Factors associated with presenting >12 hours after symptom onset of acute myocardial infarction among Veteran men

BMC Cardiovascular Disorders

Stephan Fihn¹  Elliott Lowy¹  Ranak Trivedi¹  Charles Maynard¹  Kelly McDermott² 

[1] Health Services Research & Development Northwest Center of Excellence, Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Met Park West, Seattle, WA, 98101, USA;Osher Center for Integrative Medicine, University of California, San Francisco, 1545 Divisadero St., 3rd Floor, Box 1726, San Francisco, CA 94115, USA

关键词: Delayed presentation;    Time from symptom onset;    Acute myocardial infarction;    Veterans;   

Others  :  1084366
DOI  :  10.1186/1471-2261-12-82

 received in 2012-03-09, accepted in 2012-09-20,  发布年份 2012

【 摘 要 】

Background

Approximately 2/3 of Veterans admitting to Veterans Health Administration (VHA) facilities present >12 hours after symptom onset of acute myocardial infarction (AMI) (“late presenters”). Veterans admitted to VHA facilities with AMI may delay hospital presentation for different reasons compared to their general population counter parts. Despite the large descriptive literature on factors associated with delayed presentation in the general population, the literature describing these factors among the Veteran AMI population is limited. The purpose of this analysis is to identify predictors of late presentation in the Veteran population presenting with AMI to VHA facilities. Identifying predictors will help inform and target interventions for Veterans at a high risk of late presentation.

Methods

In our cross-sectional study, we analyzed a cohort of 335 male Veterans from nine VHA facilities with physician diagnosed AMI between April 2005 and December 2006. We compared demographics, presentation characteristics, medical history, perceptions of health, and access to health care between early and late presenting Veterans. We used standard descriptive statistics for bivariate comparisons and multivariate logistic regression to identify independent predictors of late presentation.

Results

Our cohort was an average of 64 ± 10 years old and was 88% white. Sixty-eight percent of our cohort were late presenters. Bivariate comparisons found that fewer late presenters had attended at least some college or vocational school (late 53% vs. early 66%, p = 0.02). Multivariate analysis showed that presentation with ST-elevation myocardial infarction (STEMI) was associated with early presentation (OR = 0.4 95%CI [0.2, 0.9]) and ≥2 angina episodes in the prior 24 hours (versus 0-1 episode) was associated with late presentation (OR = 7.5 95%CI [3.6,15.6]).

Conclusions

A significant majority of Veterans presenting to VHA facilities with AMI were late presenters. We found few differences between early and late presenters. Having a STEMI was independently associated with early presentation and reporting ≥2 angina episodes in the 24 hours prior to hospital admission was independently associated with late presentation. These independent predictors of early and late presentation are similar to what has been reported for the general population. Despite these similarities to the general population, there may be untapped opportunities for patient education within the VHA to decrease late presentation.

【 授权许可】

   
2012 McDermott et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Bradley EH, Herrin J, Wang Y, McNamara RL, Radford MJ, Magid DJ, Canto JG, Blaney M, Krumholz HM: Door-to-drug and door-to-balloon times: where can we improve? Time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI). Am Heart J 2006, 151(6):1281-1287.
• [2]McDermott KA, Helfrich CD, Sales AE, Rumsfeld JS, Ho PM, Fihn SD: A review of interventions and system changes to improve time to reperfusion for ST-segment elevation myocardial infarction. Journal of general internal medicine 2008, 23(8):1246-1256.
• [3]Kastrati A, Mehilli J, Nekolla S, Bollwein H, Martinoff S, Pache J, Schuhlen H, Seyfarth M, Gawaz M, Neumann FJ, et al.: A randomized trial comparing myocardial salvage achieved by coronary stenting versus balloon angioplasty in patients with acute myocardial infarction considered ineligible for reperfusion therapy. J Am Coll Cardiol 2004, 43(5):734-741.
• [4]Sheifer SE, Rathore SS, Gersh BJ, Weinfurt KP, Oetgen WJ, Breall JA, Schulman KA: Time to presentation with acute myocardial infarction in the elderly - Associations with race, sex, and socioeconomic characteristics. Circulation 2000, 102(14):1651-1656.
• [5]Abbate A, Biondi-Zoccai GG, Appleton DL, Erne P, Schoenenberger AW, Lipinski MJ, Agostoni P, Sheiban I, Vetrovec GW: Survival and cardiac remodeling benefits in patients undergoing late percutaneous coronary intervention of the infarct-related artery: evidence from a meta-analysis of randomized controlled trials. J Am Coll Cardiol 2008, 51(9):956-964.
• [6]Schomig A, Mehilli J, Antoniucci D, Ndrepepa G, Markwardt C, Di Pede F, Nekolla SG, Schlotterbeck K, Schuhlen H, Pache J, et al.: Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12hours from symptom onset: a randomized controlled trial. Jama 2005, 293(23):2865-2872.
• [7]Ting HH, Bradley EH, Wang Y, Nallamothu BK, Gersh BJ, Roger VL, Lichtman JH, Curtis JP, Krumholz HM: Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction. Am J Med 2008, 121(4):316-323.
• [8]Larsen GC, Zobel R, McFalls E, Pineros SL, Li Y, Neugaard B, Rumsfeld JS, Bradley M, Tenney S, Sales A, et al.: Characteristics and outcomes of inpatients wtih elevated troponins but without an Acute Coronary Syndrome in 9 Veterans Affairs Hospitals: A prospective multicenter study. Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Scientific Annual Forum, Baltimore, MD; 2008.
• [9]Helfrich CD, Sharp ND, Pineros SL, Lowey E, McDermott KA, Sales AE, Larsen GC, Fihn SD: How Veterans Health Administration facilities have changed practices to improve care for patients with acute coronary syndromes. Circulation 2007, 115(21):e591. [Abstract]
• [10]Petersen LA, Normand SL, Daley J, McNeil BJ: Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients. N Engl J Med 2000, 343(26):1934-1941.
• [11]Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Prodzinski J, McDonell M, Fihn SD: Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease. J Am Coll Cardiol 1995, 25(2):333-341.
• [12]Zijistra F, Patel A, Jones M, Grines CL, Ellis S, Garcia E, Grinfeld L, Gibbons RJ, Ribeiro EE, Ribichini F, et al.: Clinical characteristics and outcome of patients with early (< 2h), intermediate (2-4h) and late (> 4h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction. Eur Hear J 2002, 23(7):550-557.
• [13]Gibler WB, Armstrong PW, Ohman EM, Weaver WD, Stebbins AL, Gore JM, Newby LK, Califf RM, Topol EJ: Persistence of delays in presentation and treatment for patients with acute myocardial infarction: The GUSTO-I and GUSTO-III experience. Ann Emerg Med 2002, 39(2):123-130.
• [14]Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C, Degrandsart A, Vicaut E: STEMI and NSTEMI: are they so different? 1year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry). Eur Hear J 2007, 28(12):1409-1417.
• [15]Ting HH, Chen AY, Roe MT, Chan PS, Spertus JA, Nallamothu BK, Sullivan MD, DeLong ER, Bradley EH, Krumholz HM, et al.: Delay from symptom onset to hospital presentation for patients with non-ST-segment elevation myocardial infarction. Arch Intern Med 2010, 170(20):1834-1841.
• [16]Piette JD, Moos RH: The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction. Health Serv Res 1996, 31(5):573-591.
• [17]Ting HH, Bradley EH, Wang Y, Lichtman JH, Nallamothu BK, Sullivan MD, Gersh BJ, Roger VL, Curtis JP, Krumholz HM: Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction. Arch Intern Med 2008, 168(9):959-968.
• [18]Cannon CP, Gibson CM, Lambrew CT, Shoultz DA, Levy D, French WJ, Gore JM, Weaver WD, Rogers WJ, Tiefenbrunn AJ: Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. Jama-Journal of the American Medical Association 2000, 283(22):2941. -+
• [19]Alcaras NM, Roper JM: Chest pain among combat veterans: A conceptual framework. Military Medicine 2006, 171(6):478-483.
• [20]Burnett RE, Blumenthal JA, Mark DB, Leimberger JD, Califf RM: Distinguishing between early and late responders to symptoms of acute myocardial infarction. Am J Cardiol 1995, 75(15):1019-1022.
• [21]Al-Mallah MH, Alsheikh-Ali AA, Almahmeed W, Sulaiman K, Al Suwaidi J, Ridha M, Al-Motarreb A, Alenezi F, Zubaid M: Missed Opportunities in the Management of ST-Segment Elevation Myocardial Infarction in the Arab Middle East: Patient and Physician Impediments. Clin Cardiol 2010, 33(9):565-571.
• [22]Elder GH Jr, Clipp EC: Wartime losses and social bonding: influences across 40years in men's lives. Psychiatry 1988, 51(2):177-198.
• [23]El Gaylani N, Weston CF, Griffith K, Wong PSC, Norris RM, Penny WJ: Investigators UKHAS: Acute myocardial infarction: are there missed opportunities for reperfusion? Coronary Artery Disease 1998, 9(11):753-758.
• [24]Cohen M, Gensini GF, Maritz F, Gurfinkel EP, Huber K, Timerman A, Santopinto J, Corsini G, Terrosu P, Joulain F, et al.: The role of gender and other factors as predictors of not receiving reperfusion therapy and of outcome in ST-segment elevation myocardial infarction. Journal of Thrombosis and Thrombolysis 2005, 19(3):155-161.
• [25]Goff DC Jr, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, Meischke H, Goldberg RJ, Luepker RV, Raczynski JM, et al.: Knowledge of heart attack symptoms in 20 US communities. Results from the Rapid Early Action for Coronary Treatment Community Trial. Prev Med 2004, 38(1):85-93.