|Year : 2016 | Volume
| Issue : 3 | Page : 163-168
An Observational study of prehospital and hospital delay in reperfusion for acute myocardial infarction at a University Hospital in India
Rahul Choudhary1, Shashi Mohan Sharma1, Vimla Kumar2, Dinesh Kumar Gautam1
1 Department of Cardiology, Sawai Man Singh Medical College, Jaipur, India
2 Department of Cardiology, Dr. SN Medical College, Jodhpur, Rajasthan, India
|Date of Web Publication||2-Mar-2017|
Department of Cardiology, Sawai Man Singh Medical College, JLN Marg, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
Objective: Cardiovascular disease is the leading cause of death among Indian adults, and approximately 50% of deaths usually occur during the 1st hour after symptom onset before arriving at the hospital. A study was planned to evaluate the prehospital and hospital delay in patients with acute myocardial infarction (AMI). Methods: This was a prospective observational study of 390 patients with AMI admitted to the Department of Cardiology between March 2014 and August 2015. Detailed patient demographics, socioeconomic status, and prehospital and hospital delay were reviewed. Results: The mean age of presentation for male and female was 57 ± 12.91 and 61.5 ± 12.83 years, respectively. The mean prehospital delay, time to act after chest pain, and travel time were 9.08 ± 6.3, 7.16 ± 6.1, and 1.84 ± 0.8 h, respectively, and only three (9.7%) patients reached the hospital within 2 h after symptom onset. Out of 300 patients who received reperfusion therapy, thrombolysis was done in 276 (92%) patients while primary percutaneous coronary intervention was performed in only 24 (8%) patients. Mean door-to-needle (D-N) time and door-to-device time for those who received reperfusion therapy were 27.8 ± 4.3 and 78.95 ± 9.5 min, respectively. A multivariate logistic regression analysis revealed that the prehospital delay was significantly associated with older age, female sex, rural background, diabetes, having atypical pain, and lack of knowledge regarding the seriousness of chest pain. Conclusion: Approximately 79% of total prehospital delay was due to patient-related factors; old age, female sex, rural background, diabetes, atypical angina, and lack of knowledge being the significant attributes. D-N time and door-to-device time were within the limits of those recommended by current guidelines.
Keywords: Acute coronary syndrome, prehospital delay, reperfusion, ST-elevation myocardial infarction
|How to cite this article:|
Choudhary R, Sharma SM, Kumar V, Gautam DK. An Observational study of prehospital and hospital delay in reperfusion for acute myocardial infarction at a University Hospital in India. J Pract Cardiovasc Sci 2016;2:163-8
|How to cite this URL:|
Choudhary R, Sharma SM, Kumar V, Gautam DK. An Observational study of prehospital and hospital delay in reperfusion for acute myocardial infarction at a University Hospital in India. J Pract Cardiovasc Sci [serial online] 2016 [cited 2019 Sep 18];2:163-8. Available from: http://www.j-pcs.org/text.asp?2016/2/3/163/201378
| Introduction|| |
The prevalence of cardiovascular disease (CVD) is on the rise globally and accounts for 30% of deaths worldwide. By the year 2020, India will have the maximum burden of CVD as compared to other countries. It was observed that about 50% of myocardial infarctions (MIs) occur in males below 50 years of age and 25% of these occur below 40 years., The CREATE registry had also reported that incidence of ST-elevation MI (STEMI) was higher (60.6%), and the mortality was more (8.6%) among Indian population than that of Western countries.
Approximately 50% of acute MI (AMI) deaths usually occur during the 1st h after symptom onset before arriving at the hospital. Every 30 min of delay increases the 1-year mortality risk by 7.5%. Studies indicate that reperfusion interventions decrease the mortality by up to 25%–30%. Despite these facts, a significant number of AMI patients have a delay in receiving treatment. This prehospital delay includes two time intervals, i.e., from the onset of the chest pain/symptoms to making a decision and from the patient's decision for medical help arriving at the hospital. The period between the onset of chest pain and the decision to seek medical help remains the most significant cause of the total delay.
Previous studies reported factors such as age, sex, mode of transportation, socioeconomic status, history of coronary heart disease, and the cognitive status of patients as the main factors contributing to the prolonged prehospital delay in AMI.,,,, In India, where prehospital paramedical support and ambulance services are generally not available, most patients reporting to the hospital use personal modes of transportation. Most of the peripheral hospitals lack facilities to record electrocardiogram. This, together with a preference to initially seek advice from a nearby practitioner, contributes significantly to the delay in presentation to hospital for definitive treatment of MI.
The studies from India were performed almost a decade ago., Significant improvements in health-care system, emergency ambulance services (108 ambulance service), and connectivity among individuals were observed during the last decade. Therefore, epidemiological studies are required to assess the current status of this issue at grass-root level so as to plan accordingly at a regional and national level for the care of STEMI patients. The present study was aimed to identify the prehospital and hospital delay and the factors contributing to the prehospital delay at a tertiary care hospital in Jaipur, Rajasthan.
| Methods|| |
Study design and patient population
This hospital-based descriptive study was conducted on patients hospitalized due to acute STEMI in Department of Cardiology, SMS Medical College, Jaipur, from March 2014 to August 2015. Patients who were not remembering the time of onset of pain or those who received treatment at the periphery and then referred to SMS Hospital but not having documents regarding treatment given were excluded from the study. The patients or their immediate family members were approached on day 1 in coronary care unit after AMI and were interviewed using a predesigned pro forma. Patients who received thrombolysis/primary percutaneous coronary intervention (PPCI) were approached just after the reperfusion therapy. The chief constituents of the questionnaire included the demographic characteristics, socioeconomic status of the patient, nature and time of symptom onset, preexisting illness, treatment received, and any previous knowledge about symptoms of heart attack. The patients were also asked about the time at which they presented to the emergency unit, which was corroborated with the entry time mentioned on computerized emergency entry ticket. The main outcome variables included: (i) prehospital delay (time interval between the onset of symptoms suggestive of AMI and arrival in the hospital) and (ii) door-to-needle (D-N)/device time (time interval between arrival at the hospital and administration of thrombolytic therapy/PPCI. The above-mentioned time intervals were obtained from hospital records.
For the purpose of this study, delay was defined as a time interval >12 h from the onset of symptoms to the presentation of the patient to the hospital. This has been used as the point of dichotomizing data in previous studies and also there are definite benefits of restoring coronary patency in the first 12 h after AMI.
Time of onset of symptoms
Onset of symptoms during 8 pm to 6 am was taken as night and from 6 am to 8 pm as day.
Socioeconomic status of the patient
Class of patient was defined according to Kuppuswamy's socioeconomic status scale for 2014.
The study protocol was approved by the Ethics Committee of SMS Medical College and conducted according to the principles of the Declaration of Helsinki. All patients provided written informed consent before enrolment.
Statistical analysis was performed with the Microsoft Excel, SPSS statistical package, version 20.0 (SPSS, Chicago, IL, USA), and PRIMER. The data were analyzed using both descriptive and inferential statistics. Patients were divided into groups based on delay in hospital presentation (≤12 h vs. >12 h).
The categorical data were presented as numbers (percent) and were compared among groups using Chi-square test. Demographic data of groups were presented as a mean and standard deviation (SD) and were compared using Students t-test. Univariate analysis was done by odd ratio, and binary logistic regression was used for multivariate analysis to identify independent risk factors for the prehospital delay. P < 0.05 was considered statistically significant.
| Results|| |
A total of 400 patients presented with STEMI during the recruitment period (from March 2014 to August 2015) and all were assessed for eligibility. Out of these, ten patients were excluded from the study because they did not meet the inclusion criteria. Thus, a total of 390 (97.5%) patients including 223 (57%) males and 167 (43%) females met the inclusion criteria and consented to participate [Figure 1].
Sociodemographic characteristics of these participants are shown in [Table 1]. The mean age of presentation for male and female patients was 57 ± 12.91 and 61.5 ± 12.83 years, respectively. Two-third of the population was <65 years of age. Among the risk factors, 48.2% were smoker, and 30.3% were diabetics.
|Table 1: Demographic and baseline clinical characteristics of the patients (n=390)|
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The median prehospital delay, time to act after chest pain, and travel time were 7 (4–14 interquartile range [IQR]), 5 (IQR 2–12), and 2 (IQR 1–2) h, respectively [Table 2]. The mean prehospital time delay was 9.08 (SD 6.3) hrs. Only 38 (9.7%) patients reached the hospital within 2 h after the appearance of the symptoms.
|Table 2: Various time intervals from the onset of pain to the reperfusion therapy (thrombolytic therapy/primary percutaneous coronary intervention)|
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Thrombolysis was the main mode of reperfusion therapy and was performed in 276 patients out of 300 patients. PPCI was done in only 24 (8%) patients. Mean D-N time and door-to-device time for those who received reperfusion therapy were 27.8 ± 4.3 and 78.95 ± 9.5 min, respectively.
Univariate analysis of variance using the general linear model was conducted to identify factors significantly associated with the prehospital delay [Table 3]. The variables of being female, age ≥65 years, low level of education, living in rural area, smoker, the onset of symptoms during night, low socioeconomic status, having atypical pain, not having knowledge about the seriousness of chest pain, and having inferior wall MI (IWMI) were significantly associated with prehospital delay.
|Table 3: Univariate analysis of variables and odds ratio for prehospital delay|
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A multivariate logistic regression analysis (with prehospital delay as dependent variable and all parameters as independent variables) revealed that the prehospital delay was significantly associated with old age, female sex, rural background, diabetes, having atypical pain, and lack of knowledge regarding the seriousness of chest pain [Table 4].
|Table 4: Independent predictors of the prehospital time delay at multivariable regression analysis|
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| Discussion|| |
The aim of this study was to evaluate various time intervals from the symptom onset to the reperfusion therapy and identifying the factors contributing to the prehospital delay at a tertiary care teaching hospital in India. The mean age of patients admitted with MI was 57 ± 12.91 and 61.5 ± 12.83 years for males and females, respectively. Patients from Indian subcontinent usually present almost a decade earlier as compared to other countries. Various studies from India had reported the age ranging from 55.0–58.2 years for males to 55.7–60 years for females, whereas the average age of first MI is 65.8 years for males and 70.4 years for females in the US.
This study revealed that median prehospital delay time was 420 (IQR 240–850) min with a mean of 546 min (9.1 h). The prehospital delay was reported to be over 24 h from a study conducted as early as 1972 (Gupta RN). This interval has considerably decreased in recent studies to a median of 300 (IQR 137–985) min (CREATE registry 2008). The improvement of the emergency medical service and the increment of public awareness have been probably influential in this reduction. The reasons for delayed presentation include economic reasons, atypical symptoms, lack of awareness of the importance of the symptoms, and different types of health-care providers that prevent timely access to tertiary care hospitals. Prehospital delay in our study was higher than what was observed in CREATE registry. Possible explanation for this could be the heterogeneous nature of study population in these two studies. Our study population included more elderly individuals (18% vs. 11.1%; age >70 years), higher proportion of rural patients (52.82% vs. 17%), and more number of diabetics (30.36% vs. 26%). All these variables are known to be associated with delayed presentation. When mean prehospital delay was further evaluated, it was observed that approximately 79% of the total prehospital delay was due to patient-related factors and only 21% of delay duration consisted of transportation time. About 7 h were wasted after the onset of symptoms before considering it significant so as to consult a doctor.
In the present study, the variables such as being female, low level of education, and living in the rural area were relevant to more delay in referring to the hospital. Most of the previous studies also reported the female gender as one of the main factors contributing to the prehospital delay in patients with AMI.,, This may be related to the less specificity of signs and symptoms of AMI, lack of knowledge due to poor literacy, and the difference in the manner of responding to these symptoms.,, The effect of the educational level of the reduction of prehospital delay could be attributed to the higher awareness of patients about the disease, its relevant symptoms, and the importance of timely referring to the hospital. In this research, the age below 65 years has been followed by less delay, and the difference was statistically significant. Rajagopalan et al. also reported the age above 65 as a significant factor in the prehospital delay. This issue might be due to the dependence of elder people to their relatives, greater frequency of atypical or symptomless infarction, more adaptation with and less sensitivity to the health problems, and decreased symptom perception in the elderly. Mortality from AMI is significantly higher in the elderly, and the absolute reduction in the risk of death after thrombolytic therapy is greater than in younger individuals., Reduction in a prehospital delay in this group will play a major role in improving outcomes after MI. Prehospital delay indirectly correlated with the socioeconomic status of the patient. Gärtner et al. reported that the patients with higher income had referred to the hospital earlier than the others. This study also concluded that nonsmokers, nondiabetics, patients having anterior wall MI, and those having typical anginal pain had significantly less delay. In other studies also, these factors have been correlated with patients' less prehospital delay.,, Ängerud et al. stated that apart from suppression of pain due to diabetic neuropathy, other factors such as adjustment of patients suffering from chronic disorders to their symptoms leading to ignorance of newer symptoms and attributing associated symptoms of MI such as sweating and dizziness to hypoglycemia could be the reason of delayed presentation after symptom onset. Acute IWMI may have atypical symptoms which lead to more delayed presentation to hospital. They also reported that onset of symptoms at night was associated with a delayed presentation. This relationship was also established in our study and was attributed to the unwillingness of patient to disturb other family members regarding his symptoms and less availability of transportation modes during night.
Another aspect of prehospital delay highlighted by our study was knowledge regarding heart attack symptoms. Patients who knew about the symptoms of a heart attack had a delay which was less than those who were ignorant (5.1 vs. 13.6 h). It seems that the patients who perceived their symptoms as a cardiac disease better recognized the significance of the problem and hence decided to refer to the hospital earlier. Thus, educational approaches are essential to reduce the extent of the patient delay and to enhance the widespread use of time-dependent management strategies in patients with AMI.
Most of the patients, who were eligible for reperfusion therapy, were thrombolysed in this study population, and only 8% received PPCI. The reason for not performing percutaneous coronary intervention (PCI) in rest of the patients was financial as most of them were poor, and cost of thrombolysis was far less than PPCI. Furthermore, lack of knowledge regarding benefits of PPCI prevented some of the patients and/or relatives to opt for this procedure during an acute emergency. The D-N time has also decreased over time from 210 to 50 min  (CREATE registry). These intervals are still longer as compared to recent reports from other countries (40 min in European Heart Survey [EHS] 1, 2002 and 37 min in EHS 2, 2004).,
Data from our study suggest that the overall mean time from initial hospital presentation to receipt of fibrinolysis (D-N time) was 27.8 ± 4.3 min and to PPCI (D-B time) was 79 ± 9.5 min for patients with STEMI. These delay times were within the limits of those recommended by current guidelines., Taken from a global perspective (of developed nations), this was encouraging. This shows significant improvement in the management of AMI at a tertiary care center during recent years. However, a large proportion of patients were not eligible for thrombolysis/PPCI due to delayed presentation to emergency (34%). Increased delay times to restoration of coronary flow are associated with increased infarction size, increased risk of congestive heart failure, and higher mortality. In a review of 2635 patients with STEMI enrolled in various randomized trials of PPCI versus thrombolysis, patients with symptom onset to presentation time of >4 h had significantly increased rates of a combined end point of death, nonfatal reinfarction, and stroke compared with those with symptom onset to presentation times <2 h (thrombolysis: 19.4 vs. 12.5%; PCI: 7.7 vs. 5.8%).
Strengths and limitations of our study
The major strength of this study lies in its prospective design. This allowed us to explore certain components of delay more fully than would have been possible by retrospective chart review.
There are several limitations of the present study. The effect of prehospital delay on disease outcomes was not studied. Patients who died of AMI outside the hospital and those with silent MI were not studied. Finally, it is not easy to extrapolate the results of this study to other areas of a country, in which the standards of medical practice are extremely heterogeneous. However, our data are representative of a typical tertiary care hospital, and therefore, such data can be generalized to other hospitals as well.
| Conclusion|| |
The prehospital delay was the main reason for not timely receiving reperfusion therapy. The main factors contributing to prehospital delay were old age, diabetes mellitus, poor knowledge of symptoms, atypical presentations, and unavailability of rapid transport facilities in rural areas. Patients often ignored their symptoms, self-medicated, and even when they decided to seek medical help, they consulted nonphysicians. To overcome these barriers, organized patient education, and awareness programs are urgently needed. Such programs should not only use methods such as public lectures, rural camps, and print materials but should also focus on television, the internet, and social media.
The public should be educated that an ECG and consultation from a specialist are a must for acute pain or discomfort from jaw to epigastrium including upper limbs. They should also know the significance of timely reaching the 'right' hospital or physician for STEMI care. Provision of rapid transportation facilities can help reduce the excessive case fatality rates attributed to prehospital delay.
What is already known about this subject?
Cardiovascular deaths are the leading cause of death among Indian adults, and most deaths are attributed to delayed presentation of the patient to the hospital. Prehospital and hospital delay in Indian population are significantly greater than Western countries.
What does this study add?
The prehospital delay was far from ideal in this study, but once the patient reached the emergency, the D-N time and door-to-device time were within recommended range. Even in a tertiary care hospital, PPCI was done in only 8% of patients who were eligible for reperfusion therapy, mostly due to financial constraints. This study also found that 80% of total prehospital delay was due to patient-related factors; old age, female sex, rural background, diabetes mellitus, atypical angina, and lack of knowledge.
How might this impact on clinical practice?
To deal with prehospital delay, which still remains a major issue in this decade also, we need awareness programs on a larger scale and should also focus on television, the internet, and social media. The government should provide bolus fibrinolytics and stents at a subsidized cost to all patients, may be through health insurance schemes. We also need STEMI care centers in each city, district, and rural areas so as to curtail the delay and improve chances of survival.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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