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Delayed Hospital Presentation in Patients Who Have Had Acute Myocardial Infarction

Jerry H. Gurwitz, MD; Thomas J. McLaughlin, ScD; Donald J. Willison, ScD; Edward Guadagnoli, PhD; Paul J. Hauptman, MD; Xiaoming Gao, MSc; and Stephen B. Soumerai, ScD
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From Harvard Medical School, Harvard Pilgrim Health Care, and Brigham and Women's Hospital, Boston, Massachusetts; University of Massachusetts Medical Center and Fallon Healthcare System, Worcester, Massachusetts; and McMaster University Health Sciences Centre, Hamilton, Ontario, Canada. Acknowledgments: The authors thank the hospitals participating in the Minnesota Clinical Comparison and Assessment Program; Catherine Borbas, PhD, Barbara McLaughlin, BSN, and Nora Morris, MA, of the Healthcare Education and Research Foundation, St. Paul, Minnesota; and Linda Casey, MS. Grant Support: In part by a grant from the Agency for Health Care Policy and Research (HSO 7357-03) and the Harvard Community Health Plan Foundation. At the time of this study, Dr. Gurwitz was the recipient of a Clinical Investigator Award (KO8 AG00510) from the National Institute on Aging and Dr. Willison was a doctoral fellow of the Health Research Development Program, Ontario Ministry of Health (no. 10023). Requests for Reprints: Jerry H. Gurwitz, MD, The Meyers Primary Care Institute, University of Massachusetts Medical Center and the Fallon Healthcare System, 100 Central Street, Worcester, MA 01608. Current Author Addresses: Dr. Gurwitz: The Meyers Primary Care Institute, University of Massachusetts Medical Center and the Fallon Healthcare System, 100 Central Street, Worcester, MA 01608.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;126(8):593-599. doi:10.7326/0003-4819-126-8-199704150-00001
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Background: In patients who have had acute myocardial infarction, the delay between the onset of symptoms and hospital presentation is a critical factor in determining the initial management strategy and outcomes of treatment.

Objective: To examine the determinants of delayed hospital presentation in patients who have had acute myocardial infarction.

Design: Retrospective chart review.

Setting: 37 hospitals in Minnesota.

Patients: 2409 persons hospitalized with acute myocardial infarction between October 1992 and July 1993.

Main Outcome Measure: Hospital presentation delayed more than 6 hours after the onset of symptoms of acute myocardial infarction.

Results: Information on length of delay was available for 2404 patients. Of these patients, 969 (40%) delayed presentation to the hospital for more than 6 hours after the onset of symptoms. Factors associated with prolonged delay included advanced age and female sex. The presence of chest discomfort and a history of mechanical revascularization significantly reduced the risk for prolonged delay. Risk for delay was greatest during the evening and early morning hours (6:00 p.m. to 6:00 a.m.) Patients with a history of hypertension were more likely to delay presentation. Only 42% of all patients hospitalized with acute myocardial infarction had used emergency medical transport services.

Conclusions: Patients who have had acute myocardial infarction often delay hospital presentation. Educational interventions that encourage the prompt use of emergency medical transport services and target specific patient populations, such as elderly persons, women, and persons with cardiac risk factors, may be most successful in reducing the length of delay and improving the outcomes of patients with acute myocardial infarction.





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