Sullivan Mark D, Ciechanowski Paul S, Russo Joan E, Soine Laurie A, Jordan-Keith Kier, Ting Henry H, Caldwell James H
Department of Psychiatry and Behavioral Sciences, Division of Cardiology, University of Washington, Seattle, Wash, USA.
Circ Cardiovasc Qual Outcomes. 2009 May;2(3):148-54. doi: 10.1161/CIRCOUTCOMES.108.825471. Epub 2009 Apr 28.
Better insight into the psychosocial factors associated with prehospital delays in seeking care for acute coronary syndromes is needed to inform the design of future interventions. Delay in presenting for care after the onset of symptoms is common, limits the potential benefit of acute reperfusion, and has not been reduced by interventions tested thus far.
Seven hundred ninety-six patients with suspected ischemic heart disease scheduled for clinically indicated imaging stress tests completed questionnaires concerning psychological distress and attachment styles (worthiness to receive care, trustworthiness of others to provide care). The primary dependent variable for this study was response to a question from the rapid early action for coronary treatment trial concerning intention to "wait until very sure" before seeking care for a possible "heart attack." Responses to this question were strongly associated with actual emergency department-reported and self-reported care delay in the rapid early action for coronary treatment trial. In multivariable ordinal regression models, a more negative view of the trustworthiness of others, greater physical limitations from angina, and no previous revascularization were independently associated with increased intention to wait to seek care for a myocardial infarction. Intention to wait was not associated with inducible ischemia or self-perceived risk of myocardial infarction.
Intention to delay seeking care for acute coronary syndromes is associated with a patient's view of the trustworthiness of others, previous experience with revascularization, and functional limitations, even after adjustment for objective and perceived acute coronary syndromes risk. These findings provide insight into novel factors contributing to longer delay times and may inform future interventions to reduce delay time.
为了指导未来干预措施的设计，需要更深入地了解与急性冠状动脉综合征患者院前延迟就医相关的社会心理因素。症状发作后延迟就医的情况很常见，这限制了急性再灌注的潜在益处，而且迄今为止所测试的干预措施尚未减少这种延迟。
796例计划进行临床指征性影像应激试验的疑似缺血性心脏病患者完成了关于心理困扰和依恋风格（接受治疗的价值、他人提供治疗的可信度）的问卷调查。本研究的主要因变量是对冠状动脉治疗快速早期行动试验中一个问题的回答，该问题是关于在可能发生“心脏病发作”时是否打算“等到非常确定”才就医。在冠状动脉治疗快速早期行动试验中，对这个问题的回答与实际急诊科报告的和自我报告的就医延迟密切相关。在多变量有序回归模型中，对他人可信度的更负面看法、心绞痛导致的更大身体限制以及既往未进行过血运重建独立地与增加等待心肌梗死就医的意愿相关。等待意愿与诱发性缺血或自我感知的心肌梗死风险无关。
即使在对客观和感知到的急性冠状动脉综合征风险进行调整后，急性冠状动脉综合征患者延迟就医的意愿仍与患者对他人可信度的看法、既往血运重建经历和功能限制有关。这些发现为导致更长延迟时间的新因素提供了见解，并可能为未来减少延迟时间的干预措施提供指导。
