this study looked for differences among the people who delayed seeking treatment and who were more likely to received delayed treatment in the emergency department. One answer may be to educate health care personnel about the groups most likely to receive delayed care so that they will realize the dichotomy and provide better care, Dr. Gibler said. However, he said, medicine may have to look to society to answer the question of how to get patients to come to the hospital more quickly. “Unequivocally, in multiple studies, the time to treatment is critical,” Dr. Gibler said. “The earlier you treat people, the more likely you are to see benefits in terms of mortality or morbidity.”