The Challenge of Reducing Prehospital Delay in Patients With Acute Coronary Syndrome

Abstract

The delivery of definitive treatment for acute coronary syndrome (ACS) should begin as soon as possible after symptom onset to decrease associated morbidity and mortality.1,2 Every 30 minutes of delay results in a 7.5% increased relative risk for 1-year mortality.2 Unfortunately, the time between the onset of cardiac symptoms and admission to the hospital is far beyond optimal. Median times range from 1.5 to 6.0 hours,3 with the most recent times reported to be slightly more than 2 hours.4,5 A major limitation to achieving timely treatment is related to the patient’s indecision and reluctance to seek treatment.6 To date, efforts to reduce prehospital delay have shown limited success, despite 2 decades of research and multiple randomized, controlled trials of educational strategies directed toward the general public, healthcare professionals, and patients with ischemic heart disease.4–8 Article see p 148 In early research in this area, investigators9,10 identified the sociodemographic and clinical characteristics that were associated with prolonged prehospital delay. Knowing that older individuals, women, or patients with a history of angina are more likely to delay does not suggest appropriate interventions to reduce delay time, because none of these characteristics are amenable to change. In this issue of Circulation: Cardiovascular Quality and Outcomes, Sullivan et al11 address an alternate understanding of prehospital ACS care delay. Along with examining delay to treatment in terms of patient sociodemographic and clinical characteristics, they tested a developmental model of attachment theory to characterize patterns of interpersonal functioning. More specifically, they asked patients to answer a series of questions …