NSTEMI Patients Wait Too Long to Go to the Hospital After Symptoms Start

November 12, 2010

November 11, 2010 (Rochester, Minnesota) — Non-ST-segment-elevation-MI (NSTEMI) patients take too long to get to the hospital once they experience their first symptoms, according to the results of a new analysis [1]. Overall, more than half of the patients took more than two hours to get to the hospital, and investigators say new strategies are needed to get patients to seek care, given that delay times have not improved in recent years.

In a report published in the November 8, 2010 issue of the Archives of Internal Medicine, the researchers, led by Dr Henry Ting (Mayo Clinic, Rochester, MN), studied 104 622 patients with NSTEMI at 568 hospitals enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) national-quality improvement initiative. It is recommended that patients experiencing symptoms of an acute coronary syndrome call 911 if the symptoms persist for more than five minutes.

In the registry, the median delay from symptom onset to hospital presentation was 2.6 hours, a time that has been stable from 2001 to 2006, according to investigators. Overall, 59% of patients had delays exceeding two hours, while 11% of patients waited more than 12 hours to get to the hospital. Older patients, women, and nonwhite patients were significantly more likely to delay going to the hospital, multivariate analyses showed. Patients with diabetes and current smokers were also more likely to delay.

In addition, NSTEMI patients who experienced symptoms at night, both during the weekday and weekend, had a 25% shorter delay time when compared with individuals who had symptoms during typical office hours, 8 am to 4 pm, during the week.

Increasing Symptom Awareness

Speaking with heartwire , Dr Timothy Henry (Minneapolis Heart Institute, MN), who was not affiliated with the CRUSADE analysis, said that STEMI and NSTEMI symptoms are identical and that patients should be encouraged to get to the hospital if symptoms persist. As noted by Ting and colleagues, delays in presentation are common for STEMI patients, typically about two hours, and these delays are associated with higher death rates. These new data, said Henry, show the importance of community education, particularly among high-risk patients.

"Starting with patients with coronary artery disease is a really good place to begin," said Henry, referring to targeted campaigns designed to increase patient awareness about MI symptoms. "And then, to the extent that you can, you increase awareness in the community about cardiovascular disease and its symptoms, so that people will get to the hospital sooner."

Starting with patients with coronary artery disease is a really good place to begin.

Henry said campaigns focusing on door-to-balloon times have significantly reduced the time from emergency medical services (EMS) arrival to angioplasty, but cutting the delay from symptom onset to hospital presentation is "extremely difficult to control." Public media campaigns about symptom awareness in large cities are more challenging than in smaller communities, he noted, pointing out that the messages can be missed in media-saturated markets. In smaller towns, establishing systems of care is easier, because there is typically a local newspaper, and campaigns can be directed through them.

Regarding the relationship between delay and in-hospital mortality, the CRUSADE investigators observed a nonlinear and generally weak relationship in this NSTEMI cohort. Patients with the shortest delay time, those who presented within the first hour of having symptoms, had a higher risk of dying compared with patients who waited more than six hours. Patients with waited one to two hours, two to three hours, and three to six hours had similar, if slightly lower, mortality rates as those who waited more than six hours.

Henry said delaying is deadly for STEMI patients, whereas it doesn't appear to be as harmful for NSTEMI patients. He pointed out, however, that there are a number of confounders that can influence mortality, and it is possible that patients who presented earliest were sickest and had more severe symptoms, necessitating an immediate visit to the hospital. Regardless, as symptoms between STEMI and NSTEMI are identical, and patients are unaware how severe the coronary blockage may be, they should call for EMS if symptoms persist after taking nitroglycerin.

CRUSADE is a national quality-improvement project led by Duke Clinical Research Institute, funded by Schering-Plough. A partnership between Bristol-Myers Squibb and Sanofi-Aventis also provides funding. Millennium Pharmaceuticals also provided funding for this study. Ting and Henry report no conflicts of interest.

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