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Papers BMJ: First Published As 10.1136/Bmj.324.7344.1006 on 27 April 2002

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Papers BMJ: First Published As 10.1136/Bmj.324.7344.1006 on 27 April 2002 Papers BMJ: first published as 10.1136/bmj.324.7344.1006 on 27 April 2002. Downloaded from Decision making processes in people with symptoms of acute myocardial infarction: qualitative study Jill Pattenden, Ian Watt, Robert J P Lewin, Neil Stanford Abstract people’s knowledge of the symptoms of heart attack Department of and the correct action to take when faced with these Health Sciences, Objective To identify the themes that influence University of York, symptoms. However, the effectiveness of public aware- Heslington, York decision making processes used by patients with ness campaigns or education for patients in decreasing YO10 5DQ symptoms of acute myocardial infarction. delays is uncertain.12 Some studies report that although Jill Pattenden Design Qualitative study using semistructured research fellow such measures may increase knowledge, they are Ian Watt interviews. 13–15 unlikely to change behaviour. Other studies report professor of primary Setting Two district hospitals in North Yorkshire. some reduction in the median time from onset of care Participants 22 patients admitted to hospital with symptoms of acute myocardial infarction to arrival in RobertJPLewin professor of confirmed second, third, or fourth acute myocardial 16 17 hospital. It has also been reported that patients with rehabilitation infarction. a second infarct take as long to seek help as those hav- Neil Stanford Main outcome measure Patients’ perceptions of their ing their first one. Not all studies agree on this point, research fellow experience between the onset of symptoms and the but there may be more to decision making than knowl- Correspondence to: decision to seek medical help. edge of the symptoms of heart attack.51418For this rea- J Pattenden [email protected] Results Six main themes that influence the decision son, we studied patients who had had at least one making process were identified: appraisal of previous acute myocardial infarction. symptoms, perceived risk, previous experience, bmj.com 2002;324:1006 psychological and emotional factors, use of the NHS, http://www.bmj.com/ and context of the event. Methods Conclusions Knowledge of symptoms may not be We conducted the study in two district hospitals in enough to promote prompt action in the event of an North Yorkshire,which serve a mixed population, both acute myocardial infarction. Cognitive and emotional urban and rural. Out of hours general practitioner processes, individual beliefs and values, and the services are mainly provided by three cooperative serv- influence of the context of the event should also be ices. We obtained ethical approval from the two local considered in individual interventions designed to research ethics committees. reduce delay in the event of symptoms of acute on 24 September 2021 by guest. Protected copyright. myocardial infarction. Participants We included patients with confirmed acute myocardial infarction who had had at least one infarction Introduction previously and were able to communicate in English. People having an acute myocardial infarction need to We excluded patients who had experienced cardiac receive treatment as quickly as possible.1 Clinical trials arrest; patients who had severe heart disease or unsta- have shown reductions in morbidity and mortality in ble angina; and patients who had a note in their case patients treated with thrombolysis within one hour of record of cognitive deficits, were unable to make daily the onset of symptoms.2–4 Delay by patients in seeking decisions about their own care, or were in residential medical help, rather than the time from services being care. contacted to treatment being started in hospital, is the Nursing staff gave an information sheet describing most significant cause of delay in treatment.5 The aim the study to eligible patients two to five days after of this study was to explore patients’ thoughts and feel- admission to the coronary care unit. Semistructured ings at the onset of symptoms of heart attack, their per- interviews ranged from 30 minutes to over an hour, ceived reasons for deciding to seek medical help, and were conducted in a private room, and were the things that delayed them in making this decision. audiotaped. If a partner or relative had been present We did this study with a view to improving the during the decision making time they were interviewed outcomes of educational interventions to reduce delay. separately from the patient. In two cases in which the Many studies have investigated sociodemographic patient had been discharged, interviews took place in and clinical factors that predict delay, and some have the patient’s home. examined the appraisal and knowledge of symptoms Collection of data of acute myocardial infarction as a factor.6–11 This We asked participants to recount their experience of research has prompted interventions to improve the heart attack. We also asked them about differences BMJ VOLUME 324 27 APRIL 2002 bmj.com page1of5 Papers Appraisal of symptoms BMJ: first published as 10.1136/bmj.324.7344.1006 on 27 April 2002. Downloaded from Sociodemographic characteristics and prehospital symptoms and The appraisal of symptoms was a dynamic process behaviour of patients. Values are numbers (percentages) unless otherwise stated throughout the decision making time. Identifying and labelling symptoms often posed problems, and many Patients Characteristics (n=22) participants thought that their symptoms were not Male 20 (91) severe enough to be a heart attack. Instead of being Living with spouse 13 (59) “crushing chest pain,” many heart attacks were Alone at time of symptoms 11 (50) reported to have had a slow onset with only mild pain Predominant symptoms perceived as typical of acute myocardial 14 (64) and breathlessness. Many participants were confused infarction by the fact that their symptoms were similar to angina Predominant symptoms not perceived as typical of acute 8 (36) or indigestion; many had experienced prodromal myocardial infarction symptoms in the previous few days, which led to a nor- Up to one hour taken to seek care 11 (50) One to four hours taken to seek care 6 (27) malising or minimising of symptoms (box 2). The use Over four hours taken to seek care 5 (23) of glyceryl trinitrate spray may actually increase this Symptoms initially different from those of previous acute 20 (91) confusion, as it seems to “lessen the pain a bit” and myocardial infarction leave some people confused as to whether their pain Phoned ambulance directly 8 (36) represented angina or an acute myocardial infarction. Phoned general practitioner first 12 (55) Some people reported using glyceryl trinitrate many Went to hospital by car 1 (5) times more than recommended. Other 1 (5) Mean (SD) age years 66 (6.3) Perceived risk of acute myocardial infarction Median time (hours) from onset of symptoms to care being sought 1.5 Most patients who had always had a “healthy” lifestyle, or had changed their diet and smoking habit, and had had cardiac rehabilitation since their previous heart between this and previous acute myocardial infarc- attack, thought that this would protect them from tions, the severity of symptoms, and whether they had future cardiac problems (box 3). Some patients who perceived themselves to be at risk of an acute myocar- had had a coronary artery bypass graft or percutane- dial infarction. The data collected for each patient ous transluminal coronary angioplasty believed they included a transcript of the interview, the interviewer’s were no longer at risk of an acute myocardial notes, and, where applicable, transcripts of interviews infarction. Thus some patients were bewildered as to with family members who had been present at the time the cause of their symptoms. People had tried to put of the acute myocardial infarction. We analysed data their previous heart attack to the back of their mind from these relatives separately from the patients’ and get on with life. Many of those who did not accounts, but concurrently. We checked ambulance records for validation of reported times. After each interview we analysed the new data and http://www.bmj.com/ developed new codes and themes for use in Box 1: Factors influencing the time to action subsequent interviews. Saturation of data, whereby no • How symptoms are perceived and appraised new and relevant material arose, was achieved by the • Perceptions of risk of having an acute myocardial time 22 interviews had taken place. infarction • Previous experience of symptoms of acute Analysis of data myocardial infarction The interviews were transcribed verbatim, and the inter- • Individual psychological or emotional factors viewer verified the accuracy. We used constant compara- • Beliefs about the appropriate use of the NHS on 24 September 2021 by guest. Protected copyright. tive analysis.19 We coded data line by line, organised • The context in which symptoms were experienced similar concepts into categories, and constantly com- pared these with concepts from earlier data to produce themes. The interviewer carried out the analysis; another member of the research team separately analysed 20% Box 2: Appraisal of symptoms of transcripts to compare coding and emerging themes. We resolved discrepancies through discussion. We also Patient 14—male, aged 62; second myocardial made comparisons across participants to determine infarction. Previous infarction seven years previously. similarities and variations. Two previous “false alarms,” the second two weeks earlier. Decision time 13 hours. “Well, I’d gone down town for a walk and I’d come Results back up town in the afternoon about, I think about 2 o’clock or something like that, and I had a slight chest We collected and analysed data until no new themes pain. I didn’t think too much of it because actually I arose. The stage at which data saturation was reached had eaten some chips and I thought these chips had was decided by consensus within the research team. stuck in my chest, and you know, often when you get Twenty men and two women participated in the that sort of heartburny thing.
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