Despite important healthcare advances and the considerable resources dedicated to improving the clinical outcome of patients with ST-segment elevation acute coronary syndrome (STEACS), this condition remains a major cause of mortality and morbidity in Western countries, including Spain.1–3 There is a clear link between delays in reperfusion treatment and the extent of myocardial necrosis and short- and long-term clinical repercussions of the condition. Thus, patients who benefit most from this treatment strategy are those with a shorter time interval to reperfusion.4,5 Most resources for these patients in coordinated regional care programs are focused on achieving a faster diagnosis, improvements in between- and within-hospital patient transferals, and more generalized use of primary percutaneous coronary interventions (PPCI).6,7 Nonetheless, in Spain, as in other countries, there is little information on factors that lead to delays in the initial medical attention after symptom onset, or the contribution of this time lag to the overall delay before reperfusion.8,9 Previous studies have described several demographic, clinical, and socioeconomic factors associated with delays in prehospital medical attention in STEACS patients.10–14 However, adequate data are lacking on the reasons that determine a delay in seeking medical help. Knowledge of factors associated with a delayed request for medical care may be a key element in the design of strategies to enable faster access to revascularization in high-risk groups, thereby improving their prognosis. The aim of this study was to determine factors associated with a delay in seeking medical attention (DSMA) after the onset of symptoms in patients with STEACS.

This is a cohort study with prospective data collection in consecutive patients with a diagnosis of STEACS and an indication for PPCI attended in our hospital over a 3-year period (May 2010-May 2013). Our institution is the referral center for performing PPCI in a catchment population of 608 989 individuals in the Community of Madrid. The entire urban population resides in municipalities of more than 10 000 inhabitants, and the maximum distance to our center is 33 km. Within our publically-funded health care system, initial medical care for these patients can be carried out directly in the patient's home after activation of outpatient emergency services, or by the patient attending a primary care center, a community hospital without PPCI capability, or by going directly to our referral hospital. No specific emergency response network (eg, Infarct Code program) was operating in our area during the study period.

Mortality in STEACS is clearly related to the time that passes from the development of the acute coronary occlusion to the moment reperfusion is achieved.5 In many studies, the prehospital time has been found to contribute most to the reperfusion time.18 However, there is little information on the time interval from symptom onset to the moment when medical care is requested, the impact of this delay on total IT, and the factors contributing to the delay. Most available data on this issue are from studies performing a general analysis of “prehospital delay”,12–14,18,19 usually defined as the interval from symptom onset to hospital arrival. According to the regional organization of health care for these patients, prehospital delay would only be equivalent to the DSMA if patients were to go directly to a hospital with PPCI capability. In contrast, in organizational systems that include initial medical attention in the patient's home or primary care centers, as in Spain, the delay would have 2 components: the DSMA (dependent on the patient) and the time of initial medical attention, diagnosis, and medicalized transport to a PPCI hospital (mainly dependent on the system). This is the first study specifically and prospectively investigating DSMA and its implications. The results show that this time period, which depends exclusively on the patient, accounts for around two-thirds of the total prehospital delay and half (48%) the IT.

In the patient series studied, elderly individuals were those most clearly affected by this delay (OR=11). This factor may have contributed to the lower efficacy of mechanical reperfusion therapy reported in this patient population in previous studies.20 Our findings concur with data from studies conducted in other countries, and highlight the need for specific interventions designed for this demographic group.20–22 In a study including both STEACS patients and non—ST-segment elevation acute coronary syndrome patients, Saczynski et al12 found that the problem of delays in receiving medical attention was especially important in patients older than 75 years.

In the present study, female sex and diabetes mellitus emerged as robust independent predictors of DSMA following the onset of compatible symptoms. These findings are also consistent with those of previous studies. In a substudy of the MONICA registry, prehospital delay was specifically investigated in patients with diabetes in a cohort of more than 4000 patients with acute coronary syndrome.22 Diabetic patients showed a longer prehospital delay, with no differences between sexes.22 It is well-recognized that women and individuals with diabetes who experience STEACS have a poorer clinical course. The delay to reperfusion may play an essential role in the outcome of these subgroups, although this has not been definitely established. There is some indication that these patient subgroups may present with atypical symptoms more often, making it more difficult to recognize the severity of the condition, but the evidence supporting this notion is scant.23,24

The present study did not reveal an association between the DSMA and factors linked to reperfusion delay in other studies, such as hypertension or a previous history of myocardial infarction. Additional population studies are needed to better define elements that determine a delay in recognizing the symptoms or perceiving the severity of the disease, and to identify other factors that may lead to a delay receiving medical attention, with the consequent lengthening of the total IT.

Patients showing a longer delay before requesting medical care had higher mortality in the acute phase of the condition and at 1-year of follow-up, likely because the IT had been longer and they had epidemiologic characteristics associated with a poorer prognosis. These findings concur with those of previous studies, although it remains to be determined whether the delay time, the epidemiologic characteristics of this group (elderly individuals, women, and diabetic individuals), or a combination of both elements are responsible for the poorer prognosis.

Among STEACS patients, those older than 75 years, women, and individuals with diabetes are more likely to experience a longer DSMA. Furthermore, patients who request medical assistance from their home show longer DSMA than those who go directly to a medical center. From the clinical standpoint, the group with a longer DSMA were found to have a more prolonged IT and higher in-hospital and 1-year mortality than patients with shorter delay times. Further studies are needed to determine whether specific programs targeting STEACS patients with a higher risk of prolonged DSMA can help to improve the prognosis of this patient population.

None declared.