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PAIN AND ARRI VAL TO THE
CORONARY CARE UNIT AMONG
MINORITY AND DISADVANTAGED
PATIENTS
Jalal K. Ghali, MD, Richard S. Cooper, MD, Imad Kowatly, MD, and Youlian Liao, MD
Chicago and Maywood, Illinois
Prehospital delay is an important cause of
out-of-hospital coronary mortality. To determine the effects of decision time delay in a
patient population comprised mainly of blacks
and the underprivileged, 74 consecutive patients with acute chest pain necessitating
admission to the coronary care unit in a large
urban hospital were studied. Delay time from
onset of chest pain to the decision to seek
medical care was markedly prolonged in patients with myocardial infarction (n = 24; mean
time: 11.3 ±18 hours) as well as in patients with
chest pain who did not develop myocardial
infarction (n = 50; mean time: 20.5 ± 26 hours).
In addition, transfer time from the emergency
room to the coronary care unit was likewise
unduly long (mean time: 4 ±3.8 and 4.1 ±6
hours for patients with and without myocardial
infarction, respectively). This study documents
a significant delay in the decision time among
patients with low socioeconomic status,
mostly inner-city blacks, and in the transfer
time from emergency room to the critical care
unit in a large public hospital. These findings
From the Section of Clinical Epidemiology, Division of Cardiology, Cook County Hospital, Chicago, and the Department of
Preventive Medicine and Epidemiology, Loyola University
Stritch School of Medicine, Maywood, Illinois. Requests for
reprints should be addressed to Dr Jalal K. Ghali, Dept of
Preventive Medicine and Epidemiology, Loyola University
Stritch School of Medicine, 2160 S First Ave, Maywood, IL
60153.
180
must be taken into consideration when planning strategies to improve the health-care
delivery system to blacks and the underprivileged and further lend support to the practice of
initiating thrombolytic therapy in the emergency room. (J Nat! Med Assoc. 1993;85:180184.)
Key words * chest pain * prehospital delay * blacks
In the current era of thrombolytic therapy, the speedy
arrival of patients complaining of chest pain to acute
health-care facilities is of critical importance.",2 Numerous studies''19 have addressed the issue of prehospital
delay, and several have concluded that the time delay
between the onset of chest pain and the decision to seek
medical care is largely the cause of late arrival to
hospitals. 1-13 However, these studies have examined the
response of patients from populations composed mainly
or exclusively of nonblacks.
Our previous study reported'4 a significant time
delay between the onset of chest pain and the arrival to
the emergency room among blacks with acute myocardial infarction. The purpose of the present study was to
investigate the separate components of prehospital
delay in a consecutive group of patients complaining of
chest pain who were admitted to the coronary care unit
in a large city hospital serving blacks and other
underprivileged groups.
METHODS
Patients admitted to the coronary care unit of Cook
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 85, NO. 3
ONSET OF CHEST PAIN
County Hospital from December 1988 through April
1989 were included in the study population if they met
the following criteria: acute chest pain thought to be
ischemic in origin, the occurrence of chest pain at a
nonhealth-care facility, or the ability of the patient or
his or her relative or friend to recall the time of onset of
chest pain. All patients transferred from other hospitals
were excluded, as were patients providing implausible
time estimates (eg, >1 week).
A total of 74 patients were included in the study. A
questionnaire was administered to all patients and in
some instances, to a relative or friend. Patients were
interviewed by one of the investigators (IK) in the
coronary care unit as early as feasible in the hospital
course, within 24 hours of admission to the coronary
unit. Delay times were defined as follows:
* patient decision delay-time from onset of symptoms to a definite decision to seek medical help,
* transportation and unaccounted delay-time from
decision to seek medical help to the arrival at the
emergency room,
* delay from onset of chest pain to arrival to the
emergency room-the sum of patient decision delay
and transportation and unaccounted delay,
* emergency room delay-time from arrival in the emergency room to arrival in the coronary care unit, and
* total delay-time from onset of chest pain to arrival
in the coronary care unit.
The diagnosis of myocardial infarction was made
when a clinical history of chest pain typical of acute
myocardial infarction or the development of new Q
waves or evolving ST-T changes was accompanied by
an elevation of the CPK-MB fraction with an appropriate temporal pattern.
Because various delay times measured were not
normally distributed, both mean and median values are
presented. Student's t test was used to examine
differences in the group means. Analyses were performed separately in the total sample and in blacks
alone (who constituted 81% of the cohort). No
important differences were demonstrated, and therefore
the findings obtained in all patients are presented.
RESULTS
Tables 1 and 2 compare patient characteristics and
length of decision time between patients who had
myocardial infarction and those who had chest pain but
did not develop myocardial infarction. Patients with
myocardial infarction were older and a higher percentage were married (P<.05). Other differences, which did
not reach statistical significance, included a higher
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 85, NO. 3
TABLE 1. PATIENT CHARACTERISTICS
Myocardial Chest
Age (years)
Males
Blacks
Married
Education >9 years
Employed
Prior myocardial infarction
Diabetes
Hypertension
Family history of heart
disease
lnfarction*
Paint
63.5±14
70.8%
83.3%
73.9%
55.8±11
47.1%
26.1%
36.4%
33.3%
87.5%
41.7%
52%
80%
46%
66.7%
33.3%
42%
34%
76%
56.3%
*n =24.
tn =50.
number of females, less than 9 years of education, and
a family history of heart disease in patients with chest
pain but no myocardial infarction. The decision time as
well as the time delay from the onset of chest pain to
arrival at the emergency room was prolonged in the
group with myocardial infarction (median time: 3 and
4.6 hours, respectively) and in those without myocardial infarction (median time: 9.5 and 10.4 hours,
respectively).
The influence of various factors on the patient's
decision time were examined. The variables included
the following: age, sex, education, marital status,
employment, family history of heart disease, prior
myocardial infarction, diabetes mellitus, and having
been exposed to a cardiac procedure (including
echocardiogram, exercise test, and cardiac catheterization). In the group with no myocardial infarction, a
history of prior myocardial infarction was significantly
related to shortened decision time (mean time:
12.5 ± 16.5 hours versus 26.3 ± 30.6 hours; median
time: 5.5 hours versus 12 hours). Similar findings
emerged in patients exposed to cardiac procedures
compared with those who did not have prior exposure to
cardiac procedures (mean time: 12.1 ± 16 hours versus
33.4 ± 33.4 hours; median time: 5.8 hours versus 23
hours). None of the above mentioned variables were
found to influence decision time in patients with acute
myocardial infarction, although the sample size was
small. It should be noted that in the presence of small
sample size, the differences of potentially influential
variables may not reach statistical significance.
The transfer time from the emergency room to the
critical care unit was surprisingly longer in patients with
myocardial infarction (median time: 3 hours) than in
181
ONSET OF CHEST PAIN
TABLE 2. LENGTH OF TIME IN HOURS BETWEEN ONSET OF SYMPTOMS AND DECISION
TO SEEK MEDICAL ATTENTION
Chest Pain
Myocardial Infarction
Median
Mean
Mean
Median
9.5
20.5 ± 26.3
3
11.3±18
Total decision time
21.4 ± 26.3
10.4
4.6
12.3±18
Time from chest pain onset to arrival at
emergency room
2
4.1 ±6
3
4±3.8
Time from arrival at emergency room to
admission in critical care unit
TABLE 3. LENGTH OF PREHOSPITAL DELAY IN PREVIOUS STUDIES
Median Mean
%
No. of
(Min)
Length of Delay
Year Patients Black Condition (Min)
Authors
180 Within 14 hrs of admission
Ml
1968-69 134
Moss and Goldstein3
760
Ml
48
1970
Tjoe and Luria5
558
27
CP
-1 hr: 40%; >3 hrs: 69%
Ml, CP
1971
137
Erhardt et al8
-1 hr: 70%; -4 hrs: 90%
Ml
Simon et al6
1972
160
Ml
269
60
Gilchrist7
1973
50
Ml
73
60
1974
Gillum et a118
Ml
312 Ml developed >6 hrs of
30
60
Shroeder et al9
1975
admission
247 Q wave Ml
Ml
59
49
447 Non-Q wave Ml
Ml
260
12
240 Noncardiac pain
CP
93
18
328 Ml ruled out
CP
90
102
159
Ml
15
1978-80 110
Pressely et al10
Ml
60
1987
37
Leitch et a11
60
CP
63
Ml
83
180
678 -1 hr: 20%; -4 hrs: 63%
Current study
1988-89 24
1230 <1 hr: 10%; -4 hrs: 32%
CP
50
80
570
Abbreviations: Ml= myocardial infarction and CP = chest pain without myocardial infarction.
patients without myocardial infarction (median time: 2
hours). It is possible that the transfer was delayed
because of a chronic shortage of acute care beds. On the
other hand, patients who presented with chest pain
without evidence of acute myocardial infarction were
transferred to the step-down section of the critical care
unit without the same delay encountered in securing
beds. Moreover, none of the patients in this study
received thrombolytic therapy prior to their arrival in
the critical care unit.
DISCUSSION
The findings of this study confirm the significant time
delay encountered in our study population in the decision
to seek medical attention after experiencing chest pain.
Although several studies have documented that decision
time accounts for most of prehospital delay,141 its
magnitude in our patients is alarming. The median
182
decision time in this study is at least three times longer
than the values reported in previous series (Table 3).
It is tempting to implicate the lower socioeconomic
status of our patients to explain the prolonged delay
observed in this study.'5'19 However, previous studies
that examined this question did not find this variable to
be a factor that contributed to excessive delay. In the
study by Hackett and Cassem,4 there was a trend for a
longer decision time in the low socioeconomic group
(the mean delay was 5.4 hours longer than those with a
higher socioeconomic status). Earlier studies may not
be applicable at the present time, however. With the
significant expansion of public awareness of coronary
disease, the implications of warning signs like chest
pain could have impacted more on persons of higher
socioeconomic status. Thus, the question of the impact
of the socioeconomic status on decision time and
prehospital delay is still open.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 85, NO. 3
ONSET OF CHEST PAIN
The positive influence of prior myocardial infarction
on subsequent decision time is at variance with
previous reports.3-9'18 A possible explanation is that the
previous studies were undertaken in the late 1960s or
early 1970s, and it may well be that in the ensuing
decade, patients who suffered myocardial infarction
received more education about the importance of early
medical attention. Similarly, the finding that prior
exposure to cardiac procedures (including echocardiogram, treadmill, or cardiac catheterization) was associated with a significantly shorter decision time is
interesting. This exposure may have resulted in these
patients being more informed about the urgency of
obtaining immediate care for potential heart attack
symptoms than the general population; however, these
patients may have already been more health conscious,
which may have prompted the performance of the
cardiac procedures. The latter explanation seems more,
likely and is supported by a 2:1 ratio of prior cardiac
procedures in patients with chest pain and no myocardial infarction compared with the group with myocardial infarction.
We noted a shortening in the length of delay from the
onset of chest pain to the patient's arrival at the
emergency room (median time: 4.6 hours) compared
with our previous study (median time: 6.4 hours).
During a similar time frame (1983 to 1988), Maynard et
a120 reported a significant increase in the proportion of
patients arriving within 1 hour of symptom onset in the
Western Washington Thrombolytic Therapy Trials.
They proposed that a concerted media campaign
directed by the American Heart Association of Washington was the most likely explanation. No organized
public education campaign,21'22 however, was instituted
in the Chicago area during that period, and such an
effort has not always proven to be successful.23
Moreover, long-term effects following such a campaign
have never been evaluated. Thus, although it is possible
that there was an increased awareness of the general
public of the need for earlier response to symptoms
suggestive of heart attack, there is no evidence to
substantiate this hypothesis.
If reducing the delay in response to the symptoms of
acute health crisis such as chest pain calls less for a
knowledge-based strategy and more for a behaviorally
and affective-oriented one, then a better understanding
of the processes of symptom interpretation, denial, and
coping strategies is in order. In addition, the social
situations within which individuals evaluate and construct such strategies for coping with acute symptoms
such as chest pain should be explored further.' 524
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 85, NO. 3
Anothe.r finding from this study that deserves a
comment is the significant delay encountered in the
transfer of patients from the emergency room to the
critical care unit (median time: 3 and 2 hours for the
groups with and without acute myocardial infarction,
respectively). Such a delay gives unequivocal support
to the increasing practice of initiating thrombolytic
therapy in the emergency department.25'26
CONCLUSION
This study documents a significant delay in the
decision time among patients with low socioeconomic
status, mostly inner-city blacks. This finding must be
taken into consideration when planning ways to
improve the health-care delivery system to blacks and
the underprivileged.
Acknowledgment
The authors thank Kathleen Regalado for her secretarial
assistance.
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ONSET OF CHEST PAIN
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Raabe DE, et al. Implications for acute intervention related to
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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 85, NO. 3