Volume 166 Issue 5

Australian patients' delay in response to heart attack symptoms Kathleen Dracup, Sharon M McKinley and Debra K Moser MJA 1997; 166: 233 For comment see Langton and Thompson Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Statistical analyses - Results - Associations with delay time - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objectives: To examine delay in seeking treatment among patients with an evolving acute myocardial infarction (MI), and to identify factors which contributed to this delay. Design: Patient interview combined with medical record review. Participants and setting: 317 patients with confirmed diagnosis of acute MI interviewed within 72 hours of admission to three hospitals. Main outcome measures: Delay from onset of symptoms to arrival at hospital, and cognitive, emotional, sociodemographic and clinical factors which contributed to increased prehospital delay. Results: Median prehospital delay was 6.4 hours; 41% of patients delayed less than four hours, while 28% delayed less than two hours. Prehospital delay was increased in patients with fewer years of education (P = 0.001), lower income (P = 0.003) and transportation to the hospital by private car rather than ambulance (P = 0.02). Delay time was increased by several cognitive and emotional processes (P < 0.001), such as waiting to see if symptoms would go away, being too embarrassed to ask for assistance, and not recognising the importance of symptoms. Delay time was increased with heartburn, breathlessness or intermittent symptoms and decreased with sweating and dizziness (P < 0.05). Independent predictors of increased prehospital time (P < 0.01) were fewer than 10 years of education, not wanting to trouble anyone, failing to recognise the symptoms of delay, and the intermittent nature of symptoms. Conclusion: Over 50% of acute MI patients delay seeking treatment by six hours or more. Many factors related to cognitive and social processes that contribute to this delay may be remediable with appropriate patient and community education. MJA 1997; 166: 233-236 Introduction Every year in Australia approximately 22 000 people suffer a heart attack and approximately half of these die. Most of these deaths occur out of hospital.1 The high mortality associated with acute myocardial infarction (MI) is dismaying, given that major large-scale clinical trials have shown that thrombolytic therapy can significantly reduce mortality from MI.2 With this therapy, the shorter the interval between the onset of symptoms and when the drug is given, the better the outcome.2 If therapy is started within three hours of symptoms, mortality is reduced by 23%;3 this becomes 45% if started within one hour of symptoms.3 Similarly, the earlier the treatment, the better the resulting cardiac function and the lower the incidence of morbidity after MI.4 Prehospital delay is known to be a substantial problem. Median delay times ranging from just under two hours5 to six-and-a-half hours have been reported.6 Overall, approximately 25%-50% of MI patients delay seeking medical care for cardiac symptoms for more than six hours.7,8 In other countries, the factors associated with increased prehospital delay are being older; being female; having a clinical history of hypertension, diabetes, angina or congestive heart failure; having low emotional or somatic awareness; consultation with a spouse or other relative; consultation with a doctor; and self-treatment. Decreased prehospital delay occurs when there is haemodynamic instability, large infarct size, sudden onset of severe chest pain, recognition of symptoms as heart-related and consultation with a non-relative.8,9 We do not know if the characteristics that contribute to delay in seeking treatment for acute MI symptoms are similar for Australian patients. Such information is important for designing appropriate patient and community education programs. Therefore our aims were, firstly, to describe prehospital delay time in Australian patients experiencing symptoms of evolving acute MI and, secondly, to identify the cognitive, emotional, sociodemographic and clinical factors which contribute to this delay. Methods We gained appropriate institutional ethics committee review and approval for the study from the study hospitals and the University of Technology, Sydney. Eligible patients admitted to three hospitals between 1 March and 31 July 1995 were invited to participate in the study and gave written informed consent. Patients were eligible if they were able to read and write English, lived independently, were free from malignancy or other complicating illness, alert and orientated, were within 24 and 72 hours of hospital admission, and had a diagnosis of acute MI, determined by:Chest pain lasting longer than 20 minutes; Serial electrocardiographic evidence of acute MI (i.e., appearance of new Q waves in at least two leads of a 12-lead standard electrocardiogram); and Elevations in serum creatine kinase-MB consistent with evolving MI. Only patients with Q-wave MI were studied. Patients were excluded if they were being mechanically ventilated. The hospitals were two metropolitan university-affiliated city teaching hospitals and a district hospital, chosen because their geographical catchment areas were relatively small, so transportation time would not add significantly to the time between symptom onset and arrival at the hospital. We reviewed medical records to obtain sociodemographic and clinical data. We assessed information about the cognitive, emotional and social processes surrounding the decision to seek treatment using the Response to symptoms questionnaire, designed to obtain information about patient delay and factors contributing to delay in six domains: (1) context in which MI symptoms appeared; (2) antecedents of symptoms; (3) affective response to symptoms; (4) behavioural response to symptoms; (5) cognitive response to symptoms; and (6) the response of others to patient symptoms.10 Based on growing evidence that cognitive, symptom-appraisal and social factors may be more important determinants of delay than knowledge about appropriate re sponse to symptoms,10 we modified the instrument to further assess cognitive, symptom-appraisal and social factors surrounding a patient's decision to seek care for acute MI symptoms. The resulting instrument assesses factors surrounding the onset of acute MI symptoms, the response of others to symptoms, and the patient's response to symptoms. We established the time from symptom onset to hospital admission by reviewing the medical record for the time stated in the admission record by the admitting physician and the time of admission to the hospital. Also, each patient was asked about the time of first symptoms. If symptoms had come and gone, patients were carefully interviewed to determine the nature of those symptoms and the exact time that cardiac symptoms began. Where the patient's account differed from the time recorded by the admitting doctor, cardiac enzymes and serial electrocardiograms were reviewed to identify the most likely time of symptom onset. The value that most closely matched the expected clinical course reflected in the tests was chosen. Patients were asked if they wanted to complete the questionnaire themselves or if they wanted the researcher to read the questions; 96% chose the latter. Statistical analyses Independent t tests or analysis of variance (with post-hoc t tests adjusted for multiple comparisons) were used to assess the impact of sociodemographic, clinical, cognitive and social factors. Delay time was markedly skewed, so we used square root transformations to obtain a normal distribution, and all analyses were performed on transformed values. Multiple logistic regression and χ2 tests were used to determine odds ratios for delays of more than two hours among several sociodemographic, clinical, social and cognitive variables. Variables that were significantly different (P < 0.05) on delay time were entered into the forward stepwise logistic regression. Criteria for entry and removal of variables were based on the likelihood ratio test, with enter and remove limits set at P < 0.05 and P > > 0.05. Results Of 321 eligible patients approached, 317 agreed to participate in the study; four declined, giving fatigue as a reason. Patients were predominantly older (mean, 63 years; standard deviation, 12 years), male, married and white. There was diversity in years of formal education and socioeconomic status. Most patients experienced their symptoms at home and most went to hospital by ambulance (Box 1). Many patients were at greater than average risk for suffering an acute MI, with previous medical histories of angina pectoris (43%), MI (28%), hypertension (53%) and/or diabetes mellitus (19%). Most MIs were inferior (46%) or anterior (32%). Median prehospital delay time was 6.4 hours (interquartile range, 1.9-19.9 h; mean, 17.3 h). Only 14% of patients arrived within one hour of the onset of symptoms, 28.5% within two hours and 41% within four hours. However, 54% arrived at the hospital more than six hours after first experiencing cardiac symptoms. One hundred and fifty-three patients (48%) received thrombolytic therapy; 29 within one hour of the onset of symptoms. Associations with delay time Sociodemographic factors: Box 1 shows that there were differences in delay time according to education, annual income and use of ambulance. There was no significant association with sex, age, ethnicity, the location where symptoms occurred or whether or not a spouse was present when they occurred. Symptoms and pain: We examined breathlessness, fatigue, weakness, vague chest discomfort, chest pain, neck pain, arm numbness, pain between shoulder blades, back pain, nausea, feeling that something was wrong, dia phoresis, feeling clammy, heartburn, and dizziness. Delay time was less if patients were dia phoretic (P = 0.001) or experienced dizziness (P = 0.03) and increased if they were breathless (P = 0.03) or experienced heartburn (P = 0.03). The remaining symptoms made no difference to delay times. If symptoms were intermittent, patients took longer to seek treatment (P = 0.0001), while those who believed their symptoms to be cardiac in nature delayed for shorter times (P = 0.001). However, 60% originally attributed their symptoms to another cause (e.g., muscle pain, fatigue, indigestion). Patients who appraised their pain as very serious delayed a shorter time than patients who appraised their pain as not serious (P = 0.001). However, patients who rated their initial chest pain as severe had similar delay times to patients who rated their pain as mild (P = 0.644). Knowledge of coronary heart disease: There were no differences in the average time to arrival at hospital related to previous myocardial infarction, previous cardiac surgery, diabetes mellitus, hypertension or angina. Forty per cent of patients reported that their source of information about MI symptoms was television or reading; 27% received their information from a friend; 23% from a doctor; and 10% from a nurse. Sixteen per cent of patients knew about thrombolysis therapy for acute MI and these, on average, came to the hos pital earlier than patients who did not know about this treatment (P = 0.001). Cognitive and psychological factors: Box 2 (below) shows significant associations between patients' responses and delays in seeking medical treatment. Independent predictors of delay: We tested factors that were significant on univariate analyses in a multiple regression model. The five independent predictors of delay are shown in Box 3. Discussion In 317 patients admitted to hospital for evolving acute MI, we found that median prehospital delay was 6.4 hours. Almost 60% of patients delayed more than four hours, while more than 70% delayed longer than two hours. These times are substantially longer than those recorded in most studies from other countries,4-6,8,11 as well as those documented in previous Australian studies.12,13 The disparity between this and previous Australian studies is un doubtedly related to a difference in the definitions used to characterise prehospital delay. In the first Australian study, time from symptom onset to the first attempt to get help was reported.12 In the second, the definition of total delay time was the period from the onset of chest pain to arrival at hospital; where there were multiple episodes of chest pain, the time from the last episode of pain was used.13 Both variations in definitions would shorten reported delay time relative to the definition we used. It is unlikely that longer transportation times to the hospital contributed to longer delay times in our study because of the geographic situation of the participating hospitals and the high rate of ambulance use. Moreover, all studies on this topic have found that home-to-hospital time, as well as in-hospital time, play a minor role in the delay that occurs before definitive treatment.8,14,15 We included only those patients who survived to hospital admission and who met our inclusion criteria, and hence our patients were clearly not representative of all patients with acute MI. Unfortunately, approximately 30% of such patients die of sudden cardiac death before reaching the hospital,1 and we excluded patients because they were unable to respond to questions within the designated 72 hours of hospital admission (e.g., because they required mechanical ventilation or had compromised mental status). In the past, most researchers have focused on identifying patients who are more likely to delay a decision to come to the hospital because of various sociodemographic and clinical characteristics. In our study, the most important factor predicting delay was years of formal education, a characteristic that health professionals cannot alter. However, it may be linked with other characteristics (e.g., income, age, coping styles or other underlying cognitive mechanisms affecting delay), some of which may be amenable to change. Many of our patients had difficulty identifying their symptoms as cardiac in nature, initially thinking they were gastrointestinal, musculoskeletal, or fatigue. Many patients knew the classic signs of acute MI but did not know the diversity of its presentation, notably its often intermittent nature. Patients should be told that the symptoms may come on gradually or may not be constant, as many believe that MI is accompanied by sudden, crushing chest pain and unconsciousness. As in other studies,5,12,16,17 experience of a previous MI did not result in patients coming to the hospital sooner. Thus, the public, particularly patients at high risk for a future MI, need to be informed that the manifestations of an evolving MI may vary, even within the same individual, and should be clear about the actions to take if and when symptoms occur. In most studies in the United States, less than half of MI patients arrive by ambulance,18 whereas in our study most patients in all three hospitals used this means of transportation. Ambulance is preferable to other types of transportation because of the early treatment available and because delay times are usually reduced.18 From the accounts of patients in this study, doctors and nurses played minimal roles in providing information about the symptoms of MI, compared with knowledge gained from television, reading and friends. Counselling strategies tested in other clinical populations support the assumption that individuals who are prepared for certain signs and symptoms will delay less in seeking care than individuals who have no such preparation.19-21 They also suggest that health professionals should take a more proactive and intensive approach to educating patients about the nature of MI signs and symptoms and the steps to take to receive early treatment. These data also indicate the opportunity for professional organisations to enhance the knowledge and beliefs of patients by community educational programs via television, radio and newspapers. Very few patients knew about thrombolysis and its effectiveness in treating acute MI, but those who did presented sooner than those who did not. Based on these findings, health care professionals should emphasise the rationale for early treatment to patients at high risk for future MI, and public campaigns should advertise the benefit of seeking early treatment. Patients need to know that their decision to seek immediate treatment has important future rewards as this may override whatever trepidation they experience in acknowledging that they might be having a heart attack. In summary, almost all the significant predictors of delay we identified related to social and cognitive processes that might be amenable to change. Health care professionals should recognise the reluctance of patients to recognise MI symptoms as cardiac and provide them with the necessary guidance, so that they will seek care as soon as possible. The availability of newer forms of treatment, particularly thrombolytic therapy, provides a compelling reason for physicians and nurses to encourage patients and their families to seek care early to preserve ischaemic myocardium and reduce infarct size in the face of an evolving MI. Acknowledgements Funding for this study was provided by a Fulbright Foundation Senior Scholars grant and from the L W Hassenplug Chair funds. We thank the following nurses who assisted with data collection: Patricia Cameron, Marie Droulers, Cameron Goodear, Jennifer Kidd, Jacqueline Padley, Rebecca Scammell and Jennifer Williams. References Heart and stroke facts. Canberra: National Heart Foundation of Australia, 1995. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311-322. Gruppo Italiano per lo Studio della Stretochinasi nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; 1: 397-401. Simoons ML, Serruys PW, Brand MVD, et al. Early thrombolysis in acute myocardial infarction: Limitation of infarct size and improved survival. J Am Coll Cardiol 1986; 7: 717-721. Maynard C, Althouse R, Olsufka M, et al. Early versus late hospital arrival for acute myocardial infarction in the western Washington thrombolytic therapy trials. Am J Cardiol 1989; 63: 1296-1300. Cooper RS, Simmons B, Castaner A, et al. Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol 1986; 57: 208-211. Dracup K, Moser D. Treatment seeking behavior among those with symptoms and signs of acute myocardial infarction. Heart Lung 1991; 20: 570-575. GISSI-Avoidable Delay Study Group. Epidemiology of avoidable delay in the care of patients with acute myocardial infarction in Italy. Arch Intern Med 1995; 155: 1481-1488. Dracup K, Moser D, Eisenberg M, et al. Causes of delay in seeking treatment for symptoms of acute myocardial infarction. Soc Sci Med 1995; 40: 379-392. Burnett RE, Blumenthal JA, Mark DB, et al. Distinguishing between early and late responders to symptoms of acute myocardial infarction. Am J Cardiol 1995; 75: 1019-1022. Schwarz B, Schoberberger R, Rieder A, Dunze M. Factors delaying treatment of acute myocardial infarction. Eur Heart J 1994; 15: 1595-1598. Bett N, Aroney G, Thompson P. Impact of a national educational program to reduce patient delay in possible heart attack. Aust N Z J Med 1993; 23: 157-161. Leitch JW, Birbara T, Freedman B, et al. Factors influencing the time from onset of chest pain to arrival at the hospital. Med J Aust 1989; 150; 6-8. Schroeder JS, Lamb IH, Hu M. The pre-hospital course of patients with chest pain: analysis of the prodromal, symptomatic, decision-making, transportation and emergency room periods. Am J Med 1978; 64: 742-748. Schmidt SB, Borsch MA. The prehospital phase of acute myocardial infarction in the era of thrombolysis. Am J Cardiol 1990; 65: 1411-1415. Turi ZG, Stone PH, Muller JE, et al. Implications for acute intervention related to time of hospital arrival in acute myocardial infarction. Am J Cardiol 1986; 58: 203-209. Weilgosz ATJ, Nolan RP, Earp JA, Biro E. Reasons for patients' delay in response to symptoms of acute myocardial infarction. Can Med Assoc J 1988; 139: 853-857. Meischke H, Ho MT, Eisenberg MS, et al. Reasons patients with chest pain delay or do not call 911. Ann Emerg Med 1995; 25: 193-197. Bandura A. Self-efficacy; toward a unifying theory of behavior change. Psychol Bull 1977; 84: 191-198. Bailey WC, Richards JM Jr, Brooks CM, et al. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med 1990; 150: 1664-1667. Avis NE, Smith DW, McKinlay JB. Accuracy of perceptions of heart attack risks: what influences perceptions and can they be changed? Am J Public Health 1989; 17: 1608-1611. (Received 28 Mar, accepted 20 Nov, 1996) Authors' details University of California, Los Angeles, CA, USA. Kathleen Dracup, RN, DNSc, L W Hassenplug Professor of Nursing. University of Technology, Sydney, and Royal North Shore Hospital, Sydney, NSW. Sharon M McKinley, RN, PhD, Professor of Critical Care Nursing. College of Nursing, Ohio State University, Columbus, OH, USA. Debra K Moser, RN, DNSc, Assistant Professor. Reprints: Professor S M McKinley, Level 6, Royal North Shore Hospital, St Leonards, NSW 2065. E-mail: smckinle AT doh.health.nsw.gov.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Kathleen Dracup · Sharon M McKinley · Debra K Moser

Movement disorders with selective serotonin reuptake inhibitors Adverse Drug Reactions Advisory Committee MJA 1997; 166: 259 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Orolingual dyskinesia - Cases - Akathisia - Case - Comment - References - - ©MJA1997 The selective serotonin reuptake inhibitors (SSRIs) are being prescribed increasingly for major depression. The Adverse Drug Reactions Advisory Committee (ADRAC) has received more than 1800 postmarketing reports of adverse reactions to the SSRIs (fluoxetine, paroxetine and sertraline), with the most common reactions reported being rashes, headache, anorexia, nausea, vomiting, diarrhoea, dizziness, agitation, tremor and increased sweating. Reports describing the movement disorders of orolingual dyskinesia and akathisia are reviewed here. Orolingual dyskinesia Marchioni et al. described orolingual movements (intermittent facial movements, initially involving the tongue and lips) in a 74-year-old woman who had taken fluoxetine for seven months. 1 ADRAC has received nine reports of orolingual dyskinesia (after excluding reports describing tardive dyskinesia or orolingual movements as part of a generalised dyskinesia) where an SSRI was the only suspected drug since 18 January 1993. Fluoxetine was the suspected drug in four reports, sertraline in three and paroxetine in two. The nine reports described seven women and two men aged 22-89 years (median, 51 years). These dyskinesias were variously described as abnormal involuntary orolingual-buccal movements, persistent repetitive jaw movements, involuntary chewing movements and involuntary facial movements. In eight of the nine patients, they started within one month of starting to take the SSRI; in the remaining patient the movements started five months after starting to take the SSRI. Six of the nine patients had recovered at the time of reporting. Cases A 29-year-old woman taking no other medications was prescribed paroxetine 20 mg daily for depression. Four hours after taking only one paroxetine tablet she developed persistent repetitive jaw movements with chattering of her teeth. The movements and chattering occurred markedly for two days, and continued to occur with cold or fatigue over the next two weeks before gradually settling. She took no tablets after the first one. In another case, a 22-year-old man taking no other medications was prescribed a 20 mg paroxetine tablet daily for depression. After taking paroxetine for four weeks he experienced involuntary facial movements, accompanied by disturbed speech and agitation. He immediately stopped taking the paroxetine and quickly and fully recovered. Akathisia Olivera described a 40-year-old woman who developed akathisia (a form of restlessness in which there is the inability to sit still, an urge to move about constantly and a feeling of muscular quivering) after three days of taking paroxetine 20 mg daily. 2 ADRAC has received nine reports of akathisia where an SSRI was the only suspected drug since 17 February 1993. Fluoxetine was the suspected drug in six reports, paroxetine in two and sertraline in one. These nine reports described seven women and two men aged 29-86 years (median, 54 years). The akathisia started within 33 days of commencing the SSRI in seven patients, and the onset was within two days of commencing the SSRI in two of these seven. However, in the remaining two patients, the akathisia started five and eight months after commencing the SSRI. Eight of the nine patients had recovered at the time of reporting. Case An 86-year-old woman was prescribed 20 mg paroxetine daily for depression. Her only other medication was 5 mg felodipine daily, which she had started taking 12 months previously. She developed akathisia after taking paroxetine for five months -- she was unable to keep still, with restless legs and a constant need to pace. After she stopped taking the paroxetine only, she recovered fully. Comment Although acute dystonia is well recognised as an early adverse reaction to SSRIs, orolingual dyskinesia might be mistakenly thought to only occur later as tardive dyskinesia. It is important for prescribers to be aware that movement disorders such as orolingual dyskinesia and akathisia can occur in patients of any age, and that their onset may vary considerably from immediately on starting treatment to after many months of treatment. Adverse Drug Reactions Advisory Committee, PO Box 100, Woden, ACT 2606. References Marchioni E, Perucca E, Soragna D, et al. Choreiform syndrome associated with fluoxetine treatment in a patient with deficient CYP2D6 activity. Neurology 1996; 46: 853. Olivera AA. A case of paroxetine-induced akathisia. Biol Psychiatry 1996; 39: 910. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.