Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry)

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Abstract

Our primary study aim was to examine extent of, and factors associated with, delay in seeking medical care in a large multinational registry of patients with acute myocardial infarction (AMI) and unstable angina pectoris. A secondary goal was to examine the relation between duration of prehospital delay and receipt and timing of coronary reperfusion strategies. Investigators from 14 countries are participating in the Global Registry of Acute Coronary Events (GRACE) project. The study sample consisted of 3,693 patients with ST-segment elevation AMI, 2,935 with non–ST-segment elevation AMI, and 3,954 patients with unstable angina hospitalized between 1999 and 2001. The average and median delay times were longest in patients with non–ST-segment elevation AMI (6.1 and 3.0 hours, respectively) followed by patients with unstable angina (5.6 and 3.0 hours) and those with ST-segment elevation AMI (4.7 and 2.3 hours). Approximately 41% of patients with ST-segment elevation AMI presented to the 94 study hospitals within 2 hours of the onset of acute coronary symptoms; this compared with approximately one third of patients with non–ST-segment elevation AMI and unstable angina. Several demographic and clinical characteristics were associated with prehospital delay. In patients with ST-segment elevation AMI, duration of prehospital delay was inversely related to the receipt of thrombolytic therapy, but was inconsistently related to the use of percutaneous coronary interventions. The results of this study demonstrate that a large proportion of patients continue to exhibit prolonged delay in seeking medical care after the onset of acute coronary symptoms and remain in need of targeted educational efforts to reduce extent of delay.

Section snippets

Methods

A total of 18 cluster sites in 14 countries in North and South America, Europe, Australia, and New Zealand are currently collaborating in GRACE. Clusters were chosen based on local demographic characteristics and hospital facilities to ensure a representative sample of patients with acute coronary syndromes from each country and hospital systems of different sizes and treatment and diagnostic capabilities.1 Patients hospitalized at 94 hospitals with acute coronary syndromes are included in the

Results

The study sample consisted of a total of 10,582 patients with acute coronary disease in whom information was available about prehospital delay as ascertained through the review of medical records. This sample included 3,693 patients with ST-segment elevation AMI, 2,935 with non–ST-segment elevation AMI, and 3,954 with unstable angina. Patients were hospitalized between April 1999 and March 2001.

Discussion

The results of this large multihospital multinational study demonstrate that patients with acute coronary disease continue to exhibit prolonged delay in seeking medical care after the onset of acute coronary symptoms. Whereas patients most likely to benefit from the use of coronary reperfusion strategies, namely patients with ST-segment elevation AMI, delayed seeking care less than patients with other manifestations of acute coronary disease, patients with ST-segment elevation AMI also delayed

Acknowledgements

We would like to express our gratitude to the physicians and nurses participating in GRACE, whose continuing involvement is essential to the success of the study. Further information about the project, along with a complete list of participants, can be found at www.outcomes.org/grace.

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Grace is supported by an unrestricted educational grant from aventis pharma, bridgewater, new jersey.

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