Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. an analysis of 8630 patients in the Northern Sweden MONICA Study

<p>Abstract</p> <p>Background</p> <p>There is conflicting and only scant evidence on the effect of gender on long-term survival after a myocardial infarction (MI). Our aim was to analyse sex-specific survival of patients for up to 23 years after a first MI in northern Sweden and to describe time trends.</p> <p>Methods</p> <p>The Northern Sweden MONICA Myocardial Infarction Registry was linked to The Swedish National Cause of Death Registry for a total of 8630 patients, 25 to 64 years of age, 6762 men and 1868 women, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008.</p> <p>Results</p> <p>Median follow-up was 7.1 years, maximum 23 years and the study included 70 072 patient-years. During the follow-up 45.3% of the men and 43.7% of the women had died. Median survival for men was 187 months (95% confidence interval (CI) 179-194) and for women 200 months (95% CI 186-214). The hazard ratio (HR) for all cause mortality after adjustment for age group was 1.092 (1.010-1.18, <it>P </it>= 0.025) for females compared to males, <it>i.e</it>. 9 percent higher survival in women. After excluding subjects who died before reaching hospital HR declined to 1.017 (95%CI 0.93-1.11, <it>P </it>= 0.7). For any duration of follow-up a higher proportion of women were alive, irrespective of age group. The 5-year survivals were 75.3% and 77.5%, in younger (<57 years) men and women and were 65.5% and 66.3% in older (57-64 years) men and women, respectively. For each of four successive cohorts survival improved. Survival time was longer for women than for men in all age groups.</p> <p>Conclusions</p> <p>Age-adjusted survival was higher among women than men after a first MI and has improved markedly and equally in both men and women over a 23-year period. This difference was due to lower risk for women to die before reaching hospital.</p

Symptoms, prehospital delay and long-term survival in men vs. women with myocardial infarction : a combined register and qualitative study

The general aim of this thesis was to study symptoms, prehospital delay and time trends in long-term survival in men and women with myocardial infarction (MI). The study was based on quantitative and qualitative data collections. Study I was based on The Northern Sweden MONICA Myocardial Infarction Registry, 1989-2003, including 5072 men and 1470 women with a confirmed MI. Symptoms and prehospital delay were described and trends over time according to sex and age were studied. Typical pain was present in 86% of the men and 81% of the women and typical symptoms were more common among younger persons than older persons. Up to the age of 65 no gender differences were seen in the prehospital delay. In the oldest age group (65–74 years) time to hospital was longer than among the younger group, especially among women. Study II was based on individual interviews with 20 men with a first confirmed MI, representing the age range 65-80 years, about their experiences during the prehospital phase. The interviews were analyzed using qualitative content analysis. The interviewed older men described how the symptoms developed from diffuse ill-being, to a cluster of severe symptoms. The men had difficulties to relate to the experienced symptoms, which did not correspond to their expectations about an MI, and about whether they should seek medical care. By using different strategies the participants initially tried to understand, reduce, or treat the symptoms by themselves, with a desire to maintain an ordinary life. As the symptoms evolved to a persistent and alarming chest pain, the men realized the seriousness in the perceived symptoms, that all strategies were inefficacious and they came to the decision to seek medical care. Study III was based on individual interviews with 20 women with a first confirmed MI, representing the age range 65-80 years, about their experiences during the prehospital phase. The interviews were analyzed using qualitative content analysis. The interviewed older women described how the symptoms were perceived as a stepwise evolvement from intangible and bodily sensations to a more distinct, persistent and finally overwhelming chest pain. The women struggled against the symptoms and used different strategies, by downplaying and neglecting the symptoms in order to maintain control over their ordinary lives and maintain the social responsibilities. As the symptoms evolved to a persistent and overwhelming chest pain the women realized the seriousness in the perceived symptoms, they were not able to struggle against them anymore and they came to the decision to seek medical care. Study IV was based on The Northern Sweden MONICA Myocardial Infarction Registry which was linked to The Swedish National Cause of Death Registry for 6762 men and 1868 women, 25 to 64 years of age, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008. Between 1985 and 2006 long-term survival after a first MI increased in both men and women. Over the whole 23-year period women showed a 9 percent higher survival then men. This slight difference was due to lower risk for women to die before reaching hospital, and during the last period similar rates of long time survival were noted in men and women. In conclusion there were no major differences between men and women in symptoms, prehospital delay or long-term survival. However, older patients had fewer typical symptoms and longer prehospital delay, especially among women. The prehospital phase was found to be multifaceted with experiences difficult to interpret in both men and women, with a dynamic development of symptoms, conceptions and expectations while the participants strove to maintain the ordinary and familiar life. The symptoms experienced presented a more heterogeneous and complex picture in both men and women than is usually described in the literature. Women under the age of 65 have a slightly higher age-adjusted long-term survival than men. Over a 23-year period long-term survival has improved similarly in both men and women.Det övergripande syftet med avhandlingen var att beskriva symtom, prehospital fördröjning och långtidsöverlevnad hos män och kvinnor med hjärtinfarkt. Studien baserades på kvantitativa och kvalitativa datainsamlingar. Delstudie I baserades på data från hjärtinfarktregistret vid The Northern Sweden MONICA Study under åren 1989-2003, inkluderande 5072 män och 1470 kvinnor, med fastställd hjärtinfarkt. Symtom och tid från symtomstart till medicinsk vård beskrevs och tidstrender relaterades till kön och ålder. Resultatet visade att typisk smärta förelåg hos 86% av männen och 81% av kvinnorna och att typiska symtom var mer förekommande hos de yngre. Upp till 65 års ålder fanns inga könsskillnader mellan symtomstart och tid till medicinsk vård. I den äldsta åldersgruppen (65-74 år) var tiden till sjukvård längre, främst hos kvinnor. Delstudie II baserades på individuella intervjuer med 20 män, mellan 65 och 80 år som drabbats av sin första hjärtinfarkt, om hur de upplevde den prehospitala fasen. Intervjuerna analyserades med hjälp av kvalitativ innehållsanalys. Männen beskrev hur symtomen utvecklades från ett diffust illabefinnande, till ett kluster av  svåra symtom. De hade svårt att relatera till de upplevda symtomen som inte motsvarade deras föreställningar om hur symtom på hjärtinfarkt tar sig uttryck, och hade svårt att veta om de skulle söka vård. Deltagarna vidtog olika strategier för att försöka förstå, minska eller behandla symtomen på egen hand, i en strävan att få livet att fortgå som vanligt. När symtomen utvecklats till en alarmerande och ihållande bröstsmärta insåg männen  allvarlighetsgraden i symtombilden och att strategierna för att hantera symtomen var verkningslösa och beslutade att söka vård. Delstudie III baserades på individuella intervjuer med 20 kvinnor, med sin första hjärtinfarkt i åldern 65-80 år, för att få en djupare förståelse för hur de upplevde den prehospitala fasen. Intervjuerna analyserades med hjälp av kvalitativ innehållsanalys. De äldre kvinnorna beskrev hur symtomen stegvis utvecklades från ogripbara och kroppsliga förnimmelser, mot en mer distinkt, ihållande och slutligen överväldigande bröstsmärta. Kvinnorna kämpade mot symtomen och använde olika strategier, som att tona ner och negligera symtomen för att behålla kontrollen över livssituationen och upprätthålla det sociala ansvarstagandet. När symtomen utvecklades till en ihållande och överväldigande bröstsmärta insåg kvinnorna allvarlighets­graden i symtombilden, att de inte kunde kämpa mot symtomen längre och beslutade att söka vård. Delstudie IV inkluderade patienter med en första hjärtinfarkt mellan åren 1985 och 2006 validerade i hjärtinfarktregistret vid The Northern Sweden MONICA Study i Norr- och Västerbotten som följdes upp i dödsorsaksregistret tom 30 augusti, 2008. Totalt 6762 män och 1868 kvinnor i åldern 25-64 studerades. Även patienter som avled före sjukhusvård inkluderades. Resultatet visade att mellan 1985 och 2006 förbättrades långtidsöverlevnaden efter en första hjärtinfarkt hos både män och kvinnor. Över hela 23-års perioden hade kvinnor 9 procents högre åldersjusterad överlevnad jämfört med män. Denna skillnad berodde på lägre risk för kvinnor att avlida innan de nådde sjukhuset. Under den sista tidsperioden var långtidsöverlevnad lika hos både män och kvinnor. Sammanfattningsvis visar denna studie inga stora skillnader mellan män och kvinnors symtom, prehospitala fördröjning eller långtidsöverlevnad. Dock hade äldre patienter färre typiska symtom och längre prehospital fördröjning, särskilt hos kvinnor. Den prehospitala fasen var en mångfasetterad och svårtolkad upplevelse hos både män och kvinnor, med en dynamisk utveckling av symtom, föreställningar och förväntningar, samtidigt som deltagarna strävade efter att upprätthålla det vardagliga och välbekanta livet.  Symtomen vid hjärtinfarkten  var en mer heterogen och komplex upplevelse hos både män och kvinnor än vad som vanligtvis beskrivs i litteraturen. Över en 23-års period har långtidsöverlevnaden efter en första hjärtinfarkt förbättrats hos både män och kvinnor. Kvinnor under 65 år har en något högre långtidsöverlevnad jämfört med män

From insecurity to perceived control over the heart failure disease–A qualitative analysis

Aims and objectives: The objective in our study was to explore chronic heart failure patients’ perceived control over their heart disease. Background: Higher levels of perceived control over one’s chronic heart disease are associated with lower levels of psychological distress and a higher quality of life. Design: The study has an explorative and descriptive design using a directed manifest qualitative content analysis according to Marring. Methods: The analysis was based on nine interviews with four men and five women aged between 62-85 years, diagnosed with chronic heart failure. The study followed consolidated criteria for reporting qualitative research (COREQ). Results: Five categories emerged in the analysis, mirroring a step-by-step process. The first step, insecurity, was followed by evaluation, management and adjustment. The patients finally reached a higher level of perceived control over their lives in relation to their heart disease. Conclusions: Most of the patients stated that they could assess and manage symptoms and had adapted to their condition, which increased their level of perceived control. Relevance to clinical practice: These findings suggest that managing symptoms is important for strengthen the patients with chronic heart failure. The findings can help health care professionals in communication with the patient planning for self-care actions.DOI does not work: https://doi.org/10.15406/ncoaj.2019.06.00191</p

Gender disparities in first medical contact and delay in ST-elevation myocardial infarction : a prospective multicentre Swedish survey study

OBJECTIVES: Compare gender disparities in ST-elevation myocardial infarction (STEMI) regarding first medical contact (FMC) and prehospital delay times and explore factors associated with prehospital delay in men and women separately. DESIGN: Cross-sectional study based on medical records and a validated questionnaire. Eligible patients were enrolled within 24 hours after admittance to hospital. SETTING: Patients were included from November 2012 to January 2014 from five Swedish hospitals with catheterisation facilities 24/7. PARTICIPANTS: 340 men and 109 women aged between 31 and 95 years completed the survey. MAIN OUTCOME MEASURES: FMC were divided into five possible contacts: primary healthcare centre by phone or directly, national advisory nurse by phone, emergency medical services (EMS) and emergency room directly. Two parts of prehospital delay times were studied: time from symptom onset to FMC and time from symptom onset to diagnostic ECG. RESULTS: Women more often called an advisory nurse as FMC (28% vs 18%, p=0.02). They had a longer delay until FMC, 90 (IQR 39-221) vs 66 (28-161) min, p=0.04 and until ECG, 146 (68-316) vs 103 (61-221) min, p=0.03. Men went to hospital because of believing they were stricken by an MI to a higher extent than women did (25% vs 15%, p=0.04) and were more often recommended to call EMS by bystanders (38% vs 22%, p&lt;0.01). Hesitating about going to hospital and experiencing pain in the stomach/back/shoulders were factors associated with longer delays in women. Believing the symptoms would disappear or interpreting them as nothing serious were corresponding factors in men. In both genders bystanders acting by contacting EMS explained shorter prehospital delays. CONCLUSIONS: In STEMI, women differed from men in FMC and they had longer delays. This was partly due to atypical symptoms and a longer decision time. Bystanders acted more promptly when men than when women fell ill. Public knowledge of MI symptoms, and how to act properly, still seems insufficient

First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study

Objective: It is unknown into what extent patients with ST-elevation myocardial infarction (STEMI) utilise a joint service number (Swedish Healthcare Direct, SHD) as first medical contact (FMC) instead of Emergency Medical Services (EMS) and how this impact time to diagnosis. We aimed to (1) describe patients FMC; (2) find explanatory factors influencing their FMC (ie, EMS and SHD) and (3) explore the time interval from symptom onset to diagnosis. Setting: Multicentred study, Sweden. Methods: Cross-sectional, enrolling patients with consecutive STEMI admitted within 24 h from admission. Results: We included 109 women and 336 men (mean age 66 +/- 11 years). Although 83% arrived by ambulance to the hospital, just half of the patients (51%) called EMS as their FMC. Other utilised SHD (21%), contacted their primary healthcare centre (14%), or went directly to the emergency room (14%). Reasons for not contacting EMS were predominantly; (1) my transport mode was faster (40%), (2) did not consider myself sick enough (30%), and (3) it was easier to be driven or taking a taxi (25%). Predictors associated with contacting SHD as FMC were female gender (OR 1.92), higher education (OR 2.40), history of diabetes (OR 2.10), pain in throat/neck (OR 2.24) and pain intensity (OR 0.85). Predictors associated with contacting EMS as FMC were history of MI (OR 2.18), atrial fibrillation (OR 3.81), abdominal pain (OR 0.35) and believing the symptoms originating from the heart (OR 1.60). Symptom onset to diagnosis time was significantly longer when turning to the SHD instead of the EMS as FMC (1: 59 vs 1: 21 h, pless than0.001). Conclusions: Using other forms of contacts than EMS, significantly prolong delay times, and could adversely affect patient prognosis. Nevertheless, having the opportunity to call the SHD might also, in some instances, lower the threshold for taking contact with the healthcare system, and thus lowers the number that would otherwise have delayed even longer.Funding Agencies|Medical Research Council of Southeast Sweden (FORSS) [161061]</p

First medical contact in patients with STEMI and its impact on time to diagnosis : an explorative cross-sectional study

OBJECTIVE: It is unknown into what extent patients with ST-elevation myocardial infarction (STEMI) utilise a joint service number (Swedish Healthcare Direct, SHD) as first medical contact (FMC) instead of Emergency Medical Services (EMS) and how this impact time to diagnosis. We aimed to (1) describe patients' FMC; (2) find explanatory factors influencing their FMC (ie, EMS and SHD) and (3) explore the time interval from symptom onset to diagnosis. SETTING: Multicentred study, Sweden. METHODS: Cross-sectional, enrolling patients with consecutive STEMI admitted within 24 h from admission. RESULTS: We included 109 women and 336 men (mean age 66±11 years). Although 83% arrived by ambulance to the hospital, just half of the patients (51%) called EMS as their FMC. Other utilised SHD (21%), contacted their primary healthcare centre (14%), or went directly to the emergency room (14%). Reasons for not contacting EMS were predominantly; (1) my transport mode was faster (40%), (2) did not consider myself sick enough (30%), and (3) it was easier to be driven or taking a taxi (25%). Predictors associated with contacting SHD as FMC were female gender (OR 1.92), higher education (OR 2.40), history of diabetes (OR 2.10), pain in throat/neck (OR 2.24) and pain intensity (OR 0.85). Predictors associated with contacting EMS as FMC were history of MI (OR 2.18), atrial fibrillation (OR 3.81), abdominal pain (OR 0.35) and believing the symptoms originating from the heart (OR 1.60). Symptom onset to diagnosis time was significantly longer when turning to the SHD instead of the EMS as FMC (1:59 vs 1:21 h, p&lt;0.001). CONCLUSIONS: Using other forms of contacts than EMS, significantly prolong delay times, and could adversely affect patient prognosis. Nevertheless, having the opportunity to call the SHD might also, in some instances, lower the threshold for taking contact with the healthcare system, and thus lowers the number that would otherwise have delayed even longer