Selected Topics: Critical Care
Slow-onset and Fast-onset Symptom Presentations In Acute Coronary Syndrome (ACS): New Perspectives on Prehospital Delay in Patients with ACS

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Abstract

Background

Patient decision delay is the main reason why many patients fail to receive timely medical intervention for symptoms of acute coronary syndrome (ACS).

Study Objectives

This study examines the validity of slow-onset and fast-onset ACS presentations and their influence on ACS prehospital delay times. A fast-onset ACS presentation is characterized by sudden, continuous, and severe chest pain, and slow-onset ACS pertains to all other ACS presentations.

Methods

Baseline data pertaining to medical profiles, prehospital delay times, and ACS symptoms were recorded for all ACS patients who participated in a large multisite randomized control trial (RCT) in Dublin, Ireland. Patients were interviewed 2–4 days after their ACS event, and data were gathered using the ACS Response to Symptom Index.

Results

Only baseline data from the RCT, N = 893 patients, were analyzed. A total of 65% (n = 577) of patients experienced slow-onset ACS presentation, whereas 35% (n = 316) experienced fast-onset ACS. Patients who experienced slow-onset ACS were significantly more likely to have longer prehospital delays than patients with fast-onset ACS (3.5 h vs. 2.0 h, respectively, t = −5.63, df 890, p < 0.001). A multivariate analysis of delay revealed that, in the presence of other known delay factors, the only independent predictors of delay were slow-onset and fast-onset ACS (β = −.096, p < 0.002) and other factors associated with patient behavior.

Conclusion

Slow-onset ACS and fast-onset ACS presentations are associated with distinct behavioral patterns that significantly influence prehospital time frames. As such, slow-onset ACS and fast-onset ACS are legitimate ACS presentation phenomena that should be seriously considered when examining the factors associated with prehospital delay.

Introduction

Accurate and rapid interpretation of acute coronary syndrome (ACS) symptoms is a challenge for patients and clinicians alike, yet crucial in optimizing the survival opportunities for both men and women presenting with this condition. However, patients often have difficulties attributing symptoms to a cardiac cause, especially if their presenting symptoms do not meet their expectations of what an ACS event entails 1, 2, 3. These interpretation difficulties lead to patient decision delay, a major contributing factor to the lengthy prehospital delays associated with ACS and a main reason why many patients fail to receive the full benefits of life-saving reperfusion therapies, if they receive them at all 4, 5, 6, 7.

Unfortunately, prehospital delays have remained unchanged for the last 20 years, ranging from 2–6 h, and efforts to reduce these time frames through public health campaigns or educational interventions have met with limited success 8, 9. Recent critiques of public health education suggest that people are not receiving sufficient information to enable them to make quick and appropriate decisions in the presence of ACS. In particular, patients are not receiving enough information pertaining to illness presentation and the myriad of symptoms that may be indicative of an acute cardiac episode 4, 10.

In a recent qualitative study examining the illness presentation and help-seeking behavior of patients with ACS (N = 42), O'Donnell and Moser describe two distinct ACS presentation phenomena: slow-onset and fast-onset ACS, each of which emerged after in-depth analysis of patient presentation descriptors (11). Although the investigators initially sought to determine how patient presentations might differ between genders, it became clear that there were no gender differences; rather, there were differences in the sample based on symptom onset. Slow-onset ACS was experienced by 64% (n = 27) of their study sample, in which patients described the gradual onset of mild and intermittent typical or atypical symptoms. Fast-onset ACS was experienced by just 36% (n = 15) of the study sample, who described a presentation that often involved a combination of typical and atypical symptoms but always included the sudden onset of severe and continuous chest pain (Table 1).

O'Donnell and Moser suggest that all 42 patients expected their symptoms to be similar to fast-onset ACS presentation (11). The incongruence between expected and experienced symptoms for participants with slow-onset ACS (64%, n = 27) led to protracted delays in seeking help. Conversely, those experiencing fast-onset ACS (36%, n = 15) quickly recognized their symptoms as those associated with a heart attack, and sought help quickly.

These two ACS presentation phenomena provide a new approach to characterizing ACS symptoms and also a unique perspective on patient behavior that may be useful in the targeting of patient decision delay. Although sudden onset of severe, continuous chest pain has been previously seen to be associated with shorter delay times, the conceptualization suggested in this article has not been described or tested elsewhere. Before this information can be integrated into public health messages, it is important to examine the validity of slow-onset and fast-onset ACS presentations in a larger cohort of patients with ACS.

The aim of this study was to establish the concept of slow-onset and fast-onset ACS presentations as valid phenomena for studying prehospital delay time in ACS presentation, in a well-defined cohort of ACS patients.

The objectives of this study were:

  • To ascertain the prevalence of slow-onset and fast-onset ACS presentations in patients who have experienced an ACS event

  • To examine the sociodemographic, clinical, situational, and behavioral characteristics of patients who experience these two phenomena

  • To examine the influence of slow-onset and fast-onset ACS presentations on prehospital delay times.

Section snippets

Methods

Medical profiles and ACS symptoms were recorded for all ACS patients who participated in a large randomized control trial in Dublin, Ireland. Five major academic teaching hospitals were involved in this study, which enrolled patients from October 2007 through October 2009. Patients were deemed eligible if they received a diagnosis of ACS after admission through the Emergency Department (ED) of one of the participating hospitals. Patients were excluded if they could not speak or read English,

Results

Of the 893 patients enrolled in year 2 of the study, 65% (n = 577) presented with slow-onset ACS and 35% (n = 316) presented with fast-onset ACS. There were no significant differences between patients presenting with slow-onset ACS and fast-onset ACS in relation to gender, age, marital status, or education. With respect to differences in clinical histories, patients with slow-onset ACS were found to be significantly more likely to have diabetes than those with fast-onset ACS, where patients

Discussion

Fast-onset ACS, considered the archetypal presentation of ACS, was experienced by just 35% (n = 316) of patients in this study, and slow-onset ACS was experienced by 65% (n = 577) of patients. Moreover, only 49% (n = 117) of patients with STEMI experienced fast-onset ACS, and the remaining 51% (n = 122) experienced slow-onset ACS. As patients with STEMI have the most to gain from time-dependent reperfusion therapies, this finding is of particular clinical importance. That 51% of STEMI patients

Conclusion

King and Maguire suggest that the failure of previous educational interventions to reduce patient decision delay has been due to an inability to effectively frame the ACS patient symptom experience so that decision time is reduced (6). Slow-onset ACS and fast-onset ACS provide a new way of framing this experience in an easy and memorable format that can be easily incorporated into health education. We strongly recommend that future educational campaigns should, as well as highlighting

Acknowledgments

The authors wish to thank the patients who gave of their time and agreed to be interviewed for this study. This study is funded by the Health Research Board, Dublin, whose support is greatly appreciated.

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