When a blockage or spasm in one or more of your coronary arteries stops allowing freshly oxygenated blood to feed your heart muscle, a heart attack can happen. The faster you can access emergency treatment to address that culprit artery, the better your chances of being appropriately diagnosed. The period of time between your first symptoms and actively getting the help you need can be divided into three phases:
- decision time – the period from the first onset of acute symptoms to the decision to seek care (for example, calling 911)
- transport time – the period from the decision to seek care to arrival at the Emergency Department
- therapy time – the period from arrival at the Emergency Department to the start of medical treatment
Only the first phase is the one you have complete control over. So don’t blow it. . .
Cardiologists warn us that “time is muscle“, and that the ideal cardiac treatments are those started within one hour of the onset of heart attack symptoms –“the golden hour”, as it’s been described.(1)
Trouble is, most of us experiencing heart attack symptoms – especially females – wait far longer than we should for a number of reasons that at first blush may appear downright goofy to others.
We’re seeing more emerging research about these reasons. Here are some highlights of just a few studies on the important subject of women’s treatment-seeking delay behaviours:
1. The first study I ever came upon about this subject(2) was profoundly meaningful to me because I recognized myself in each of the six behaviour patterns identified. It’s also the one I cite most often here on Heart Sisters and during every women’s heart health presentation I’ve delivered since 2008. See also: Knowing & Going’ – Act Fast When Heart Attack Symptoms Hit
The lead author of that study, published in the American Journal of Critical Care in 2005, was Dr. Anne Rosenfeld of Oregon Health & Science University. She and her research team identified six important patterns of treatment-seeking delay in female heart attack survivors. These six patterns are:
- knowing and going (women acknowledged something was wrong, made a decision to seek care, and acted on their decision within a relatively short time, typically 5-15 minutes)
- knowing and letting someone else take over (women told someone they had symptoms and were willing to go along with recommendations to seek immediate medical care)
- knowing and going on the patient’s own terms (women wanted to remain in control, were not willing to let others make decisions for them, and openly acknowledged that they did not like to ask others for help – these are the women who drive themselves to Emergency!)
- knowing and waiting(women decided that they needed help but delayed seeking treatment because they did not want to disturb others)
- managing an alternative hypothesis (women decided symptoms were due to indigestion or other non-cardiac causes, and were reluctant to call 911 “in case there’s nothing wrong and I’d feel like a fool” – until their severe symptoms changed or became unbearable)
- minimizing (women tried to ignore their symptoms or hoped the symptoms would go away, and did not recognize that their symptoms were heart-related)
But even women in that first ‘knowing and going’ behaviour group admitted being confused about the symptoms of a heart attack. The biggest obstacle to reducing women’s treatment-seeking delays is in fact women’s lack of awareness in interpreting heart attack symptoms.
PLEASE NOTE: While chest pain is the most commonly reported symptom, at least 10% of women experience no chest pain during a heart attack.(3)
2. Swedish researchers interviewed women heart attack survivors over age 65 three days after each had been admitted to hospital for a confirmed first heart attack.(4) The aim of this study was to explore older women’s pre-hospital experiences of their first heart attack. Here’s how researchers described their findings:
” The women perceived their symptoms as a strange and unfamiliar development, from indistinct physical sensations to persistent and overwhelming chest pain. Understanding the complex experiences of older women in the pre-hospital phase is essential to reducing these patient decision times. The findings of this study should be incorporated into the education of professionals involved in the care of cardiac patients, including those who answer informational and emergency telephone lines.”
This study identified these pre-hospital delaying strategies:
- downplaying and neglecting cardiac symptoms
- symptoms seen as intrusions in their daily lives
- women defending themselves against this intrusion to remain in control and to maintain social/family responsibilities
- as their symptoms evolved into constant chest pain, the women began to realize the seriousness of their symptoms
- when pain became unbearable, they finally took the decision to seek medical care
3. Another Swedish study found similar commonalities behind treatment-seeking delay behaviour decisions.(5) . This time, researchers reported that diabetes, older age, and living in a small town or rural area compared to a big city were factors associated with pre-hospital delay times of over two hours.
You might think that having vague or atypical cardiac symptoms might affect how quickly patients would seek emergency medical care, but this particular research found that atypical cardiac symptoms were NOT a significant predictor for pre-hospital delay times longer than for textbook Hollywood Heart Attack symptoms (chest pain, pain down your left arm, etc.) But see #5 for differing conclusions from Arkansas researchers . . .
4. A more recent study on treatment-seeking delay during heart attack was presented at the Canadian Cardiovascular Congress in Vancouver.(6) .The study’s lead author Dr. Catherine Kreatsoulas and her Harvard-based research team developed the term “symptomatic tipping point” to describe what they had observed about that transitional period between initial symptom onset and seeking medical attention. They identified six transitional stages common to both men and women during a heart attack, although they found that men respond to their symptoms faster than women do.
The six stages, in more or less chronological order, include:
- a period of uncertainty (patient attributes their symptoms to another health condition)
- denial or dismissal of symptoms
- seeking assistance/second opinion of someone such as a friend or family member
- recognition of severity of symptoms with feelings of defeat
- seeking medical attention
5. A 2004 study published in the Journal of Cardiovascular Nursing also looked at this treatment-seeking delay behaviour in women heart attack survivors. University of Arkansas researchers found that women often underestimated the seriousness of their situation particularly when experiencing vague or atypical cardiac symptoms – unlike the findings in the Swedish study cited in #3. Arkansas researchers also concluded that “beliefs of low self-perceived vulnerability to heart attack” were behind women’s treatment-seeking delay.(7)
In other words, heart attacks happen to other people (e.g. men!) and not to me.
6. An Australian/American study identified similar reasons for our treatment-seeking delay.(8) Like the Swedish study in #2, both the Australian and American heart patients studied (about 1/3 female, mean age 60) had a number of factors in common associated with ignoring symptoms, including:
- lower incomes
- known diabetes
- symptom onset while at home
- considered their symptoms as not serious
- waited for symptoms to go away
- worried about troubling others
- embarrassed about seeking help
“What we don’t need is yet another study that says:
“Sucks to be female. Better luck next life.”
.The common thread throughout each of these studies on women’s treatment-seeking delay decisions is this:
We must call 911 right away. . . as soon as we start experiencing troubling symptoms that we suspect might be heart-related (or in other words, when we know these symptoms do not feel “normal” for us!)
YOU KNOW YOUR BODY!
YOU KNOW WHEN SOMETHING IS JUST NOT RIGHT!
NOTE FROM CAROLYN: I wrote much more about cardiac symptoms – both common and very uncommon – in Chapter 1 of my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 30% off the list price when you order).
Q: Have you ever downplayed symptoms that later turned out to be serious?.
(1) FG Kushner et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction and ACC/AHA/SCAI guidelines on percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 2009
(2) Rosenfeld A et al. Understanding Treatment-Seeking Delay in Women with Acute Myocardial Infarction: Descriptions of Decision-Making Patterns. American Journal of Critical Care. July 2005 vol. 14 no. 4 285-293
(3) Canto JG, Rogers WJ, Goldberg RJ, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307(8):813-822.
(4) Rose-Marie Isaksson et al. Older women’s prehospital experiences of their first myocardial infarction. Journal of Cardiovascular Nursing 2013. Jul-Aug;28(4):360-9
(5) Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the Northern Sweden MONICA Study. BMC Cardiovascular Disorders 2013, 13:6.
(6) Kreatsoulas C et al. The Symptomatic Tipping Point: Factors That Prompt Men and Women To Seek Medical Care. Presented at the Canadian Cardiovascular Congress, October 2014. Canadian Journal of Cardiology Volume 30, Issue 10, Supplement, Page S132.
(7) Lefler LL, Bondy KN. “Women’s delay in seeking treatment with myocardial infarction: a meta-synthesis.” J Cardiovasc Nurs. 2004 Jul-Aug;19(4):251-68.
(8) McKinley S, Moser DK, Dracup K. “Treatment-seeking behavior for acute myocardial infarction symptoms in North America and Australia.” Heart Lung. 2000 Jul-Aug;29(4):237-47.