Pre-hospital attitudes adopted by patients faced with the symptoms of acute myocardial infarction

Esta série de casos teve o objetivo de avaliar as condutas adotadas pelos pacientes, durante a fase pré-hospitalar do infarto agudo do miocárdio (IAM). Avaliaram-se 115 indivíduos portadores de IAM, com supradesnivelamento do segmento ST. Foi aplicado o teste quiquadrado e o teste exato de Fisher. Os indivíduos que não associaram os sintomas à doença cardiovascular atribuíram, mais frequentemente, às seguintes origens: gastrointestinal (38%), osteomuscular (29,7%), intoxicação alimentar e/ou medicamentosa (8,5%) e decorrentes do aparelho respiratório (6,3%). A proporção de desfechos maiores e de pacientes que chegaram à emergência após 12 horas foi mais elevada entre mulheres, indivíduos com renda mensal de até um salário mínimo, que usaram analgésicos e não associaram os sintomas à doença cardiovascular. Constatou-se que indivíduos em condições socio-conômicas desfavoráveis, que interpretaram os sintomas de forma incorreta, chegaram mais tardiamente à emergência e apresentaram piores desfechos intra-hospitalares.


Introduction
The pre-hospital phase in Acute Myocardial Infarction (AMI) care, is comprehended as the onset of pain and the recognition of the symptomology by the patient, up to seeking first aid, including travelling time to the nearest hospital service (1)(2) .According to data of the American Heart Association (AHA), transport to hospital is the phase where more time is lost.It is estimated that the time interval between the appearance of symptoms and the arrival at the emergency unit ranges from an hour and a half to six hours (2)(3) .To guarantee a good prognosis, it is ideal that patients should not exceed more than 45 minutes between the interpretation of the symptoms and the search for healthcare.The presentation of AMI ranges from classic to nonspecific symptoms, which can interfere with the choice of appropriate behavior for the treatment (4) .The correct interpretation of the Rev. Latino-Am.Enfermagem 2011 Sep.-Oct.;19(5):1080-7.
symptoms results in a decrease in the delay of arrival at the emergency unit.However, the lack of autonomy and the progressive disability caused by the onset and progression of the symptoms may contribute to the individual becoming more passive in relation to the situation, reducing the chances of survival (4)(5) .
The importance that the patient attributes to the symptoms also influences the choice of behavior (6)(7) .In a study conducted by the AHA, it was observed that the majority of the patients did not attribute great importance to the symptoms of AMI, classifying them as "irrelevant" and the behavior related to this interpretation was to wait for the symptoms to finish (8) .Some socio-cultural characteristics, such as religion, gender, education level and number of people per domicile, may also influence the choice of behavior (9)(10) .The aim of this study was to evaluate the pre-hospital attitudes faced with the symptoms suggestive of AMI in patients attended in a cardiology emergency unit.Behaviors defined as beneficial for the treatment of AMI were those recommended by the III Brazilian Guidelines for the Treatment of AMI (1) .Myocardial Revascularization Surgery (MRS), coronary angioplasty, angina recurrence during the period of hospitalization, cerebrovascular accident (CVA) and death were considered as major outcomes.

Method
To collect the data a questionnaire was used which included questions regarding the socio-economic and demographic conditions, pre-hospital behavior

Results
The sample was composed of 115 individuals.The majority (94.8%) of the interviewees lived in brick built houses, with a mean of 3.8 inhabitants per domicile, outside the municipality of Recife, and had a mean monthly income of 1.7 minimum wages (Table 1).The individuals that interpreted the symptoms as unrelated to cardiovascular disease, most often attributed them to the following sources: digestive system (38%), musculoskeletal system (29.7%),food and/or medication poisoning (8.5%) and the respiratory apparatus (6.3%).A small percentage (9.6%)opted for two or more behaviors simultaneously or in sequence faced with the symptoms presented.Only 18.7% of the individuals chose, at least, one behavior that really resulted in benefit for their health condition.An expressive variety of behaviors were registered, such as:   Although not statistically significant, a higher proportion of women with low monthly incomes and without anyone present during the AMI presented more travel time to the emergency unit and a higher proportion and major outcomes (Table 3).The proportion of individuals who arrived at the emergency department after more than 12 hours was significantly higher among those who self-medicated with analgesics (p=0.040).A higher percentage of individuals who interpreted the symptoms as not arising from the heart and did not engage in any conduct when the symptoms presented arrived later at the emergency unit, presenting a higher proportion of major outcomes (Table 4).

Discussion
AMI episode and presented more atypical symptoms (13) .
These data may in part account for the high female intra-hospital mortality after the first 24 hours of hospitalization for AMI and the delay in introducing thrombolysis (14)(15) .
Even without a statistically significant association, the majority of patients who arrived at the emergency unit within 12 hours were residents of the city of Recife, white, and had better financial conditions.These findings are similar to those of studies that evaluated the difference in the perception of the symptoms between black and white people and between people of different financial conditions (16) .A multicentric study showed that patients in Australia and New Zealand took less time to arrive at the emergency unit, when compared with Brazilians and Argentineans (17) .Among those individuals who arrived earlier at the emergency unit, a large percentage were accompanied by people unrelated to them.Conversely, authors who have studied the influence of the interpretation of the symptoms on the time taken to arrive at the hospital, verified that family members more often suggest attitudes that delayed the time of arrival at the emergency unit, when compared to people unrelated to the victim (18) .
The majority of the patients who interpreted the symptoms as cardiovascular disease (CVD) managed to arrive at the emergency unit within 12 hours.These Socio-demographic and clinical factors are able to interfere with the interpretation and choice of behavior by the patients, thus influencing the time for seeking care and the start of thrombolysis and, therefore, the prognosis and survival of the individuals (2,(9)(10) .The low level of education and the limited financial conditions identified in this sample may have limited the access of these individuals to health education, influencing the time to search for health services of high complexity confirming the findings of other authors (10) .The majority of the people interpreted the symptoms as problems of gastrointestinal origin.These data are consistent with studies conducted in England and in Sweden where the majority of the patients interpreted the symptoms as indigestion or of musculoskeletal origin (11)(12) .
Although the majority arrived in the emergency unit within 12h, few adopted pre-hospital behavior that would result in benefit to the AMI condition.A qualitative study performed in England, with a sample of ten women, evaluated the perception of the symptoms of AMI.The results showed that there was consistency between the interpretation of the symptoms and the behavior adopted by the patients (12) .Similar to the findings of the present study, another study showed that men and younger people took less time to seek health services when compared with women and the elderly, who had more difficulties to interpret the symptoms as being an Rev. Latino-Am.Enfermagem 2011 Sep.-Oct.;19(5):1080-7.
data are similar to the results of other studies where the majority of the individuals who interpreted the symptoms as being of another origin took more time to seek assistance (19) .In a multicenter study that evaluated 228 patients it was verified that only 25% of them recognized the symptoms as CVD and that the faster decisions were taken by those who interpreted the symptoms correctly (19) .Another study carried out in Japan showed that the patients who associated the symptoms with CVD, sought the emergency services more quickly and arrived with more chance of undergoing mechanical thrombolysis (20) .
The  (14,21) .The majority of the patients who used nitrates and aspirin arrived at the emergency unit after 12 hours.These behaviors may have contributed, in part, to the delay in the decision to go to the hospital.
This hypothesis can be confirmed by a statistically significant association between the use of analgesics and the prolonged time to arrive at the emergency unit.
Individuals that arrived at the emergency unit earlier adopted less appropriate measures to deal with the symptoms and, perhaps due to this, went more rapidly to the emergency unit, since the behaviors adopted did not produce a beneficial effect or may have even contributed to the worsening of clinical condition.
Among the patients who had major outcomes a higher proportion of females was observed, aged up to 60 years, with low levels of education, non-white skin color, with a monthly income of up to one minimum wage and with no one present during the episode.Some studies have shown that individuals with white skin color, with better financial conditions and more education were quicker in seeking clinical care in relation to nonwhite people (22) .This might be explained by the fact that individuals with unfavorable social conditions take longer to access emergency services, delaying the time to the start of thrombolysis.It is possible that the small sample size may have influenced the lack of statistically significant association, and that measurement bias in relation to the variable outcome occurred due to deficiencies of the service, which did not always offer all the procedures in the different levels of complexity.In addition, for a short period of time the institution had no thrombolytics.Thus, some patients were transferred to other hospitals or discharged to perform the procedure(s) later.
Popular education is one of the fundamental tools of health promotion.Knowledge about the symptoms of a disease can influence the interpretation of these and consequently the behavior adopted by the patient and, in the majority of cases, this will be consistent with the interpretation that the patient attributes to the symptoms.Therefore, it is necessary to guide the population through educational campaigns, rationally and backed by scientific data, and to disseminate the symptoms of AMI, especially among the elderly and women, as these groups presented greater delay in searching for healthcare.While performing health education activities, it is important that the professionals adopt strategies that can encourage and respect the notion of the patient as an individual responsible for their own health, this can start the process that leads to improvement, recognizing in themselves the need to change their attitude when faced with the predictive symptoms of the disease (23) .In this perspective, the health professionals are democratizing knowledge, respecting autonomy, and potentializing the self-care capacity in the patients, contributing to the reduction of mortality from AMI.

Conclusion
Individuals with unfavorable socioeconomic conditions, who interpreted the symptoms incorrectly and did not adopt any behavior when the symptoms presented, arrived later at the emergency unit and presented worse intra-hospital outcomes.
This is a descriptive case series study, conducted from February to June 2008, in the Cardiology Emergency Unit of Pernambuco/PROCAPE.The sample consisted of hospitalized individuals with a confirmed diagnosis of AMI with ST segment elevation.Individuals were excluded who were not able to provide information because they were suffering from mental disorders or were undergoing pharmacological treatment that interfered with cognition, or even due to unfavorable clinical conditions such as: cardiogenic shock, acute pulmonary edema, respiratory failure and mechanical ventilation, among others.The interpretations by the patients of the symptoms were classified as being of cardiovascular origin or originating in other systems.
performed by the individuals faced with predictor symptoms of AMI, past morbidity and cardiovascular risk factors.The outcomes were collected through the medical records.With the intention of minimizing memory bias, the maximum time for the application of the questionnaire was 48 hours after admission to the cardiology emergency unit.For the analysis of the variables the chi-square test or the Fisher's exact test were applied as necessary.All the conclusions were based on a significance level of 5%.The software used was Excel 2000 and SPSS version 8.0.The research project was approved by the research ethics committee of the Health Sciences Center of the Federal University of Pernambuco (CCS/UFPE) under protocol number 405/07.

Table 1 -
Distribution of the evaluated patients by socio-

Table 2 -
Distribution of the evaluated patients by clinical characteristics and behaviors adopted faced with the predictor symptoms of AMI.Recife, PE, Brazil, 2009 (continue...)

Table 4 -
Distribution of the evaluated patients by socio-demographic and clinical characteristics according to the major outcomes.Recife, PE, Brazil, 2009
delay in seeking care can be influenced by