Psychological and cognitive factors related to prehospital delay in acute coronary syndrome: A systematic review.

BACKGROUND: In acute coronary syndrome the time elapsed between the start of symptoms and the moment the patient receives treatment is an important determinant of survival and subsequent recovery. However, many patients do not receive treatment as quickly as recommended, mostly due to substantial prehospital delays such as waiting to seek medical attention after symptoms have started. OBJECTIVE: To conduct a systematic review with meta-analysis of the relationship between nine frequently investigated psychological and cognitive factors and prehospital delay. DESIGN: A protocol was preregistered in PROSPERO [CRD42018094198] and a systematic review was conducted following PRISMA guidelines. DATA SOURCES: The following databases were searched for quantitative articles published between 1997 and 2019: Medline (PubMed), Web of Science, Scopus, Psych Info, PAIS, and Open grey. REVIEW METHODS: Study risk of bias was assessed with the NIH Quality Assessment Tool for Observational, Cohort, and Cross-Sectional Studies. A best evidence synthesis was performed to summarize the findings of the included studies. RESULTS: Forty-eight articles, reporting on 57 studies from 23 countries met the inclusion criteria. Studies used very diverse definitions of prehospital delay and analytical practices, which precluded meta-analysis. The best evidence synthesis indicated that there was evidence that patients who attributed their symptoms to a cardiac event (n = 37), perceived symptoms as serious (n = 24), or felt anxiety in response to symptoms (n = 15) reported shorter prehospital delay, with effect sizes indicating important clinical differences (e.g., 1.5-2 h shorter prehospital delay). In contrast, there was limited evidence for a relationship between prehospital delay and knowledge of symptoms (n = 18), concern for troubling others (n = 18), fear (n = 17), or embarrassment in asking for help (n = 14). CONCLUSIONS: The current review shows that symptom attribution to cardiac events and some degree of perceived threat are fundamental to speed up help-seeking. In contrast, social concerns and barriers in seeking medical attention (embarrassment or concern for troubling others) may not be as important as initially thought. The current review also shows that the use of very diverse methodological practices strongly limits the integration of evidence into meaningful recommendations. We conclude that there is urgent need for common guidelines for prehospital delay study design and reporting.

Psychosocial markers of pre-hospital decision delay and psychological distress in acute coronary syndrome patients.

Objectives Both pre-hospital decision delay - the time patients wait before seeking medical attention after symptoms have started - and high psychological distress after the cardiac episode predict poor prognosis of patients with acute coronary syndromes (ACS). We aimed to identify psychosocial markers of these prognostic factors. Design A cross-sectional study of 102 consecutive, clinically stable ACS survivors. Methods Participants completed a questionnaire measuring pre-hospital decision delay, psychological distress, and several known psychosocial factors related to cardiovascular health: type D personality, resilience, social support, and concerns during the cardiac event. Multiple linear regression and mediation analyses were conducted. Results Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress post-ACS, and these relationships were mediated by longer pre-hospital decision delay. In contrast, resilience was related to lower psychological distress. Social support and social concerns about help-seeking were not related to the outcome variables. Conclusions Type D personality may be a risk factor for more delayed help-seeking for an ACS and higher psychological distress after the cardiac event. Resilience, in contrast, emerged as a potential protective factor of patients' mental health after the cardiac event. Pre-hospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Statement of Contribution What is already known on this subject? Longer pre-hospital decision delay, that is waiting longer to seek medical attention after symptoms have started, predicts poor prognosis of acute coronary syndrome patients. High psychological distress post-ACS, such as the development of anxiety and/or depression, also predicts poor prognosis of these patients. What does this study adds? This study identifies several psychosocial markers of longer prehospital decision delay and high psychological distress post-ACS. Prehospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress, and these relationships were mediated by longer prehospital decision delay. Resilience was related to lower psychological distress post-ACS.

Who does what the cardiologist recommends? Psychosocial markers of unhealthy behavior in coronary disease patients.

Patients diagnosed with coronary heart disease should follow lifestyle recommendations that can reduce their cardiovascular risk (e.g., avoid smoking). However, some patients fail to follow these recommendations and engage in unhealthy behavior. With the aim to identify psychosocial factors that characterize patients at high risk of repeated cardiovascular events, we investigated the relationship between social support, mental health (coping, self-esteem, and perceived stress), and unhealthy behavior. We conducted a cross-sectional study of 419 patients recently diagnosed with coronary heart disease (myocardial infarction or angina) who participated in the National Health Survey in Spain (2018). Unhealthy behaviors were defined according to the European Guidelines on cardiovascular disease prevention. Only 1% of patients reported no unhealthy behaviors, with 11% reporting one, 40% two, 35% three, and 13% four or more unhealthy behaviors. In multiple regression controlling for demographic and traditional risk factors, mental health was the only significant psychosocial factor, doubling the odds of accumulated unhealthy behaviors, OR(high vs. low) = 2.03, 95% CI [1.14, 3.64]. Mental health was especially strongly related to unhealthy behavior among patients with obesity, OR(high vs. low) = 3.50, 95% CI [1.49, 8.45]. The relationship between mental health and unhealthy behaviors suggests that a large proportion of patients may not adhere to lifestyle recommendations not because they purposefully choose to do so, but because they lack coping skills to maintain the recommended healthy behaviors. Low mental well-being may be especially detrimental for behavior change of patients with obesity.