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Inability to act when experiencing heart attack symptoms

HeartSome patients experiencing a heart attack have a paralysing inability to act on the symptoms, putting them in a life-threatening situation, according to Swedish research.

Most deaths from heart attack occur in the first few hours after the start of symptoms. Quick treatment is crucial to restore blood flow to blocked arteries and save lives. The time it takes for patients to interpret and respond to symptoms is the main reason for delays in getting to a hospital and the care they need.

The study enrolled 326 patients undergoing acute treatment for a first or second heart attack. Participants completed the validated questionnaire "Patients' appraisal, emotions and action tendencies preceding care-seeking in acute myocardial infarction" (PA-AMI).
Patients in the study waited a median of three hours before seeking medical help. Some delayed for more than 24 hours. So, what went through their minds during that period? This study, for the first time, identified two general reactions.

A perceived inability to act had a significant impact on patients who waited more than 12 hours. These patients said: "I lost all power to act when my symptoms began"; "I did not know what to do when I got my symptoms"; "my symptoms paralysed me"; and "I felt I had lost control of myself when I got my symptoms."

"This immobilisation during ongoing heart attack symptoms has not been shown or studied before," said study author Dr Carolin Nymark, of Karolinska University Hospital, Stockholm, Sweden. "At the moment we don't know why some patients react in this way. It is possibly linked to fear or anxiety. This should be a novel element in educating people about what to do when they have heart attack symptoms."

Inaccurate symptom appraisal also affected those who delayed for more than twelve hours. These patients said it took a long time to understand their symptoms; they thought the symptoms would pass; they thought the symptoms were not serious enough to seek medical care; and they thought it would be difficult to seek medical care.

Conversely, patients who accurately identified their heart attack symptoms and sought medical help quickly had a wish to seek care, knew the symptoms were serious and where they should go to get help, and did not try to divert their thoughts away from the symptoms.

"Our previous research has shown that some patients believe their symptoms aren't serious enough to call an ambulance," said Nymark. "Others think the intensive care unit is closed in the middle of the night, perhaps because they do not think clearly during the event."

Warning signs of a heart attack include moderate to severe discomfort such as pain in the chest, throat, neck, back, stomach or shoulders that lasts for more than 15 minutes. It often comes with nausea, cold sweat, weakness, shortness of breath, or fear. "Another red flag is feeling you have no power to act on your symptoms," said Nymark. "This may indicate a real health threat and the need to call an ambulance."

Nymark said this new signal could be discussed in outpatient appointments for those with cardiovascular risk factors and in cardiac rehabilitation programmes for heart attack survivors. The study questionnaire could be used to identify patients who previously experienced an inability to act or poor symptom appraisal.

"Our findings are worrying because even a small reduction in delay would save heart muscle and lives," said Nymark. "Reducing patient delays appears to be a complex task and we need to find innovative ways to inform and educate patients and the public."

Nymark concluded: "If you have symptoms that may be caused by a heart attack, don't ignore them. Call for help immediately. It is better to be wrong about the symptoms than dead."

Background: The out-of-hospital mortality in patients with acute myocardial infarction remains unchanged in contrast to a decrease in inhospital mortality. Interventions aiming to shorten patient delay have been largely unsuccessful. A deeper understanding is apparently needed on patients’ appraisal prior to care-seeking.
Aim: To investigate whether appraisal processes influence patient delay, and if the questionnaire ‘Patients’ appraisal, emotions and action tendencies preceding care seeking in acute myocardial infarction’ (PA-AMI) could discriminate between patients with prolonged care-seeking and those with a short delay.
Methods: A cross-sectional study including 326 acute myocardial infarction patients filling out the validated questionnaire PA-AMI. The impact of subscales on delay was analysed by projection to latent structures regression. Discrimination opportunities between patients with short and long delays were analysed by projection to latent structures discriminant analysis.
Results: The subscales ‘perceived inability to act’ and ‘symptom appraisal’ had a major impact on patient delay (P<0.0001). ‘Perceived inability to act’ had its main influence in patients with a delay exceeding 12 hours, and ‘symptom appraisal’ had its main influence in patients with a delay shorter than one hour.
Conclusion: Appraisal processes influence patient delay. Acute myocardial infarction patients with a prolonged delay were, besides a low perceived symptom severity and urgency to seek medical care, characterised by a perceived loss of control and ability to act. Therefore, future interventions aimed at decreasing delay should pay attention to appraisal processes, and perceived inability to act may be a sign of a health threat and therefore a signal to seek medical care.

Carolin Nymark, Peter Henriksson, Anne-Cathrine Mattiasson, Fredrik Saboonchi, Anna Kiessling

[link url=""]European Society of Cardiology material[/link]
[link url=""]European Journal of Cardiovascular Nursing abstract[/link]

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