Cardiovascular Diseases (CVD), especially Coronary Heart Disease (CHD), have assumed epidemic proportion worldwide. Diagnosis and treatment of coronary heart disease is very important to reduce mortality rate [1]. Amongst all non -communicable diseases worldwide, 2.6 million people die annually due to acute myocardial infarction or increased cholesterol [2]. Treatment with percutaneous coronary interventions or fibrinolytic therapy within one to two hours of onset of acute myocardial infarction can reduce AMI related mortality by 50% and can prevent the life threatening complications like dysrhythmias, heart failure and death [3]. 

Being a life threatening manifestation of coronary heart disease, Acute Myocardial Infarction (AMI) needs prompt recognition and management. Approximately one-third of deaths from AMI occurs within few hours of onset of symptoms and usually before the patients reach to the hospital. In both developed and developing countries, 40–75 per cent of all heart attack victims die before reaching to the hospital. In India, more than 10.5 million deaths occur annually and it was reported that 20.3% of these deaths in men and 16.9% in women [2]. The mortality varies from less than 10% in rural location in less developed states to more than 35% in more developed urban locations [3,4].

The WHO reported in 2010, non-communicable diseases led to 5.87 million deaths globally and in India led to 1.2 million deaths in men and 0.9 million deaths in women. Patient delay in seeking treatment following the onset of symptoms in myocardial infarction has largely focused on demographic, symptom related, educational status and clinical factors as predictors of delay in reaching hospital. Delay does not appear to be related to the severity of pain associated with the acute event. The notion that patients may delay because they do not recognize their symptoms and having lack of knowledge has led to increasing interest in the role of symptom interpretation as a source of delay in acute Myocardial Infarction [5,6].

A descriptive study was carried out on patients with AMI who were admitted in National Heart Institute, New Delhi. Demographic data, educational status, marital status, type of residence, type of family, per capita income, symptomatic factors (nature of discomfort, symptoms associated with chest pain, radiation of pain etc.), situational factors (time of discomfort experienced, place where discomfort experienced, reached to other hospital/clinic before reaching to present hospital, transport used other than ambulance etc.) and psychological factors (anxious when experienced discomfort, feeling low when experienced discomfort etc.) were collected via structured closed ended questionnaire. 100 patients who were suffered from acute MI, having other comorbidity or associated diseases like hypertension, diabetes mellitus and renal diseases, between age of 30 to 60 years were included and patients who were unconscious after the diagnosis of acute myocardial infarction and were admitted and diagnosed with repeated MI were excluded in the study. Data was analyzed by using descriptive and inferential statistics. The chi- square test was used to analyze association between selected demographic variables and factors and p = 0.05 was considered statistically significant.

Among AMI patients in the study, majority (79%) were males, 41% were qualifies up to degree and above, majority (98%) of them were residing in urban area and 85% of them were between 46- 60 years of age.49% of subjects hold per capita income of below 25,000, majority (65%) of the were from nuclear family.

Table 1 showing percentage wise distribution of patients with acute myocardial infarction according to their pre hospital treatment delay, which depicts that highest and more or less percentage (70.87% and 63.85%) were shown by situational factors and symptomatic factors respectively. Whereas, lowest percentage (14.75%) were shown by psychological factors. Hence, it can be interpreted that in the present study situational factors are the leading cause for pre hospital treatment delay in acute myocardial infarction patients.

Table 1: Factors Associated with Pre Hospital Treatment Delay

Table 2 showing percentage wise distribution of patients with acute myocardial infarction according to their situational factors shows that 99% of them felt “discomfort at day time”. The reasons for their discomfort were highest percentage (43%) of them felt their symptoms in “early morning” and lowest percentage (2%) of them felt their symptoms “after midnight”.

Lowest percentage (21%) of acute myocardial infarction patients “felt discomfort out of their house” and their reasons were 10% of patient felt their symptoms “at office” and 1% of them were felt symptoms while “travelling to some places”.

Table 2: Frequency and Percentage Distribution of Patients with Acute Myocardial Infarction According to Situational Factors and Their Reasons N = 100

Lowest percentage (47%) of acute myocardial infarction patients “gone to some other clinics/physicians/hospital” before coming to this hospital and their reasons were 25% of patients went to “nearby clinics” and 4% each were those who “went to PHC’s/dispensary” and “nursing homes” respectively.

Highest percentage (58%) of acute myocardial infarction patient’s “distance of home to hospital were beyond 10 km” and their reasons were majority (52%) of the patients were “residing between 10- 20 km” of distance and 1% of them were “residing above 30 km” of distance from present hospital.

Highest percentage (70%) of acute myocardial infarction patients were “with somebody when experienced symptoms” and their reasons were majority (30%) of the patients were “with their children” and 5% were “with their siblings” when symptoms experienced.

Highest percentage (89%) of acute myocardial infarction patients “availed any transport other than ambulance” and their reasons were majority (75%) of patients were came in “their own vehicle” and 1% were those who “came by other mean” such as by walking to hospital because they stayed nearby to the hospital.

Highest percentage (92%) of acute myocardial infarction patients were “accompanied by family members to hospital” and their reasons were majority (56%) of patients were “accompanied by their children and spouse” and 10% were “accompanied by their friends and coworkers” to the hospital.

Highest percentage (91%) of acute myocardial infarction patients “reached to hospital beyond 2 hours of discomfort experienced” and their reasons were majority (66%) of patients were reached “beyond 2-4 hours” and 5% were “taken > 8 hours” to reach the hospital after they felt their symptoms/ chest discomfort.

Factors Leading to Pre Hospital Treatment Delay in Acute Myocardial Infarction Patients

In the present study it was found that the factors which are leading to pre hospital treatment delay were situational factors which is measuring sub factors like patient’s “time of onset of pain” (day and night), “place at discomfort felt” (in the house or out of the house), “went to other clinic or PHC”, “distance from home to hospital”, “availed other transport than ambulance”, “accompanied by someone when you felt discomfort”, “reached to hospital beyond 2 hours of the discomfort” respectively, which was supported by a study where 32.5% of patients were admitted within 90 minutes of symptoms onset, long distance from living location to hospital and type of transport used were the cause for delay in treatment respectively [7,8].

Whereas in another study, 69% of acute myocardial infarction patients referred to general physician before referring to hospital, the severity of symptoms (day vs. night) were determined to be related to having delay in seeking treatment [9].

Another study depicts that the factors associated with delays were ignoring of symptoms, indecisiveness and reluctance to seek treatment, self-medication, being unconvinced that the symptoms were serious and waiting for a worsening of pain were leads to delay in seeking treatment [10].

Association Between Factors and Demographic Variables

In the present study the association between factors with demographic variables were checked and found that there are no association between age, educational qualification, type of employment, per capita income, marital status, type of family, residence except gender in symptomatic factors, no association between age, type of employment, marital status, type of family, except gender, educational qualification, per capita income and residence in situational factors, no association between age, educational qualification, type of employment, marital status, types of status, residence except gender, per capita income in psychological factors which is supported by the study where gender, age, literacy, mode of transport and past history of MI were not significant factors for treatment delay respectively, which is supported by another study which showed that gender, age, literacy, mode of transport and past history of MI were not significant factors of pre hospital treatment delay [3]. Whereas another study showed that location of residency and type of transport could significantly predict the delay in treatment for patient with MI.

Delimitations

The present study is delimited to 1. Patients aged between 30 to 60 years and 2. All Acute MI patients with other comorbidity or associated diseases like hypertension, diabetes mellitus and renal diseases.

Most patient with AMI arrived late after the onset of symptoms. Route of transport, home to hospital distance, perception of symptoms, self -medications, time of onset of pain, consulted to local health professionals etc. were the factors of pre hospital treatment delay in AMI patients.

1. Chitra, R. et al. “Analysis of myocardial infarction risk factors in heart disease data set.” Biology and Medical Case Report, vol. 1, 2017, pp. 9–15.

2. Tummala, S.R. and A. Farshid. “Patients’ understanding of their heart attack and the impact of exposure to a media campaign on pre-hospital time.” Heart, Lung and Circulation, vol. 24, no. 1, 2015, pp. 4–10.

3. Youssef, G.S. et al. “Pre-hospital and hospital delay in patients with non-st elevation acute coronary syndromes in tertiary care.” The Egyptian Heart Journal, vol. 69, no. 3, 2017, pp. 177–181.

4. Gupta, R. et al. “Trends in coronary heart disease epidemiology in India.” Annals of Global Health, vol. 82, no. 2, 2016, pp. 2214–9996.

5. Fathi, M. et al. “Risk factors of delayed pre-hospital treatment seeking in patients with acute coronary syndrome: A prospective study.” Turkish Journal of Emergency Medicine, vol. 15, no. 4, 2015, pp. 163–167.

6. Prabhakaran, D. et al. “Cardiovascular diseases in India: Current epidemiology and future directions.” Circulation, vol. 133, no. 16, 2016, pp. 1605–1620.

7. World Health Organization. “Fact sheet: Cardiovascular diseases.” WHO, Sept. 2016, www.who.int.

8. Medical Record Department. Acute Myocardial Infarction Admission and Mortality Data 2013–2017. 2018.

9. World Health Organization. Global Status Report on Non-Communicable Diseases 2010. WHO, 2010, www.who.int/nmh/publication/ncd-report-full-en.pdf.

10. World Health Organization. Global Status Report on Non-Communicable Diseases 2017. WHO, 2017, www.who.int/nmh/publication/ncd-report-full-en.pdf.