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Symptoms, prehospital delay and long-term survival in men vs. women with myocardial infarction: a combined register and qualitative study
Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The general aim of this thesis was to study symptoms, prehospital delay and time trends in long-term survival in men and women with myocardial infarction (MI). The study was based on quantitative and qualitative data collections.

Study I was based on The Northern Sweden MONICA Myocardial Infarction Registry, 1989-2003, including 5072 men and 1470 women with a confirmed MI. Symptoms and prehospital delay were described and trends over time according to sex and age were studied. Typical pain was present in 86% of the men and 81% of the women and typical symptoms were more common among younger persons than older persons. Up to the age of 65 no gender differences were seen in the prehospital delay. In the oldest age group (65–74 years) time to hospital was longer than among the younger group, especially among women.

Study II was based on individual interviews with 20 men with a first confirmed MI, representing the age range 65-80 years, about their experiences during the prehospital phase. The interviews were analyzed using qualitative content analysis. The interviewed older men described how the symptoms developed from diffuse ill-being, to a cluster of severe symptoms. The men had difficulties to relate to the experienced symptoms, which did not correspond to their expectations about an MI, and about whether they should seek medical care. By using different strategies the participants initially tried to understand, reduce, or treat the symptoms by themselves, with a desire to maintain an ordinary life. As the symptoms evolved to a persistent and alarming chest pain, the men realized the seriousness in the perceived symptoms, that all strategies were inefficacious and they came to the decision to seek medical care.

Study III was based on individual interviews with 20 women with a first confirmed MI, representing the age range 65-80 years, about their experiences during the prehospital phase. The interviews were analyzed using qualitative content analysis. The interviewed older women described how the symptoms were perceived as a stepwise evolvement from intangible and bodily sensations to a more distinct, persistent and finally overwhelming chest pain. The women struggled against the symptoms and used different strategies, by downplaying and neglecting the symptoms in order to maintain control over their ordinary lives and maintain the social responsibilities. As the symptoms evolved to a persistent and overwhelming chest pain the women realized the seriousness in the perceived symptoms, they were not able to struggle against them anymore and they came to the decision to seek medical care.

Study IV was based on The Northern Sweden MONICA Myocardial Infarction Registry which was linked to The Swedish National Cause of Death Registry for 6762 men and 1868 women, 25 to 64 years of age, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008. Between 1985 and 2006 long-term survival after a first MI increased in both men and women. Over the whole 23-year period women showed a 9 percent higher survival then men. This slight difference was due to lower risk for women to die before reaching hospital, and during the last period similar rates of long time survival were noted in men and women.

In conclusion there were no major differences between men and women in symptoms, prehospital delay or long-term survival. However, older patients had fewer typical symptoms and longer prehospital delay, especially among women. The prehospital phase was found to be multifaceted with experiences difficult to interpret in both men and women, with a dynamic development of symptoms, conceptions and expectations while the participants strove to maintain the ordinary and familiar life. The symptoms experienced presented a more heterogeneous and complex picture in both men and women than is usually described in the literature. Women under the age of 65 have a slightly higher age-adjusted long-term survival than men. Over a 23-year period long-term survival has improved similarly in both men and women.

Abstract [sv]

Det övergripande syftet med avhandlingen var att beskriva symtom, prehospital fördröjning och långtidsöverlevnad hos män och kvinnor med hjärtinfarkt. Studien baserades på kvantitativa och kvalitativa datainsamlingar.

Delstudie I baserades på data från hjärtinfarktregistret vid The Northern Sweden MONICA Study under åren 1989-2003, inkluderande 5072 män och 1470 kvinnor, med fastställd hjärtinfarkt. Symtom och tid från symtomstart till medicinsk vård beskrevs och tidstrender relaterades till kön och ålder. Resultatet visade att typisk smärta förelåg hos 86% av männen och 81% av kvinnorna och att typiska symtom var mer förekommande hos de yngre. Upp till 65 års ålder fanns inga könsskillnader mellan symtomstart och tid till medicinsk vård. I den äldsta åldersgruppen (65-74 år) var tiden till sjukvård längre, främst hos kvinnor.

Delstudie II baserades på individuella intervjuer med 20 män, mellan 65 och 80 år som drabbats av sin första hjärtinfarkt, om hur de upplevde den prehospitala fasen. Intervjuerna analyserades med hjälp av kvalitativ innehållsanalys. Männen beskrev hur symtomen utvecklades från ett diffust illabefinnande, till ett kluster av  svåra symtom. De hade svårt att relatera till de upplevda symtomen som inte motsvarade deras föreställningar om hur symtom på hjärtinfarkt tar sig uttryck, och hade svårt att veta om de skulle söka vård. Deltagarna vidtog olika strategier för att försöka förstå, minska eller behandla symtomen på egen hand, i en strävan att få livet att fortgå som vanligt. När symtomen utvecklats till en alarmerande och ihållande bröstsmärta insåg männen  allvarlighetsgraden i symtombilden och att strategierna för att hantera symtomen var verkningslösa och beslutade att söka vård.

Delstudie III baserades på individuella intervjuer med 20 kvinnor, med sin första hjärtinfarkt i åldern 65-80 år, för att få en djupare förståelse för hur de upplevde den prehospitala fasen. Intervjuerna analyserades med hjälp av kvalitativ innehållsanalys. De äldre kvinnorna beskrev hur symtomen stegvis utvecklades från ogripbara och kroppsliga förnimmelser, mot en mer distinkt, ihållande och slutligen överväldigande bröstsmärta. Kvinnorna kämpade mot symtomen och använde olika strategier, som att tona ner och negligera symtomen för att behålla kontrollen över livssituationen och upprätthålla det sociala ansvarstagandet. När symtomen utvecklades till en ihållande och överväldigande bröstsmärta insåg kvinnorna allvarlighets­graden i symtombilden, att de inte kunde kämpa mot symtomen längre och beslutade att söka vård.

Delstudie IV inkluderade patienter med en första hjärtinfarkt mellan åren 1985 och 2006 validerade i hjärtinfarktregistret vid The Northern Sweden MONICA Study i Norr- och Västerbotten som följdes upp i dödsorsaksregistret tom 30 augusti, 2008. Totalt 6762 män och 1868 kvinnor i åldern 25-64 studerades. Även patienter som avled före sjukhusvård inkluderades. Resultatet visade att mellan 1985 och 2006 förbättrades långtidsöverlevnaden efter en första hjärtinfarkt hos både män och kvinnor. Över hela 23-års perioden hade kvinnor 9 procents högre åldersjusterad överlevnad jämfört med män. Denna skillnad berodde på lägre risk för kvinnor att avlida innan de nådde sjukhuset. Under den sista tidsperioden var långtidsöverlevnad lika hos både män och kvinnor.

Sammanfattningsvis visar denna studie inga stora skillnader mellan män och kvinnors symtom, prehospitala fördröjning eller långtidsöverlevnad. Dock hade äldre patienter färre typiska symtom och längre prehospital fördröjning, särskilt hos kvinnor. Den prehospitala fasen var en mångfasetterad och svårtolkad upplevelse hos både män och kvinnor, med en dynamisk utveckling av symtom, föreställningar och förväntningar, samtidigt som deltagarna strävade efter att upprätthålla det vardagliga och välbekanta livet.  Symtomen vid hjärtinfarkten  var en mer heterogen och komplex upplevelse hos både män och kvinnor än vad som vanligtvis beskrivs i litteraturen. Över en 23-års period har långtidsöverlevnaden efter en första hjärtinfarkt förbättrats hos både män och kvinnor. Kvinnor under 65 år har en något högre långtidsöverlevnad jämfört med män.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2011. , 82 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1404
Keyword [en]
myocardial infarction, symptoms, prehospital delay, men and women, long-term survival, time trend, experiences
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-41191ISBN: 978-91-7459-151-4OAI: oai:DiVA.org:umu-41191DiVA: diva2:404935
Public defence
2011-04-15, Aulan, konferenscenter, Sunderby sjukhus, Luleå, Sunderby sjukhus, Luleå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-03-25 Created: 2011-03-18 Last updated: 2011-04-07Bibliographically approved
List of papers
1. Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study.
Open this publication in new window or tab >>Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study.
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2007 (English)In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953, Vol. 7, no 2, 152-158 p.Article in journal (Refereed) Published
Abstract [en]

Background

Few studies have examined the time between onset of myocardial infarction (MI) symptoms and arrival at hospital (prehospital delay time) and symptoms in men vs. women.

Aims

To describe prehospital delay time and symptoms in men vs. women with MI and to analyse trends over time and according to age.

Methods

The Northern Sweden MONICA myocardial infarction registry, 1989–2003, included 5072 men and 1470 women with a confirmed MI.

Results

Typical pain was present in 86% of the men and 81% of the women. The proportion with typical symptoms decreased over time for men and increased for women. Typical symptoms were more common among younger persons than older persons. Insufficiently reported symptoms was unchanged in men over time and decreased among women. Up to the age of 65, no gender differences were seen in the prehospital delay. In the oldest age group (65–74 years) time to hospital was longer than among the younger groups, especially among women.

Conclusion

There were no major gender differences in prehospital delay or type of symptoms. However, over time the proportion with typical symptoms decreased in men and increased in women. Older patients had longer prehospital delay and less typical symptoms.

Keyword
Gender; Myocardial infarction; Prehospital delay; Symptoms; Time trend; Cohort study
Identifiers
urn:nbn:se:umu:diva-6787 (URN)10.1016/j.ejcnurse.2007.09.001 (DOI)17980668 (PubMedID)
Available from: 2007-12-18 Created: 2007-12-18 Last updated: 2013-03-20Bibliographically approved
2. Prehospital experiences of older men with a first myocardial infarction: a qualitative analysis within the Northern Sweden MONICA Study
Open this publication in new window or tab >>Prehospital experiences of older men with a first myocardial infarction: a qualitative analysis within the Northern Sweden MONICA Study
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aim: To explore older men’s prehospital experiences of their first MI.

Background:  The delay between the onset of symptoms to the initiation of medical care is a major determinant of prognosis in myocardial infarction (MI).  The largest single component of the delay is the time it takes the person to respond to the symptoms by seeking care. The majority of people experiencing MI are men. But few studies have been conducted solely on men’s experiences before seeking medical care for MI. The objective of this study was to explore older men’s experiences of symptoms and their reasoning during the prehospital phase of their first MI.

Method: Data collection was carried out through individual interviews with 20 men representing the age range 65–80 (mean 71) years. The participants were interviewed three days after admission for a confirmed first MI (with or without ST elevation). The interviews were designed to prompt the men to describe their symptoms and their reasoning up to the decision to seek care. A qualitative content analysis was used to analyse the interviews.        

Findings: The prehospital phase in older men was found to be a complex and extended journey. The symptoms were perceived from diffuse ill-being to a cluster of alarming symptoms. During this journey the participants dealt with conceptions about MI symptoms. They were unsure both about the cause of their symptoms, which did not correspond to their expectations about an MI, and about whether they should seek medical care. They had difficulty making the final decision to seek care and strived to maintain a normal life. They initially tried to understand, reduce, or treat the symptoms by themselves. The decision to seek medical care preceded a movement from uncertainty to conviction.

Conclusions:Understanding older men’s prehospital experiences of MI is essential to reduce their patient decision times. This requires knowledge about the complexity and dynamic evolvement of symptoms, beliefs and strategies to maintain an ordinary life.

Keyword
experiences, older men, myocardial infarction, prehospital delay, symptoms
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-41193 (URN)
Available from: 2011-03-18 Created: 2011-03-18 Last updated: 2014-12-04Bibliographically approved
3. Older women's prehospital experiences of their first myocardial infarction: a qualitative analysis from the Northern Sweden MONICA Study
Open this publication in new window or tab >>Older women's prehospital experiences of their first myocardial infarction: a qualitative analysis from the Northern Sweden MONICA Study
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2013 (English)In: Journal of Cardiovascular Nursing, ISSN 0889-4655, E-ISSN 1550-5049, Vol. 28, no 4, 360-369 p.Article in journal (Other academic) Published
Abstract [en]

Background: Few qualitative studies have been conducted on older women’s experiences of myocardial infarction (MI) and, in particular, the time before they seek medical care.

Objective: The aim of this study was to explore older women’s prehospital experiences of their first MI.

Methods: Qualitative content analysis was performed on data from individual interviews with 20 women, aged 65 to 80 years (mean, 73.0 years). The participants were interviewed 3 days after admission to a hospital for a confirmed first MI.

Results: The women perceived their symptoms as a strange and unfamiliar development from indistinct physical sensations to persistent and overwhelming chest pain. Throughout the prehospital phase, they used different strategies such as downplaying and neglecting the symptoms. The symptoms were seen as intrusions in their daily lives, against which the participants defended themselves to remain in control and to maintain social responsibilities. As their symptoms evolved into constant chest pain, the women began to realize the seriousness of their symptoms. When the pain became unbearable, the women took the decision to seek medical care.

Conclusion: Understanding the complex experiences of older women in the prehospital phase is essential to reducing their patient decision times. The findings of this study should be incorporated into the education of professionals involved in the care of cardiac patients, including those who answer informational and emergency telephone lines.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2013
Keyword
aging, myocardial infarction, prehospital delay, qualitative, symptoms
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-41195 (URN)10.1097/JCN.0b013e31824bcebc (DOI)22495804 (PubMedID)
Available from: 2011-03-18 Created: 2011-03-18 Last updated: 2016-05-20Bibliographically approved
4. Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. An analysis of 8630 patients in the Northern Sweden MONICA Study.
Open this publication in new window or tab >>Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. An analysis of 8630 patients in the Northern Sweden MONICA Study.
Show others...
2011 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 11, 1- p.Article in journal (Refereed) Published
Abstract [en]

Age-adjusted survival was higher among women than men after a first MI and has improved markedly and equally in both men and women over a 23-year period. This difference was due to lower risk for women to die before reaching hospital.

Identifiers
urn:nbn:se:umu:diva-40632 (URN)10.1186/1471-2261-11-1 (DOI)21208409 (PubMedID)
Available from: 2011-03-03 Created: 2011-03-03 Last updated: 2016-05-18Bibliographically approved

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