BMJ 1998;316:1060-1065 ( 4 April )

General Practice

Patients' action during their cardiac event: qualitative study exploring differences and modifiable factors

Editorial by Evans

Annmarie Ruston, research fellow,  Julie Clayton, research associate,  Michael Calnan, professor. 

Centre for Health Services Studies, George Allen Wing, University of Kent at Canterbury, Canterbury CT2 7NF

Correspondence to: Dr Ruston a.ruston{at}ukc.ac.uk

Objectives: To explore the circumstances and factors that explain variations in response to a cardiac event and to identify potentially modifiable factors.
Design: Qualitative analysis of semistructured, face to face interviews with patients admitted to two district hospitals for a cardiac event and with other people present at the time of the event. Patients were divided into three groups according to the length of delay between onset of symptoms and calling for medical help.
Subjects: 43 patients and 21 other people present at the time of the cardiac event. Patients were divided into three groups according to the length of time between onset of symptoms and seeking medical help: non-delayers (<4 h; n=21), delayers (4-12  h; n=12), and extended delayers (>12 h; n=10).
Main outcome measures: Decision making process, strategies for dealing with symptoms, and perception of risk and of heart attacks before the event according to delay in seeking help.
Results: The illness and help seeking behaviour of informants had several components, including warning, interpretation, preliminary action, re-evaluation, and final action stages. The length of each stage was variable and depended on the extent to which informants mobilised and integrated resources into a strategy to bring their symptoms under control. There were obvious differences in informants' knowledge of the symptoms that they associated with a heart attack before the event. Non-delayers described a wider range of symptoms before their heart attack and twice as many (13) considered themselves to be potentially at risk of a heart attack compared with the other two groups. For most informants the heart attack differed considerably from their concept of a heart attack.
Conclusion: The most critical factor influencing the time between onset of symptoms and calling for professional medical help is that patients and others recognise their symptoms as cardiac in origin. This study suggests that various points of intervention in the decision making process could assist symptom recognition and therefore faster access to effective treatment.

Key messages

  • Research using methods that can explain variations in response to cardiac events has been neglected

  • Informants in this study thought of heart attacks as sudden dramatic events in which people collapse and probably die, rather than as the evolving event that they experienced

  • Those who sought medical help within 4 hours were more likely to see themselves as potentially at risk, knew a wider range of symptoms of a heart attack, and were much less likely to use drugs to treat their symptoms compared with those who waited longer

  • Intervention at various points in the decision making process could help recognition of symptoms and speed access to effective treatment


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