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American Journal of Critical Care. 2008;17: 26-35
Copyright © 2008 by the American Association of Critical-Care Nurses.
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Response to Signs and Symptoms of Acute Coronary Syndrome: Differences Between Lebanese Men and Women

By Samar Noureddine, RN, PhD, Mary Arevian, RN, MPH, Marina Adra, RN, MSc and Houry Puzantian, RN, MSc. Samar Noureddine is an associate professor, Mary Arevian is a clinical associate professor, Marina Adra is a clinical assistant professor, and Houry Puzantian is a clinical research coordinator at the American University of Beirut, Beirut, Lebanon.

Corresponding author: Samar Noureddine, RN, PhD, School of Nursing, American University of Beirut, PO Box 11-0236, Beirut 1107 2020, Lebanon (e-mail: sn00{at}aub.edu.lb).


   Abstract
Top
 Abstract
Relevant Literature
 Methods
 Results
 Discussion
 References
 
Background Signs and symptoms of acute coronary syndromes differ between men and women, but whether men and women respond differently to these indications is not well understood. Such responses influence health outcomes because success of treatment depends on how quickly healthcare is sought.

Objective To explore differences between Lebanese men and women in cognitive, emotional, and behavioral responses to signs and symptoms of acute coronary syndromes.

Methods A convenience sample of 149 men and 63 women with unstable angina or acute myocardial infarction were interviewed within 72 hours of admission to coronary care in a tertiary center by using the Response to Symptoms Questionnaire. Demographic and clinical data were obtained from medical records.

Results Women were older, less educated, and more often widowed than men. More women had hypertension but more men were current smokers. Women had shoulder pain, dyspnea, nausea and vomiting, and palpitations more often than men did. Women’s signs and symptoms were rated more severe by the women than men’s were by the men. Women were less likely to know signs and symptoms of myocardial infarction than were men and delayed coming to the hospital longer than men did. Delay correlated with the characteristics of the signs and symptoms and not realizing their importance in men and with dyspnea and taking the "wait and see" approach in women.

Conclusion Factors related to promptness in seeking care for acute coronary syndromes differ between Lebanese men and women.

Coronary artery disease (CAD) remains the leading cause of morbidity and mortality in industrialized countries.1 The greatest increases in prevalence are shifting from developed to developing countries, where CAD is estimated to become the leading cause of death by 2010.2 In Lebanon, the Ministry of Health reports that heart disease is the leading cause of death.3 Prompt treatment of acute coronary syndromes (ACS) is essential for reducing mortality and improving outcomes4,5; the effectiveness of treatment is highest within 1 hour of the onset of signs and symptoms and is lowest 6 hours or more after onset. Unfortunately, people experiencing ACS delay seeking healthcare, thereby precluding any benefit of effective treatment.6

In a national study7 of 433 patients with acute myocardial infarction (AMI) in Lebanon, 46% of patients arrived at the hospital more than 6 hours after the onset of signs and symptoms. Sawaya et al7 did not report mean or median delay times; rather, they reported the proportion of patients who arrived at the hospital within set time intervals: 38% arrived within 3 hours and 38% arrived 12 hours or more after the onset of signs and symptoms. A greater proportion of women (48.5%) than men (34.5%) arrived more than 12 hours after the onset of signs and symptoms (P = .02), whereas a smaller proportion of women (27.3%) than men (41.4%) arrived within 3 hours (P = .01). The proportion of patients who arrived between 3 and 12 hours after the onset of signs and symptoms did not differ between men and women.8

Understanding the determinants of the difference in delay in seeking treatment between men and women is important to guide interventions. In Lebanon, most middle-aged women are housewives who take responsibility for the home and children and depend on their families for healthcare and insurance. No studies on differences in behaviors related to seeking healthcare between male and female Lebanese cardiac patients have been published. The purpose of our study was to determine whether Lebanese men and women differ in their responses when they experience signs and symptoms of ACS and how such responses are related to the behaviors of men and women in seeking healthcare.


   Relevant Literature
Top
 Abstract
 Relevant Literature
Methods
 Results
 Discussion
 References
 
The study was based on the common-sense model of illness representation,9 which posits that a person’s response to a sign or symptom is shaped by a process of appraisal whereby the person matches the sign or symptom to the disease with which the person associates that sign or symptom. This appraisal results in cognitive and emotional responses that produce the behavior the person uses to cope with the sign or symptom. Sociocultural characteristics and the context in which the sign or symptom is experienced are assumed to influence the responses.9


Women report more neck pain, cough, and fatigue, and less chest pain and sweating than do men.

 

Differences in Signs and Symptoms of ACS Between Women and Men
A similar prevalence of chest pain was reported in men and women across all types of ACS,10 with a tendency for women to report more severe pain.11,12 Moreover, women with CAD and unstable angina reported significantly more jaw and back pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations than men did.12–14 Similar findings were reported in a review15 of studies of AMI patients: women were more likely to report neck pain, cough, and fatigue, but less likely to report chest pain and sweating than were men. Moreover, in a qualitative study of 40 women with AMI, McSweeney and Crane16 found a prodromal phase of 2 weeks to 2 years before the infarction; during that time, women experienced unusual fatigue, discomfort in the shoulder blade area, and chest sensations.

Misdiagnosis and undertreatment of ACS in women are problems17 and may be linked to the more frequent occurrence of atypical signs and symptoms in women. In addition, women with ACS are older and have a higher prevalence of diabetes and hypertension than do men with ACS,18 characteristics that contribute to worse outcomes. Data from the American National Registry of Myocardial Infarction (1994–2002) indicated that women were less likely to undergo coronary angiography and receive reperfusion therapy and were more likely to die in the hospital than were men.19

In the lone study conducted in Lebanon,8 women participants were older than the men (65 vs 60 years; P < .001), and a higher proportion of women than men had hypertension (33.3% vs 23.4%; P = .06). Use of thrombolytic therapy or angioplasty did not differ between men and women, but women (10.1%) were less likely than men (20.0%) to receive thrombolytic agents within 3 hours of arrival (P = .02) and had higher in-hospital mortality (16.2%) than men did (8.1%; P = .04).8 Atypical clinical manifestations and higher cardiovascular risk may explain the difference between the sexes in the management and outcomes of ACS.

Differences Between Men and Women in Responses to Signs and Symptoms of ACS
Results of many studies8,18,20–25 indicate that women experiencing signs and symptoms of ACS delay seeking care significantly longer than men do, whereas no significant difference was reported in a few studies.11,26–28 Nevertheless, researchers who reported significant differences in delay between the sexes had larger samples than did their counterparts.29 Despite the recent trend of including both men and women in studies of ACS, many investigators did not explicitly compare the experiences of women and men in dealing with a cardiac event and seeking healthcare.11


Women had higher HDL and lower triglyceride levels than did men.

 

Some investigators compared the responses of men and women, whereas others studied each group separately. Ashton26 studied the behavioral response to signs and symptoms in 121 first-time ACS patients and found that women were significantly more likely than men to call a family member other than their spouse when the signs and symptoms occurred, whereas men were more likely to inform their wives.

Lefler and Bondy29 reviewed 48 studies of cognitive and behavioral responses to signs and symptoms of ACS. The results indicated that women, more often than men, did not attribute their signs and symptoms to the heart, did not perceive the signs and symptoms as serious, and were more likely to consult with their children or use some other coping strategies—behaviors that translated into longer prehospital delays. Signs and symptoms that were nonspecific, progressed slowly in severity, or were not severe and presence of comorbid conditions correlated with longer delays in women.

Emslie30 reviewed 60 qualitative studies done in Western countries in which researchers explored the signs and symptoms in men and women with CAD, the patients’ perceptions of the experience, and what made the patients delay coming to the hospital. The findings highlighted the influence of social roles as determinants of delay; female patients had difficulties reconciling family responsibilities and medical advice, whereas male patients worried about being absent from work.

In a study11 of 194 patients with AMI, older age and history of AMI correlated with longer delays in seeking care in women, whereas history of AMI correlated with shorter delays in men. In addition, not wanting to trouble others correlated with longer delays in women but not in men. Knowledge of thrombolytic therapy correlated with shorter delays in men but not in women. Other cognitive and affective variables—attribution of signs and symptoms to the heart, perceived seriousness of the signs and symptoms, and anxiety—correlated with shorter delays in both sexes.11

In studies of women with AMI, appraisal of the signs and symptoms and self-help correlated with care-seeking behavior. In a qualitative study of 16 women with AMI,31 women did not realize the seriousness of their signs and symptoms and tried self-help strategies to ameliorate them. Only when self-treatment failed did the women consult with family members, finally deciding to seek healthcare.31 In another study of 52 women with AMI,32 women took 1 of 2 paths in response to their signs and symptoms: one group knew that they would seek help and another group minimized their signs and symptoms or tried self-management. Even those women who knew that they would seek healthcare did not do so immediately but consulted a family member first. These women had significantly higher perceived threat of heart disease and neuroticism and lower social support than did the women in the other group, who thought that the signs and symptoms were not serious and subsequently delayed longer.32

More studies on differences between the sexes in responses to signs and symptoms of ACS are needed. Identifying these differences would guide the development of appropriate interventions to reduce delay in seeking care. Our aim was to explore differences between the sexes in responses to signs and symptoms of ACS in a Lebanese sample. The 3 research questions were as follows:

  1. What are the differences between men and women in the clinical manifestations of ACS and in the risk factors for ACS?
  2. Are there differences between the sexes in the cognitive, affective, and behavioral responses to the experience of signs and symptoms of ACS?
  3. Are there differences between the sexes in the correlates of time from the onset of signs and symptoms to arrival at the emergency department (delay time)?


   Methods
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 Abstract
 Relevant Literature
 Methods
Results
 Discussion
 References
 
Sample and Procedures
A convenience sample of 212 Lebanese patients (149 men and 63 women) with ACS was studied. Patients admitted to the coronary care unit of a major tertiary center in Lebanon who were more than 30 years old and had a diagnosis of unstable angina, suspected myocardial infarction, or confirmed myocardial infarction were recruited. Diagnoses were confirmed by electrocardiographic findings and the results of cardiac enzyme studies and cardiac catheterization. Only patients who were admitted through the emergency department were included. Patients with cognitive, psychiatric, or hemodynamic derangements documented in the medical record and patients experiencing trauma were excluded. Patients who were transferred from other hospitals also were excluded.

Approval was secured from the institutional review board. Nurses from the coronary care unit were trained to screen patients’ medical records to see if patients met the study criteria. Nurses from the coronary care unit approached eligible patients and invited them to participate in the study. Patients were interviewed within 72 hours of admission, after they had provided informed consent. A total of 250 patients were approached. Of these, 36 refused to participate because of anxiety or fatigue. In addition, a patient who experienced chest pain in the emergency department when he brought his spouse for treatment and another patient who had chest pain in the emergency department when he was visiting a friend who works there were excluded from the analyses because the delay time for them was zero. The final sample included 212 subjects.

Instruments
Data from the medical records were collected on demographics (sex, age, marital status, medical insurance, and occupation), medical diagnosis, risk factors (history of diabetes mellitus, CAD, angina, myocardial infarction, hypertension, hyperlipidemia, smoking, family history of heart disease, height, and weight), date and time of arrival in the emergency department, diagnostic findings (initial signs and symptoms, electrocardiographic findings on admission, cardiac enzyme levels, serum levels of lipids, cardiac catheterization results, ejection fraction), and treatment received (medications, percutaneous intervention, surgery).

Interview questions were based on the Response to Symptoms Questionnaire as modified by Dracup and Moser.33 Content validation and acceptable internal consistency of the questionnaire have been reported.33,34 The questionnaire highlights responses to the experience of signs and symptoms of ACS. The first question was a request for the date and time of onset. In the next 3 questions, a multiple-choice format was used to address the context; that is, where the patient was, with whom, and what the patient was doing when the signs and symptoms occurred. Other multiple-choice questions covered the first thing the patient did at the onset of signs and symptoms (behavioral response) and the response of witnesses present.

Next, each patient was asked to select from a checklist what he or she thought the problem was (cognitive response). Three items with a 5-point Likert scale (1 = not at all to 5 = very much) addressed anxiety and belief about the patient’s ability to control the signs and symptoms (affective responses) and the patient’s perception of the seriousness of the signs and symptoms. In the next 8 questions, a 5-point Likert scale was used to address the importance of factors in causing delay. The factors included cognitive responses (waiting for signs and symptoms to go away, not wanting to trouble others, embarrassment about seeking help, not knowing that the signs and symptoms were cardiac, not knowing the signs and symptoms of myocardial infarction, and not realizing the importance of the signs and symptoms), affective response (fearing what may happen), and characteristics of the signs and symptoms (signs and symptoms came and went). Each patient also was asked to rate the severity of his or her signs and symptoms on a scale of 0 to 10 and to state whether he or she knew about the use of thrombolytic drugs to treat AMI. Finally, level of education, income, and mode of transportation to the hospital were obtained.


In those with myocardial infarction, women had fewer percutaneous coronary interventions or surgical treatments than men.

 

The Response to Symptoms Questionnaire was translated into Arabic and then translated back to English; the original and back-translated English versions were consistent. A panel of experts (the nurse manager of the coronary care unit, a critical care clinical nurse specialist, and a cardiologist) supported the content validity and cultural appropriateness of the instrument. The Arabic questionnaire was pilot tested with 5 patients before the study; no modifications were warranted.

Delay time was calculated by subtracting the date and time of arrival in the emergency department noted in the medical record from the date and time of onset of signs and symptoms reported by the patient. In order to facilitate recall of the time of onset, patients were asked what they were doing and what the usual time for that activity was.

Data Analysis
The data were analyzed by using SPSS software (version 12, SPSS Inc, Chicago, Illinois). Means, standard deviations, and frequencies were used for descriptive analyses. A variety of tests, including t tests, odds ratios, and {chi}2 tests, were used to answer the first 2 research questions. For question 3, separate analyses were done for men and women. First, bivariate analyses were done between delay time and all study variables. Second, stepwise multiple regression analyses of the backward method were used to check for correlations with delay time in men and women. Significant correlates of delay time were entered, then variables that did not contribute significantly to the change in R2 were removed sequentially until only significant correlates were retained in the final model. This method was chosen because not enough literature was available to guide the ordering of entry of the variables. The delay time data were skewed, so a logarithmic transformation of this variable was used in the analyses. Alpha was set at .05.


There was no gender difference in thrombolytic therapy use.

 


   Results
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 Abstract
 Relevant Literature
 Methods
 Results
Discussion
 References
 
Differences in Risk Factors and Signs and Symptoms Between Men and Women
Differences in demographic and clinical variables between women and men are shown in Table 1Go. The women were significantly older, more likely to be widowed, less educated, and less likely to be employed than were the men. In terms of cardiovascular risk factors, women were more likely to have hypertension and less likely to be current smokers than were men. Moreover, the women had significantly higher levels of high-density lipoprotein cholesterol and lower levels of triglycerides than did the men. No significant difference between the sexes was noted in the primary medical diagnosis, but women had fewer diseased vessels (mean [SD], 1.57 [1.13] vs 2.00 [1.10]; t158 = 2.25; P = .03) than men had. In addition, women overall were less likely to be treated with percutaneous coronary interventions or surgery than were men (29.5% vs 52.1%; {chi}2 = 8.80; P = .003). Analysis by medical diagnosis group showed that in the group with confirmed myocardial infarction, women were less likely than men to receive percutaneous coronary interventions or surgical treatment (32% vs 60.6%; {chi}2 = 5.95; P = .02), but the difference between the sexes was not significant in patients with diagnoses of unstable angina or suspected myocardial infarction. The use of thrombolytic therapy did not differ between men and women.


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  		Table 1 Demographic and clinical characteristics of men and womena

 
Table 2Go shows differences between men and women in the signs and symptoms experienced on arrival in the emergency department. Women were significantly more likely to have shoulder pain, dyspnea, nausea and vomiting, and palpitations than were men. The frequency of chest pain and sweating did not differ between men and women.


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  		Table 2 Differences between men and women in signs and symptoms of acute coronary syndromes

 
Differences in the Context of Signs and Symptoms of ACS Between Women and Men
Women experienced signs and symptoms of ACS more often at home (P < .01) and in the company of family members (P < .001) than men did. A total of 86% of women had the signs and symptoms at home; 4.8% had them either while visiting relatives or friends or in a public place. On the other hand, 65.8% of men had the signs and symptoms at home, 10.7% at work, 6% in a public place, 5.4% during a social visit, and 4.7% while driving a car.

Among the women, 33.3% had the signs and symptoms in the presence of a family member other than their husband, 20.6% were with their husband, 17.5% were with a health professional, 14% were alone, and 6.3% were with friends. Among the men, 46.3% were with their wives when the signs and symptoms occurred, 19.5% were alone, 9.4% were with a health professional, 8.7% were with another family member, 7.4% were with friends, and 6.9% were with work colleagues. The response of others present when the signs and symptoms occurred did not differ between men and women.

Differences Between Men and Women in the Cognitive and Affective Responses to Signs and Symptoms of ACS
Table 3Go shows the cognitive, affective, and behavioral responses to signs and symptoms of ACS in women and in men. Women’s signs and symptoms were rated more severe by the women than men’s were by the men. Women also tended to perceive the signs and symptoms as more serious than men did. Women were more likely to be embarrassed to seek help and less willing to trouble others than were men, although the differences were not significant. Women were significantly less knowledgeable about the signs and symptoms of myocardial infarction than were men, and women were less likely to have heard of thrombolytic drugs (odds ratio, 0.39; confidence interval, 0.15–0.99; P = .03).


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  		Table 3 Differences between men and women in response to signs and symptoms of acute coronary syndromesa

 
Affectively, women tended more toward anxiety and fear in response to signs and symptoms than did men, but men and women did not differ in feeling control over the signs and symptoms.

Differences Between Women and Men in the Behavioral Responses to Signs and Symptoms of ACS
The mean time from the onset of signs and symptoms to arrival at the hospital was longer in women than in men, but the difference was not significant. Median time was 4.5 hours for men (range, 10 minutes to 5.7 days) and 5.5 hours for women (range, 15 minutes to 6.5 days).

The behavioral response to the signs and symptoms did not differ significantly between men and women (Table 3Go). The 2 most frequently reported actions, in order, in both groups were telling someone (32% of women vs 26% of men) and taking medication (18% of women vs 22% of men). Other common responses included trying to relax (21% of women vs 20% of men) and trying some self-help activity such as drinking herbal tea (16% of women vs 17% of men). A few men and women pretended nothing had happened (3% of women vs 6% of men). Less frequent responses also included prompt transportation to the hospital (5% of women vs 4% of men) and wishing for signs and symptoms to go away (3% of women vs 3% of men). Calling a physician was attempted by 3% of women and 1% of men.

Factors Correlated With Delay in Men
In men, longer delay times correlated with having dyspnea (mean [SD], 17.52 [30.24] hours in men with dyspnea vs 12.52 [23.27] in men without dyspnea; t147 =–2.016; P =.05), signs and symptoms that came and went (r = 0.35; P < .001), not knowing the signs and symptoms of myocardial infarction (r =0.19; P =.02), not realizing the importance of the signs and symptoms (r =0.31; P <.001), and waiting for the signs and symptoms to go away (r =0.23; P =.005). On the other hand, shorter delay times correlated with the severity of the signs and symptoms (r =–0.24; P =.003) and their perceived seriousness (r = –0.27; P = .001).

Table 4Go shows the final step of the backward regression of delay time in men. The variables entered were perceived seriousness of the signs and symptoms, experiencing dyspnea, signs and symptoms that came and went, severity of the signs and symptoms, not knowing the signs and symptoms of myocardial infarction, waiting to see if the signs and symptoms would go away, and not realizing the importance of the signs and symptoms. After 4 steps, 4 significant factors remained that explained 27% of the variance in delay time. Delay was longer when signs and symptoms came and went, when signs and symptoms were not perceived as severe, when the importance of the signs and symptoms was not realized, and when dyspnea was experienced.


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  		Table 4 Final model of the stepwise regression analyses of delay time in men (n = 147)a

 
Factors Correlating With Delay in Women
In women, the response of witnesses was significantly related to delay time ( F9,53 = 2.55; P = .02). The delay was shortest when the witnesses called the emergency system and longest when they did not do anything or suggested drinking something or calling a doctor. In addition, longer delays correlated significantly with waiting for the signs and symptoms to go away (r = 0.35; P = .005), not recognizing the signs and symptoms as cardiac (r = 0.28; P = .03), not knowing the signs and symptoms of myocardial infarction (r = 0.27; P = .03), not realizing the importance of the signs and symptoms (r = 0.28; P = .03), and occurrence of the signs and symptoms on a weekday rather than on a weekend (mean [SD] 26.29 [37.93] hours for weekdays vs 12.34 [18.65] hours for weekends; t61 = 2.04; P = .045). Women who experienced dyspnea delayed longer than did women without dyspnea (mean [SD] 27.10 [35.69] hours in women with dyspnea vs 15.40 [30.39] hours in women without dyspnea), but the difference was not significant (P = .07).

Table 5Go shows the final step of the backward regression for delay in women. The variables entered were the response of others, whether the signs and symptoms happened on a weekend or on a weekday, whether the patient thought the signs and symptoms were cardiac or not, waiting for the signs and symptoms to go away, not realizing the importance of the signs and symptoms, not knowing the signs and symptoms of myocardial infarction, having signs and symptoms that came and went, and dyspnea. Dyspnea was added although it was not significantly related to delay because the lack of significance could be due to the small number of women in the group, and we wanted to see whether dyspnea was a common correlating factor for both sexes.


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  		Table 5 Final model of the stepwise regression analyses of delay time in women (n = 62)a

 
After 7 steps, the final model retained 2 factors, waiting for signs and symptoms to go and dyspnea, that explained 21% of the variance in delay. Women delayed more when they experienced dyspnea and when they decided to wait for the signs and symptoms to go away. With dyspnea significantly related to delay in the multivariate but not the bivariate analyses, interaction effects of dyspnea and waiting for signs and symptoms to go away were tested. The difference in delay in relation to dyspnea was significant for waiting for signs and symptoms to go away only. Patients who waited for signs and symptoms to go away delayed significantly more if they had dyspnea, whereas the delay in patients who did not wait for the signs and symptoms to go away did not vary with the presence of dyspnea.


In women, the response of witnesses was significantly related to delay time.

 


   Discussion
Top
 Abstract
 Relevant Literature
 Methods
 Results
 Discussion
References
 
We detected similarities and differences between Lebanese men and women in the responses to the signs and symptoms of ACS. The difference between men and women in education in this sample reflects the generation of middle-aged women in Lebanon, who are usually less educated than their peer men and less likely to be employed. In our sample, 75% of the women reported being housewives.

The older age among women compared with men in this sample is expected in patients with ACS. The differences we found between women and men in cardiovascular risk factors agree with the findings of Sawaya et al8: women had higher CAD risk from hypertension but lower risk from smoking than men did. The difference we found between men and women in the frequency and severity of signs and symptoms is consistent with the results of published reports,12,14,15 except that jaw and neck pain did not differ between men and women in our study; those 2 symptoms were rather uncommon in both groups.

The trend for women to delay longer than men in seeking healthcare is consistent with the findings of most studies we reviewed.8,18,20–25 Cultural influences are apparent in the responses of our patients to the signs and symptoms of ACS. Women, who most often were at home with a family member when signs and symptoms occurred and got rather anxious about them, hesitated to ask for help more than men did. In the Lebanese culture, women assume responsibility for their families, which often takes priority over attending to the women’s ailments. This difference is consistent with the conclusions of Emslie,30 who reported that women feel uncomfortable asking for help from their children, wanting to avoid being a burden on their families and hoping to ensure that housework is not interrupted. Also, the longer delay when signs and symptoms occurred on a weekday rather than a weekend suggests that women did not want to disrupt their spouse’s or children’s work.

On the other hand, although underestimating the severity and seriousness of their signs and symptoms was more common in men than in women, almost half of the men experienced the signs and symptoms in the presence of their wives, who may have pushed them to seek healthcare, thus explaining the tendency for men to have shorter delay times than women did. Men are the primary breadwinners in Lebanese families, and wives are concerned with protecting their husbands’ health. These findings agree with those of Ashton,26 who reported that men inform mostly their wives about signs and symptoms.

In men, experiencing dyspnea, signs and symptoms that came and went, not perceiving the signs and symptoms as severe, and not realizing the importance of the signs and symptoms correlated with longer delay times. Not realizing the importance of the signs and symptoms was strongly correlated with lack of knowledge of the signs and symptoms of myocardial infarction (r = 0.65; P < .01), a finding that may explain the loss of significant contribution of the knowledge variable in the multiple regression. These findings suggest lack of knowledge of the signs and symptoms of ACS.


Patients who waited for symptoms to go away delayed more if they had dyspnea.

 

In women, the only significant correlates of delay were dyspnea and waiting for the signs and symptoms to go away; this result may be due to the small number of women in the study. The waiting was strongly correlated with not recognizing the signs and symptoms as cardiac (r = 0.40; P = .001), suggesting lack of knowledge. Waiting also can be explained by the women’s unwillingness to trouble others, as was found by Moser et al11; most of these women depend on others for access to healthcare. Similar to men, women did not seem to consider dyspnea serious enough to warrant seeking help.

In the multivariate analyses, dyspnea correlated with longer delay in both men and women. One possible explanation is that dyspnea may not be perceived to be as serious as chest pain is, thus the delays in seeking healthcare among patients with dyspnea. Absence of chest pain is associated with longer delays in seeking healthcare22,35; however, in our study all of the participants who experienced dyspnea also had chest pain. The co-occurrence of dyspnea with chest pain may override the chest pain sensation, a situation that could alter the patients’ recognition of the heart as the origin of their signs and symptoms. The attribution of signs and symptoms (cardiac or not), however, did not differ by whether dyspnea was experienced. An alternative explanation is that patients who experienced dyspnea had chronic illnesses such as heart failure or respiratory disorders and thought the dyspnea was an exacerbation of such illness to which they had adapted over the years; however, less than 5% of participants had such problems, making this possibility unlikely. A cultural explanation of the longer delay in those who had dyspnea may be related to the meaning the Lebanese attach to dyspnea, but information on that topic cannot be gleaned from the data in this study.

Our results are limited by the convenience sample that was recruited from a single setting and that excluded patients transferred from other hospitals; generalizability of the results is therefore limited. Nevertheless, our sample characteristics are similar to those of the national Lebanese study8 sample. The smaller size of the women’s group in our study may account for some of the nonsignificant results. Another possible limitation is that participants did not accurately remember their ACS experience. Interviews were conducted within 72 hours of admission to circumvent this possibility.

To achieve a better understanding of the cognitive and affective processes that underlie the participants’ behavioral responses to their signs and symptoms of ACS, we recommend a qualitative inquiry into the decision-making patterns of patients with ACS. In addition, further exploration of the signs and symptoms that people usually associate with ACS and the quality of the clinical features that would motivate them to seek healthcare promptly is warranted.

Our findings suggest the need to assess men and women’s perceptions and management of the signs and symptoms of ACS and to tailor education accordingly. When planning discharge teaching, nurses can assess patients’ perceptions of ACS and its signs and symptoms and clarify any identified misconceptions. For women, for instance, nurses can emphasize that waiting so as not to trouble others could lead to more adverse consequences that would place a greater burden on the family the patients are trying to protect, whereas seeking care promptly would reduce complications and enhance recovery.

FINANCIAL DISCLOSURES
The research was supported by grants from the University Research Board and the Medical Practice Plan of the American University of Beirut.

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   REFERENCES
Top
 Abstract
 Relevant Literature
 Methods
 Results
 Discussion
 References
 

  1. Elsaesser A, Hamm C. Acute coronary syndrome: the risk of being female. Circulation. 2004;109(5):565–567.[Free Full Text]
  2. World Health Organization. Strategic priorities of the WHO cardiovascular disease programme. http://www.who.int/cardiovascular_diseases/priorities/en/. Accessed October 23, 2007.
  3. Nawfal H. Resident Issues in Lebanon Ten Years After the World Conference on Residents and Development: The National Report 2004. Beirut, Lebanon: Dar El Koutoub; 2004.
  4. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non ST-segment elevation myocardial infarction: summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40(7):1366–1374.[Free Full Text]
  5. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2000 guidelines for the management of patients with unstable angina and non ST-segment elevation myocardial infarction, summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2000;36(3):970–1062.[Free Full Text]
  6. Rosenfeld AG, Lindauer A, Darney BG. Understanding treatment-seeking delay in women with acute myocardial infarction: descriptions of decision-making patterns. Am J Crit Care. 2005;14(4):285–293.[Abstract/Free Full Text]
  7. Sawaya JI, Jazra C, Farhat F, Alam S, Eid EV, Sabra R. Inhospital mortality after acute myocardial infarction in Lebanon: incidence, associations, and influence of newer treatment regimens. J Med Leban. 2000;48(2):63–69.
  8. Sawaya JI, Jazra C, Eid EV, Sabra R. Gender differences in the diagnosis and treatment of acute myocardial infarction in Lebanon. J Med Leban. 1999;47(1):2–6.
  9. Diefenbach M, Leventhal H. The common-sense model of illness representation: theoretical and practical considerations. J Soc Distress Homeless. 1996;5(1):11–38.
  10. DeVon HA, Zerwic JJ. Symptoms of acute coronary syndromes: are there gender differences? A review of the literature. Heart Lung. 2002;31(4):235–245.[Medline]
  11. Moser DK, McKinley S, Dracup K, Chung ML. Gender differences in reasons patients delay in seeking treatment for AMI symptoms. Patient Educ Couns. 2005;56(1):45–54.[Medline]
  12. Granot M, Goldstein-Ferber S, Azzam ZS. Gender differences in the perception of chest pain. J Pain Symptom Manage. 2004;27(2):149–155.[Medline]
  13. Eastwood JA, Doering LV. Gender differences in coronary artery disease. J Cardiovasc Nurs. 2005;20(5):340–351.[Medline]
  14. DeVon HA, Zerwic JJ. The symptoms of unstable angina: do men and women differ? Nurs Res. 2003;52(2):108–118.[Medline]
  15. Chen W, Woods SL, Puntillo K. Gender differences in symptoms associated with acute myocardial infarction: a review of the research. Heart Lung. 2005;34(4):240–247.[Medline]
  16. McSweeney JC, Crane PB. Challenging the rules: women’s prodromal and acute symptoms of myocardial infarction. Res Nurs Health. 2000;23(2):135–146.[Medline]
  17. Kudenchuk PJ, Maynard C, Martin JS, Wirkus M, Weaver WD. Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (The Myocardial Infarction Triage and Intervention Registry). Am J Cardiol. 1996;78(1):9–14.[Medline]
  18. Boccardi L, Verde M. Gender differences in the clinical presentation to the emergency department for chest pain. Ital Heart J. 2003;4(6):371–373.[Medline]
  19. Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med. 2005;353(7):671–682.[Abstract/Free Full Text]
  20. Barakat K, Wilkinson P, Suliman A, Ranjadayalan K, Timmis A. Acute myocardial infarction in women: contribution of treatment variables to adverse outcome. Am Heart J. 2000; 140(5):740–746.[Medline]
  21. Bouma J, Broer J, Bleeker J, van Sonderen E, Meyboom-de Jong B, DeJongste MJ. Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time. J Epidemiol Community Health. 1999;53(8): 459–464.[Abstract]
  22. Gurwitz JH, McLaughlin TJ, Willison DJ, et al. Delayed hospital presentation in patients who have had acute myocardial infarction. Ann Intern Med. 1997;126(8):593–599.[Abstract/Free Full Text]
  23. Karlson BW, Herlitz J, Hartford M. Prognosis in myocardial infarction in relation to gender. Am Heart J. 1994;128(3):477–483.[Medline]
  24. Ottesen MM, Køber L, Jørgensen S, Torp-Pedersen C, on behalf of the TRACE Study Group. Determinants of delay between symptoms and hospital admission in 5978 patients with acute myocardial infarction. Eur Heart J. 1996;17(3): 429–437.[Abstract/Free Full Text]
  25. Perers E, Caidahl K, Herlitz J, et al. Spectrum of acute coronary syndromes: history and clinical presentation in relation to sex and age. Cardiology. 2004;102(2):67–76.[Medline]
  26. Ashton KC. How men and women with heart disease seek care: the delay experience. Prog Cardiovasc Nurs. 1999; 14(2):53–60, 74.[Medline]
  27. Grace SL, Abbey SE, Bisaillon S, Shnek ZM, Irvine J, Stewart DE. Presentation, delay, and contraindication to thrombolytic treatment in females and males with MI. Womens Health Issues. 2003;13(6):214–221.[Medline]
  28. Zerwic JJ, Ryan CJ, DeVon HA, Drell MJ. Treatment seeking for acute myocardial infarction symptoms: differences in delay across sex and race. Nurs Res. 2003;52(3):159–167.[Medline]
  29. Lefler L, Bondy KN. Women’s delay in seeking treatment with myocardial infarction: a meta-synthesis. J Cardiovasc Nurs. 2004;19(4):251–268.[Medline]
  30. Emslie C. Women, men and coronary heart disease: a review of the qualitative literature. J Adv Nurs. 2005;51(4):382–395.[Medline]
  31. Dempsey SJ, Dracup K, Moser DK. Women’s decision to seek care for symptoms of acute myocardial infarction. Heart Lung. 1995;24(6):444–456.[Medline]
  32. Rosenfeld AG. Treatment-seeking delay among women with acute myocardial infarction: decision trajectories and their predictors. Nurs Res. 2004;53(4):225–236.[Medline]
  33. Dracup K, Moser D. Beyond sociodemographics: factors influencing the decision to seek treatment for symptoms of acute myocardial infarction. Heart Lung. 1997;26(4):253–262.[Medline]
  34. Reilly A, Dracup K, Dattolo J. Factors influencing prehospital delay in patients experiencing chest pain. Am J Crit Care. 1994;3(4):300–306.[Abstract]
  35. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283(24):3223–3229.[Abstract/Free Full Text]

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