Did you know that even when experiencing textbook heart attack symptoms (like my own chest and left arm pain), people wait an average of four hours before seeking medical help? The tragic irony is that heart patients who do best are those who can be treated within the first hour of those initial acute symptoms.
Heart attacks are dangerous and scary – so why do so many of us suffer silently for hours (and in many cases, far longer?) This treatment-seeking delay behaviour concerns many researchers, including Yale University’s Dr. Angelo Alonzo. He told me:
“Ask people what they would do if they had a heart attack and, of course, they’d all insist they would seek care immediately. Sounds easy! But in reality, few people actually do drop everything to get help.”
When it comes to heart attacks, time is muscle. And since delaying treatment for more than 60 minutes may cause irreversible damage to the heart muscle, Yale researchers want to figure out why so many of us appear so reluctant to “drop everything to get help”.
Yale Heart Study researchers led by Dr. Alonzo, the study’s principal investigator, developed an online, self-tailoring survey to examine how people behave during a heart attack.
Unlike lots of previous research on treatment-seeking delay in heart patients, this Yale study will gather a far broader sample of heart attack survivors, and will also focus on survivors living in rural, suburban, urban and in-between settings.
Despite all those previous studies, Dr. Alonzo remains frustrated:
“We still have not come up with an effective intervention for getting people to the hospital much earlier than the typical median time of around four hours.”
This Yale study will take a look at a wide range of behavioral variables that lead to our treatment-seeking delay behaviour during a heart attack. For example, the online survey includes questions were designed to gather valuable information about:
- how we made decisions during our cardiac events
- our perception and interpretation of symptoms
- the situational setting of our cardiac events
- the advice and perceptions of laypeople helping us
- the day and time of day
- our prior experience with the Emergency Department, first responders like ambulance/fire personnel, and the health care system
- how our evaluation and level of concern changed over the care-seeking period
Personally, I am particularly interested not only in how survivors describe our past treatment-seeking delay behaviour, but also in how fast heart attack survivors react during a second or third (or fifth!) cardiac event in the future.
We know, for example, that women who have already had a heart attack are at high risk for another one. But the symptoms of a second heart attack are not always the same as the first. It can sometimes be hard to tell heart attack chest pain from routine chest pain (angina) that has become “normalized”.
You might imagine that those of us who’ve already survived a heart attack would act with laser-like haste in seeking help if we ever recognize those familiar symptoms again any time in the future. Trouble is, I’ve met a distressingly high number of survivors who reported delaying medical help even during subsequent heart attacks - both when symptoms felt very different compared to their first cardiac event, but also when their symptoms were completely the same.
WARNING: If your doctor has prescribed nitroglycerin for chest pain, call 911 if you need more than two doses of nitro because your cardiac symptoms do not go away. If your symptoms are different, stronger, or last longer than usual, call 911 right away – it could be a heart attack.
To try to track other specific reasons for subsequent heart attack care-seeking delay, Dr. Alonzo also embedded into his survey a Post Traumatic Stress Disorder (PTSD) scale. He hopes this will assess accumulation of survivors’ PTSD-like experiences that may inhibit effective care-seeking during those subsequent events. These include:
- details about the prior cardiac event itself
- the Emergency Medical Services experience
- changes in lifestyle that may have ensued
- the hassle of dealing with medical bills and insurance matters
- previous life events of a traumatic nature
This phenomenon of surviving multiple previous traumatic events, he says, is known as cumulative adversity*.
“People may delay a bit longer, wanting to make certain that the event is real, wanting to avoid potential embarrassment, not wanting to repeat the same experiences, and not wanting to burden family or friends if unwarranted (e.g. not crying wolf).
“All of these factors may conspire to delay subsequent heart attack care-seeking.”
Dr. Angelo Alonzo has been working on the problems of delayed heart attack care-seeking for about 40 years, ever since he was a public health officer with the National Institutes of Health. Back then, he and a fellow officer, Dr. Arthur Simon, began interviewing patients who had experienced an acute myocardial infarction (heart attack) – and thus was born their first study on this topic:
“I once gave a talk about my work called ‘Who Is Going to Feed the Canary?’ It’s a reference to the fact that, even in mid-heart attack, we are so embedded and invested in our daily lives that we are very, very reluctant to just drop everything and seek medical care.”
Based on this work, Dr. Alonzo offered some possible reasons for our alarming reluctance to ‘drop everything’ even for something so serious as a heart attack :
- we have to be certain it is a real problem
- we have to finish the task at hand
- we need to make arrangements if we end up being hospitalized
- we have to cancel appointments
- our work activities are important to our identity
- we are just too strongly tied to our social obligations to just leave them
- we have to make sure we are clean for a doctor visit
- we do not want to bother others
- we do not want to bother the hard-working doctor
- we do not want to be taken out of our office or home by emergency personnel by ambulance
For far too many of us, he added, it’s only when the cardiac signs and symptoms become so overwhelming that we have few other choices are we likely to finally agree to seek and accept medical help.
So far, Dr. Alonzo told me, the Yale Heart Study has recruited enough research participants, over 2,300 survivors, in order to obtain a representative sample.
Dr. Alonzo also reminded me that women in general take more online health surveys than men do. His team will ultimately be able to tease out study result differences by sex, age and race.
The Yale Heart Study team has been funded by a grant from the National Heart, Lung and Blood Institute of the National Institutes of Health. All data collected will be used to develop strategies to maximize effective care-seeking in the future.
* Turner, R. J., & Lloyd, D. A. (1995). Lifetime traumas and mental health: the significance of cumulative adversity. Journal of Health and Social Behavior, 36(4), 360-376. American Sociological Association
- “Knowing and Going”: Act Fast When Heart Attack Symptoms Hit
- The Myth of the ‘Hollywood Heart Attack’ for Women
- Why Wouldn’t You Call 911 For Heart Attack Symptoms?