AIM: Delay time for non-STEMI presentation remains high
The delay from symptom onset to hospital presentation among patients with non-STEMI chest pain did not change between 2001 and 2006, with a median of more than two hours. Researchers are calling for better educational efforts to help patients recognize symptoms and seek immediate care, based on the study results published Nov. 8 in the Archives of Internal Medicine.

Henry H. Ting, MD, from the Mayo Clinic College of Medicine in Rochester, Minn., and colleagues reviewed records from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) registry.

Out of the 104,622 patients they studied, the median delay time from symptom onset to hospital presentation was 2.6 hours, with 59 percent of patients having delay times greater than two hours.

"More importantly," they wrote, "delay time has not changed significantly from 2001 to 2006 among a contemporary, nationally representative cohort of patients with non-STEMI."

Ting and colleagues found a few factors associated with longer delay, including older age, female sex, nonwhite race, diabetes and current smoking. "However, the magnitude of effect—less than 10 percent—on delay time from each factor was overshadowed by the overall duration of delay," they wrote. Consequently, the authors suggested that interventions should be targeted to all patients at risk for MI, and not just those who have individual risk factors.

They also found differences in delay depending on the time of the day and week. Patients who presented during weekday evenings or weekend nights had delay times 25 percent shorter than those who presented during daytime hours. The authors surmised this could be due to heightened fear during the night, a higher tolerance for symptoms during the daytime when a patient is active or at work, or a perception of shorter waiting times and less crowding in emergency departments during the night.

Patients with prior MI or PCI had modestly shorter delay times and the researchers noted that educational efforts should target these populations to improve responsiveness to care.

"A potential educational intervention to improve delay time would be to routinely provide this during discharge planning or as a standard part of the office visit," they wrote.

The authors found a non-linear relationship between delay time and in-hospital mortality for patients with non-STEMI. In fact, patients with the shortest delay time of less than one hour had the highest risk of in-hospital death. Investigators posited that these patients "likely had greater disease severity at presentation."

Also of interest is that patients already taking aspirin, angiotensin-converting enzyme (ACE) inhibitors or statins had lower adjusted in-hospital mortality. This was not true for those taking beta-blockers.

"Because patients cannot differentiate whether symptoms are
due to STEMI or non-STEMI, early presentation is desirable
in both instances," researchers said.

They concluded, "Novel strategies to improve patient responsiveness to seek care are critical and important for both patients with STEMI or non-STEMI."