Delay in acute myocardial infarction: why don't they come to the hospital more quickly and what can we do to reduce delay?

One of the greatest advances in cardiology of the last 20 years is the use of reperfusion therapy in acute myocardial infarction (AMI). Whether by thrombolysis, angioplasty, or coronary artery bypass surgery, benefits of reperfusion in salvaging myocardium and prolonging life are well demonstrated in clinical trials. The phrase btime is muscle,Q usually applied to cardiopulmonary resuscitation, also applies to reperfusion in AMI. The length of time from the onset of the ischemia to the establishment of reperfusion is directly related to outcomes. The GISSI trial demonstrated that almost 20 years ago (Figure 1). It is increasingly evident that very early interventions can lead to interrupted infarcts, sparing the myocardium from damage. Reperfusion is a time-related intervention. Unfortunately, there are multiple sources of delay from the onset of ischemic symptoms to an appropriate intervention. Pre-hospital or patient delay describes the time from the onset of symptoms to the seeking of medical attention. Transport delay represents the time from identifying symptoms to presenting at a hospital. Hospital delay is the time taken for healthcare personnel to evaluate the patient and institute appropriate therapy. Transport delay and hospital delay periods have been significantly reduced with the advent of efficient triage systems and a prioritization of timely diagnosis and therapy of potential AMI victims. However, the major source of delay (60%-70% in most studies) is pre-hospital or patient delay. This portion of the delay, which has been recognized for many years, is the most stubborn and difficult to reduce.