Poor awareness of cardiac, stroke symptoms can delay care

Patients experiencing a heart attack or stroke face a significant barrier to receiving care -- getting themselves and others to recognize what is happening to them.

That's the conclusion of three studies published or presented in February. The problem can be a lack of knowledge of those around someone having a heart attack, according to one paper. In the case of a stroke, the problem could be delays caused by calling the physician's office first, or someone at the office not recognizing the signs, according to two papers presented at a recent conference.

"A lot of effort is being made in many hospitals in decreasing the minutes between the patient calling and the time the treatment is given," said Annette DuBard, MD, MPH, a family physician and research associate at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill. "But we're losing minutes between symptom onset and the 911 call or a patient arriving at the hospital. We cannot forget that."

With regard to heart attack, a paper in the Feb. 22 Morbidity and Mortality Weekly Report documented that 93% of those surveyed by the Behavioral Risk Factor Surveillance System in 2005 could identify shortness of breath as a sign of a possible myocardial infarction, but only 48% said pain in the jaw, neck or back could be an indication of this condition. Only 31% could name all five symptoms, and the concern is that this lack of awareness may translate into delays in care.

"The overall public awareness of heart attack signs and the importance of calling for emergency medical assistance quickly ... was alarmingly low," said Jing Fang, MD, lead author on that paper and an epidemiologist with the Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention.

Experts said this study reiterated the need for education, not just once but repeatedly.

"This is where community grassroots efforts can be so successful. We need to continue to educate everybody," said Margaret Gradison, MD, associate professor in the Dept. of Community and Family Medicine at Duke University in Durham, N.C.

This paper also highlighted the importance of targeting the message because it found significant disparities. Knowledge varied widely from state to state and from one demographic to another. Well-educated Caucasian women were far more likely to know the signs of a heart attack than African-American men with less than a high school education. Those in West Virginia were more knowledgeable on this subject than those in Washington, D.C.

"We need to do a better job of targeting public health messages to those who are not receiving them," said Dr. DuBard, who has authored studies linking a lack of English proficiency with a lack of stroke and heart attack knowledge among Hispanics.

These public health messages also may be needed with regard to the actions patients should take at the first signs of a stroke and how health care personnel they initially encounter should deal with them. A pair of studies presented at International Stroke Conference 2008 in New Orleans last month suggested that contacting a doctor's office rather than emergency services could delay access to care.

For one paper, researchers in Australia found that calling a physician's office rather than an ambulance more than tripled the time it took a stroke patient to get to a hospital. For the other, researchers in West Virginia found that all medical receptionists surveyed could identify heart attack symptoms in a hypothetical patient and would advise them to call 911. This was not the case with stroke, and 29% would tell patients with these kinds of symptoms to come in later in the day if they did not feel better. The authors say this is a marker of the success of educational programs for medical office staff about heart attack symptoms, and are calling for similar efforts to be made around stroke.

"There's such a limited therapeutic window, and they're adding another step in the whole thing," said Brett Jarrell, MD, lead study author and an emergency physician at Cabell Huntington Hospital in Huntington, W.Va."For so many years, there was nothing you could do, but now we really have options."

But experts also expressed caution that the pendulum not swing too far the other way, sending many more people than necessary to emergency departments and overburdening an already strained system. The signs of a stroke are nonspecific and can be subtle.

"It's not as straightforward as these articles might suggest. We cannot just send everyone to the emergency room. We have to put their evolving symptoms in context with what we already know about the patient," said Peter Toth, MD, PhD, director of Preventive Cardiology at the Sterling (Ill.) Rock Falls Clinic.