Rochester, MN - MI patients who are older, female, Hispanic, or black or who have diabetes have particularly long delays in hospital presentation, a new study has found [1]. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care, the authors conclude.

The study, published in the May 12, 2008 issue of the Archives of Internal Medicine, was conducted by a group led by Dr Henry Ting (Mayo Clinic, Rochester, MN). They studied risk factors individually and in combination to determine the cumulative effect on delay times in 482 327 patients with ST-elevation MI enrolled in the National Registry of Myocardial Infarction (NRMI) between 1995 and 2004.

Results showed that the mean time to presentation was 114 minutes from symptom onset. Less than one-third (30.9%) of the patients arrived at the hospital within one hour of the onset of symptoms. Nearly half of the patients (45.5%) presented more than two hours and 8.7% presented more than 12 hours after the onset of symptoms.

Age over 70 years, diabetes, female sex, and black or Hispanic race were all factors associated with longer times to presentation. Some patient subgroups with more than one of these factors had times 40 to 60 minutes longer than patients without these characteristics. For example, an elderly, black, diabetic man or woman arrived 166 or 170 minutes, respectively, after the onset of symptoms, compared with 106 minutes for a younger white man without diabetes, the authors note. Similarly, men or women aged over 70 with diabetes who were Hispanic had delay times 51 minutes longer than younger men identified as white and without diabetes.

"The combination of older age, black or Hispanic race, female sex, and diabetes represented particularly vulnerable subgroups who exhibited delays of much larger magnitude compared with patients with a single risk factor for delay," Ting et al say.

They point out that the mean time to hospital presentation fell from 123 minutes in 1995 to 113 minutes in 2004 and also decreased in some high-risk groups (elderly patients, women, nonwhite patients, and those with noncommercial insurance), which they suggest may be related to educational initiatives such as the National Heart, Lung, and Blood Institute's National Heart Attack Alert Program.

They say: "The present study documented that delays from symptom onset to hospital presentation remain common for patients with STEMI" and: "Of particular concern from this study was that 8.7% of patients with STEMI presented more than 12 hours after the onset of symptoms, which is beyond the window of eligibility for reperfusion therapy as recommended by current guidelines."

Noting that a previous large randomized trial that attempted to decrease times to hospital presentation using an intervention of mass-media campaigns for entire, diverse communities was largely unsuccessful, they point out that the present study identified specific subgroups who are at greatest risk for delays and say that the design and implementation of future interventions must consider how to reach these vulnerable subgroups effectively.