Quality of Symptoms, Symptom Onset Characteristics, and Pre-hospital Delay during Acute Coronary Syndrome

Introduction: Early diagnosis of acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) is important for patient outcomes, patient care, and resource allocation. Decision to delay seeking treatment for symptoms of ACS increases the risk for serious complications, disability, and death. Aim: To describe the quality of symptoms, reported by patients ruled-in and ruled-out for ACS in the ED, to determine if there was an association between gradual vs. abrupt symptom onset and prehospital delay, and to examine the relationship between activities at symptom onset and gradual vs. abrupt symptom onset for patients with ACS. Methods: This was a secondary analysis of a large prospective multi-center study. The sample consisted of 1,064 patients presenting to the ED with symptoms that triggered a cardiac workup. Research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to the ED. Results: The sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; p = 0.002) and was a significant predictor for an ACS diagnosis in men (OR, 1.10 [CI,1.03-1.17]; p = 0.003). Women also reported more chest pressure (n=206, 51.75% vs. 44.65; p = 0.02) compared to men and chest pressure was a significant predictor for an ACS diagnosis (OR, 1.61 [CI, 1.03-2.53]; p = 0.02). Pre-hospital delay time was 4 hours. Being uninsured (β = 0.120, p = 0.031) and having a gradual onset of symptoms (β = 0.138, p = 0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (STEMI) (β = -0.205, p = 0.001) and arrival by ambulance (β = -0.317, p < 0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs. gradual symptom onset (2.57 hours vs. 8 hours, p < 001). Among men with an abrupt onset of symptoms and a STEMI diagnosis, 54% reported that symptoms were triggered by exertion (p = 0.046). Conclusion: Symptom characteristics are not sufficient to differentiate patients with and without ACS in the ED. Patients should be counseled that a gradual onset of symptoms for potential ACS is an emergency and they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent ACS.