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The initial phase of an acute coronary syndrome: symptoms, patients' response to symptoms and opportunity to reduce time to seek care and to increase ambulance use
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis aims to describe the initial phase of an acute coronary syndrome (ACS) in overall terms from a national perspective and to evaluate the impact of an information campaign designed to inform the public about how to act when suspecting an ACS. A total of 1939 patients at 11 hospitals in Swedenwith diagnosed ACS and symptom onset outside hospital completed a questionnaire(I-IV).In Study V, a questionnaire was completed by 116 patients withACS before the campaign and 122 after it. Register data were followed every year to evaluate ambulance use and emergency department (ED) visits.

With regard to symptoms, patients with ST-elevation ACS (STE-ACS) more frequently had associated symptoms and pain with an abrupt onset reaching maximum intensity within minutes. However, fewer than half the patients with STE-ACS had this type of symptom onset. There were more similarities than differences between genders and differences between age groups were minor (I).

Three-quarters of the patients interpreted the symptoms as cardiac in origin. The majority contacted a family member after symptom onset, whereas few called directly for an ambulance. Approaching someone after symptom onset and the belief that the symptoms were cardiac in origin were factors associated with a shorter pre-hospital delay (II).

Half the patients went to hospital by ambulance. Independent factors for ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when experiencing chest pain, severe symptoms, abrupt onset of pain, STE-ACS, increasing age and distance to hospital of > 5 km. Reasons for not calling for an ambulance were thinking self-transport would be faster or not being ill enough (III). Pain with abrupt onset, STE-ACS, symptoms such as vertigo or near syncope, experiencing the pain as frightening, interpreting the pain as cardiac in origin and knowledge were major factors associated with a short delay between symptom onset and decision to seek medical care, patient decision time (IV).

The information campaign did not result in a reduction in patient decision time, but it appeared to increase ambulance use and the number of patients seeking the ED for acute chest pain (V).

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2012. , 75 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 67
Keyword [en]
Acute coronary syndrome, pre-hospital delay, ambulance use, symptoms, decision making
National Category
Medical and Health Sciences Cardiac and Cardiovascular Systems
Research subject
Medicine; Cardiology
Identifiers
URN: urn:nbn:se:oru:diva-21672ISBN: 978-91-7668-859-5 (print)OAI: oai:DiVA.org:oru-21672DiVA: diva2:503692
Public defence
2012-03-16, Wilandersalen, Universitetssjukhuset, Örebro, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2012-02-16 Created: 2012-02-16 Last updated: 2012-04-25Bibliographically approved
List of papers
1. Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes
Open this publication in new window or tab >>Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes
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2005 (English)In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 150, no 2, 234-242 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Various efforts to reduce patient delay in acute coronary syndrome (ACS) have had limited success. One reason might be a misinterpretation of the symptoms of ACS. The aim of this study was therefore to explore the characteristics and severity of symptoms among patients with an ACS in overall terms and in relation to the type of ACS, sex, age, and diabetes.

METHODS:

A total of 1939 patients at 11 hospitals in Sweden answered a questionnaire containing questions relating to the localization and intensity of symptoms, the presence of associated symptoms, the characteristics and experience of pain/symptoms, and the type of symptom onset.

RESULTS:

Patients with ST elevation differed from those without by more frequently having associated symptoms. They had higher pain/discomfort intensity and more frequently had pain with abrupt onset reaching maximum intensity within minutes. However, this type of symptom onset was only seen in less than half the patients with ST elevation and only 1 in 5 fulfilled all the criteria usually associated with a severe heart attack. Women differed from men in a few respects. They more frequently reported pain/discomfort in the neck or jaw and back, vomiting, and scored their pain/discomfort slightly higher than men. Differences between age groups were minor and there was no difference between patients with and without diabetes.

CONCLUSIONS:

The most striking finding was the low proportion of patients with the type of symptoms that are commonly associated with ACS. This is important for the planning of educational campaigns/programs to reduce patient delay.

National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-4066 (URN)10.1016/j.ahj.2004.08.035 (DOI)
Available from: 2008-12-03 Created: 2008-12-03 Last updated: 2012-02-20Bibliographically approved
2. Thoughts, actions, and factors associated with prehospital delay in patients with acute coronary syndrome
Open this publication in new window or tab >>Thoughts, actions, and factors associated with prehospital delay in patients with acute coronary syndrome
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2007 (English)In: Heart & Lung, ISSN 0147-9563, E-ISSN 1527-3288, Vol. 36, no 6, 398-409 p.Article in journal (Refereed) Published
Abstract [en]

Objective The objective was to study patients’ interpretations, thoughts, and actions after symptom onset in acute coronary syndrome (ACS) in total and in relation to gender, age, history of coronary artery disease, type of syndrome, and residential area and its influence on prehospital delay. Setting We performed a national survey comprising intensive cardiac care units at 11 hospitals in Sweden. Method A total of 1939 patients with diagnosed ACS and symptom onset outside hospital completed a questionnaire containing standardized questions within 3 days after admission. Results Three-quarters of the patients interpreted their symptoms as cardiac in origin, and the most common reason was that they knew someone who had had an acute myocardial infarction. The majority contacted a family member, whereas only 3% directly called for an ambulance. Interpreting the symptoms as cardiac in origin and severe pain were major reasons for deciding to seek medical care. Approaching someone after symptom onset and the belief that the symptoms were cardiac in origin were factors associated with a shorter prehospital delay, whereas taking medication to relieve pain resulted in the opposite. The reaction pattern was influenced by gender, age, a history of coronary artery disease, and the type of ACS, but to a lesser extent by residential area. Conclusions Interpreting symptoms as cardiac in origin and approaching someone after symptom onset were major reasons for a shorter prehospital delay in ACS.

Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2007
National Category
Medical and Health Sciences Clinical Medicine Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:oru:diva-3375 (URN)10.1016/j.hrtlng.2007.02.001 (DOI)18005801 (PubMedID)
Available from: 2008-12-03 Created: 2008-12-03 Last updated: 2012-02-20Bibliographically approved
3. Factors that influence the use of ambulance in acute coronary syndrome
Open this publication in new window or tab >>Factors that influence the use of ambulance in acute coronary syndrome
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2008 (English)In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 156, no 1, 170-176 p.Article in journal (Refereed) Published
Abstract [en]

Background

National guidelines recommend activation of the emergency medical service by patients who have symptoms of acute coronary syndrome (ACS). In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service. The aim of this study was to define factors influencing the use of ambulance in ACS.

Methods

The method used in this study was a national survey comprising intensive cardiac care units at 11 hospitals in Sweden; 1,939 patients with diagnosed ACS and symptom onset outside the hospital completed a questionnaire a few days after admission.

Results

Half of the patients went to the hospital by ambulance. Factors associated with ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when having chest pain (odds ratio [OR] 3.61, 95% CI 2.43-5.45), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08, 1.62-2.69), nausea or cold sweat (OR 2.02, 1.54-2.65), vertigo or near syncope (OR 1.63, 1.21-2.20), ST-elevation ACS (OR 1.58, 1.21-2.06), increasing age (per year) (OR 1.03, 1.02-1.04), previous history of heart failure (OR 2.48, 1.47-4.26), and distance to the hospital of >5 km (OR 2.0, 1.55-2.59). Those who did not call for an ambulance thought self-transport would be faster or did not believe they were sick enough.

Conclusions

Symptoms, patient characteristics, ACS characteristics, and perceptions and knowledge were all associated with ambulance use in ACS. The fact that knowledge increases ambulance use and the need for behavioral change pose a challenge for health-care professionals.

Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2008
National Category
Medical and Health Sciences Cardiac and Cardiovascular Systems Anesthesiology and Intensive Care
Research subject
Cardiology
Identifiers
urn:nbn:se:oru:diva-3378 (URN)10.1016/j.ahj.2008.01.020 (DOI)18585513 (PubMedID)
Available from: 2008-12-03 Created: 2008-12-03 Last updated: 2012-02-20Bibliographically approved
4. Factors of importance for patients' decision time in acute coronary syndrome
Open this publication in new window or tab >>Factors of importance for patients' decision time in acute coronary syndrome
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2010 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 141, no 3, 236-242 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Not much is known about the patients' decision time in acute coronary syndrome (ACS). The aim of the survey was therefore to describe patients' decision time and factors associated with this parameter in ACS. METHODS: We conducted a national survey comprising intensive cardiac care units at 11 hospitals in Sweden in which patients with ACS diagnosis and symptoms onset outside hospital participated. Main outcome measures were patients' decision time and factors associated with patients' decision time. RESULTS: In all, 1939 patients took part in the survey. The major factors associated with a shorter patient decision time were: 1) ST-elevation ACS, 2) associated symptoms such as vertigo or near syncope, 3) interpreting the symptoms as cardiac in origin, 4) pain appearing suddenly and reaching a maximum within minutes, 5) having knowledge of the importance of quickly seeking medical care and 6) experiencing the symptoms as frightening. The following aspects of the disease were associated with a longer decision time: 1) pain was localised in the back and 2) symptom onset at home when alone. CONCLUSION: A number of factors, including the type of ACS, the type and localisation of symptoms, the place where symptoms occurred, patients' interpretation of symptoms and knowledge were all associated with patients' decision time in connection with ACS.

Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2010
National Category
Medical and Health Sciences Cardiac and Cardiovascular Systems
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-11790 (URN)10.1016/j.ijcard.2008.11.176 (DOI)19136167 (PubMedID)
Available from: 2010-09-08 Created: 2010-09-08 Last updated: 2012-02-20Bibliographically approved
5. Impact of an information campaign on delays and ambulance use in acute coronary syndrome
Open this publication in new window or tab >>Impact of an information campaign on delays and ambulance use in acute coronary syndrome
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(English)Manuscript (preprint) (Other academic)
National Category
Cardiac and Cardiovascular Systems
Research subject
Medicine; Cardiology
Identifiers
urn:nbn:se:oru:diva-22240 (URN)
Available from: 2012-03-23 Created: 2012-03-23 Last updated: 2016-08-10Bibliographically approved

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