Introduction

A critical factor in preventing premature death or disability from a heart attack is ensuring that patients receive effective treatment to reduce damage to the heart muscle. Thrombolysis can reduce the size of the clot and hence the amount of muscle damage, but it must be given early for maximal benefit. ^{1 2} Thus patients or their associates need to recognise the symptoms and call for appropriate help immediately. We sought to explain variation in response to a cardiac event and to identify modifiable factors.

Subjects and methods

The study was conducted in two district general hospitals with coronary care units in one health authority. The subjects of the study were all admitted patients who had survived a cardiac event, which for this study was defined as a suspected or confirmed acute myocardial infarction. One patient who was too ill to be interviewed on the fifth day after the event was excluded. An integral part of the research design was interviewing, whenever possible, anyone else present at the time of the cardiac event. Subjects were recruited over five separate weeks in summer and winter months to ensure the required diversity of experience of a cardiac event and access to medical services. The original study design was intended to include associates of patients who died before arrival at hospital, but we could not obtain full ethical clearance for this.

Before the main study a pilot study was undertaken in one of the hospitals. During one week eight patients surviving a cardiac event and their associates (four relatives) were interviewed. They were not included in the main study.

Forty three patients were identified from coronary care units, accident and emergency departments, and medical and surgical wards, to ensure total coverage. Twenty one relatives and bystanders were also recruited.

Interviews
Patients were approached three to four days after admission to hospital and interviewed on the fifth day. The interviews lasted between 45 and 60 minutes. Patients were interviewed alone in the morning, and the other people were interviewed in the afternoon of the same day before they visited the patient. The emphasis in the interviews was on enabling the informants to give spontaneous accounts of their decision making at the time of the cardiac event. However, after thorough piloting we decided to add some direct questions about informants' beliefs and knowledge of cardiac events. The themes explored in the interviews covered what experiences and actions led up to the cardiac event; when informants thought that the cardiac event had begun, what they thought the problem was and why it had occurred; whom they talked to and the effect of this interaction; when the decision to call for medical help was made and by whom; and who was called. The more direct areas of questioning were informants' conception of risk factors; which groups of people they associated with heart attacks; their knowledge of symptoms before the event; their concept of a heart attack; their knowledge of thrombolytic treatment; their family history; and personal details, including risk factors.

Data analysis
The interviews were tape recorded and transcribed verbatim. Before analysis informants were divided into three groups according to the length of time between the onset of symptoms and seeking medical help. The delays were less than 4 hours (non-delayers), between 4 and 12 hours (delayers), and more than 12 hours (extended delayers). The division was prompted by current evidence, which suggests that the earlier thrombolytic treatment is given the greater the reduction in deaths¹ and that for patients presenting after 12 hours benefit is limited.² Of the patients interviewed, 21 were non-delayers, 12 delayers, and 10 extended delayers. The division of informants into these groups provided a basis for illustrating the differences between those who seek help quickly and those who do not.

Results

Forty patients were diagnosed as having a confirmed acute myocardial infarction, and 9 of them had had a previous infarction (5 were non-delayers (24%), 2 delayers (17%), and 2 extended delayers (20%)) (table 1). Three quarters of the non-delayers were men (16/21) compared with 58% (7/12) of the delayers and 50% (5/10) of the extended delayers. A greater proportion of non-delayers were under 65 years of age compared with the other two groups (67% (14/21) v 58% (7/12) and 40% (4/10) respectively). A greater proportion of non-delayers also had manual occupations (62% (13/21) v 58% (7/12) and 50% (5/10) respectively).

Decision making process
The illness and help seeking behaviour of informants had several stages, including warning, interpretation, preliminary action, re-evaluation, and final action. 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. The time between onset of symptoms and calling for medical help was directly affected by the number and quality of the resources used in the individual strategy.

Strategies for dealing with symptoms
Although most informants assigned an inappropriate diagnostic label to their symptoms at this stage, the strategy adopted for dealing with the symptoms delineated the three groups.

Non-delayers
The non-delayers generally entered a period of isolation and self evaluation, they did not consult with others, and only a few took any form of drug treatment. Most engaged in some form of diversionfor example, drinking cups of tea or moving aboutwhile they evaluated the situation (box). In doing this, their symptoms were not masked and therefore escalated to a point where re-evaluation revealed the serious nature of the event. Non-delayers used their experience, medical knowledge, and intuition to reinterpret their symptoms (box).

All of the patients in this group reached a point where they thought they were experiencing either a heart attack or something associated with the heart.

Delayers
The delayers used various medical and non-medical resources to try to bring their symptoms under control. They also consulted lay people and used the information in various ways to try to rationalise the experience of illness. This often resulted in delay as the experience of others had to be compared and discounted. Contextual and personal information was used to reinterpret the situation (box, above).

This process of treatment and continual reassurance and readjustment to the symptoms delayed the realisation that the symptoms were serious enough to require urgent medical intervention. None of the patients in this group considered that they were having a heart attack but eventually came to realise that they were experiencing something serious.

Extended delayers
The extended delayers tried treatments and movement as well as seeking both lay and medical consultation in their attempts to deal with their experience. The greater the number of interventions used, whether in the form of drugs or consultation, the greater the delay. Notable in this group was the influence of contact with the medical profession. Elements of diagnosis by health professionals that discounted patients' risk of having a heart attack and attributed symptoms to other causes both before and during the cardiac event considerably influenced decision making and added to the delay (box, next page).

Patients in this group failed to obtain effective help in managing their symptoms and were eventually admitted to hospital because they could no longer cope.

Perception of risk and of heart attacks before the event
Patients' previous perceptions of their own risk varied among the three groups, with more than twice as many of the non-delayers considering themselves to be potentially at risk of a cardiac event compared with the other two groups. In describing a typical potential victim of a heart attack, informants described a stereotype unlike themselves (box, above right).

Discussion

Studies of patient behaviour and decision making at the time of a heart attack have identified socioeconomic class, education, age, sex, marital status, and race as factors implicated in delay. ^{4 5} Other variables identified include clinical factors such as having had a heart attack before and the intensity of symptoms. ^{6 7} Our study used a qualitative approach to explain delay rather than produce statistically representative factors associated with delay. Socioeconomic group and previous occurrence of a heart attack were similar in the three groups, but the age and sex distributions varied, with a greater proportion of men under 65 being non-delayers.

The most critical factor influencing the time taken between onset of symptoms and seeking medical help is that patients and others recognise the symptoms as cardiac in origin. Our results show that intervention could take place at various points in the process to help symptom recognition and speed access to effective treatment. Non-delayers were more likely to see themselves as potentially at risk, were able to describe a wider range of symptoms of a heart attack, and were much less likely to treat their symptoms.

The main focus of information campaigns to date has been to recommend that people experiencing central chest pain (some list additional symptoms) for more than 15 minutes should call an ambulance.^8-10 We found, however, that for most people a heart attack evolved, they experienced the symptoms for much longer than 15 minutes before seeking help, and many were able to contain or relieve their symptoms to some extent. Thus, in most cases, the 15 minute rule may be too simplistic to be effective. Linked with this is the stereotypical heart attack victim and the perception of a heart attack as a dramatic event in which people collapse with crushing chest pains and probably die. Clearly, the myth that a heart attack is a dramatic event needs to be dispelled and public perceptions of a heart attack and its associated symptoms need to be changed.