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© The European Society of Cardiology 2012. Background: Patient delay in seeking treatment for acute coronary syndrome symptoms remains a problem. Thus, it is vital to test interventions to improve this behavior, but at the same time it is essential that interventions not increase anxiety. Purpose: To determine the impact on anxiety and perceived control of an individual face-to-face education and counseling intervention designed to decrease patient delay in seeking treatment for acute coronary syndrome symptoms. Methods: This was a multicenter randomized controlled trial of the intervention in which anxiety data were collected at baseline, 3-months and 12-months. A total of 3522 patients with confirmed coronary artery disease were enrolled; data from 2597 patients with anxiety data at all time points are included. The intervention was a 45 min education and counseling session, in which the social, cognitive and emotional responses to acute coronary syndrome symptoms were discussed as were barriers to early treatment seeking. Repeated measures analysis of covariance was used to compare anxiety and perceived control levels across time between the groups controlling for age, gender, ethnicity, education level, and comorbidities. Results: There were significant differences in anxiety by group (p = 0.03). Anxiety level was stable in patients in the control group, but decreased across time in the intervention group. Perceived control increased across time in the intervention group and remained unchanged in the control group (p = 0.01). Conclusion: Interventions in which cardiac patients directly confront the possibility of an acute cardiac event do not cause anxiety if they provide patients with appropriate strategies for managing symptoms.

Objectives: Symptoms are compared among patients with coronary artery disease (CAD) admitted to the emergency department with or without acute coronary syndrome (ACS). Sex and age are also assessed. Methods: A secondary analysis from the PROMOTION (Patient Response tO Myocardial Infarction fOllowing a Teaching Intervention Offered by Nurses) trial, an multicenter randomized controlled trial, was conducted. Results: Of 3522 patients with CAD, at 2 years, 565 (16%) presented to the emergency department, 234 (41%) with non-ACS and 331 (59%) with ACS. Shortness of breath (33% vs 25%, P =.028) or dizziness (11% vs 3%, P =.001) were more common in non-ACS. Chest pain (65% vs 77%, P =.002) or arm pain (9% vs 21%, P =.001) were more common in ACS. In men without ACS, dizziness was more common (11% vs 2%; P =.001). Men with ACS were more likely to have chest pain (78% vs 64%; P =.003); both men and women with ACS more often had arm pain (men, 19% vs 10% [P =.019]; women, 26% vs 13% [P =.023]). In multivariate analysis, patients with shortness of breath (odds ratio [OR], 0.617 [confidence interval [CI], 0.410-0.929]; P =.021) or dizziness (OR,.0311 [CI, 0.136-0.708]; P =.005) were more likely to have non-ACS. Patients with prior percutaneous coronary intervention (OR, 1.592 [CI, 1.087-2.332]; P =.017), chest pain (OR, 1.579 [CI, 1.051-2.375]; P =.028), or arm pain (OR, 1.751 [CI, 1.013-3.025]; P <.042) were more likely to have ACS. Conclusions: In patients with CAD, shortness of breath and dizziness are more common in non-ACS, whereas prior percutaneous coronary intervention and chest or arm pain are important factors to include during ACS triage. © 2012 Elsevier Inc. All rights reserved.

Objective: To examine the association of symptoms of persistent anxiety with the development of acute cardiac events in patients with coronary heart disease (CHD) followed for 2 years. The prevalence of symptoms of anxiety is high in patients with CHD, but their effect on cardiac events and mortality has not been well characterized. Methods: Of 3522 patients with confirmed CHD enrolled, data on symptoms of anxiety were available at two time points in 3048 patients who were then followed up for detection of the composite end point of hospitalization for myocardial infarction, unstable or stable angina, other cardiac causes, or all-cause mortality. A composite anxiety symptoms score composed of baseline and 3-month anxiety data, in which the continuous-level scores were used, was tested using Cox proportional hazards regression model. Groups (persistent anxiety [anxiety at both time points] versus nonanxious [no anxiety at either time point] versus not persistently anxious [anxiety only at one time point]) were also compared. Results: Symptoms of persistent anxiety, whether considered as a continuous-or categorical-level variable, were associated with shorter time to event. Persistent anxiety remained as an independent predictor of the end point after controlling for multiple variables (persistent anxiety as a summary score [hazard ratio = 1.27, 95% confidence interval = 1.067-1.514] and persistent anxiety as a categorical variable [hazard ratio = 1.52, 95% confidence interval = 1.149-2.015]). Conclusions: By measuring anxiety symptoms at more than one time point and controlling for relevant sociodemographic, comorbidity, risk factor, and psychological covariates, we illustrate that symptoms of persistent anxiety are a strong, independent predictor of cardiac event-free survival. © 2011 by the American Psychosomatic Society.

Objective: Prolonged prehospital delay in persons experiencing acute coronary syndrome (ACS) remains a problem. Understanding which patients respond best to particular interventions designed to decrease delay time would provide mechanistic insights into the process by which interventions work. Methods: In the PROMOTION trial, 3522 at-risk patients were enrolled from 5 sites in the United States (56.4%), Australia and New Zealand; 490 (N= 272 intervention, N= 218 control) had an acute event within 2 years. Focusing on these 490, we (1) identified predictors of a rapid response to symptoms, (2) identified intervention group subjects with a change in these predictors over 3 months of follow-up, and (3) compared intervention group participants with and without the favorable response pattern. Hypothesized predictors of rapid response were increased perceived control and decreased anxiety. Knowledge, attitudes, and beliefs were hypothesized to differ between responders and non-responders. Results: Contrary to hypothesis, responders had low anxiety and low perceived control. Only 73 (26.8%) subjects showed this pattern 3 months following the intervention. No differences in ACS knowledge, attitudes, or beliefs were found. Conclusion: The results of this study challenge existing beliefs. Practice implications: New intervention approaches that focus on a realistic decrease in anxiety and perceived control are needed. © 2011 Elsevier Ireland Ltd.

Background: Incident anxiety and depression are associated separately with cardiac events and mortality in patients after acute coronary syndromes, but the influence of persistent comorbid depression and anxiety on mortality remains unknown. The purpose of this study was to determine the prevalence of comorbid persistent depressive and anxious symptoms in individuals with ischemic heart disease and to evaluate effects on mortality. Methods: Prospective, longitudinal cohort design in the context of a randomized trial to decrease patient delay in seeking treatment for ischemic heart symptoms (PROMOTION trial) was used, with twelve-month follow-up of 2325 individuals with stable ischemic heart disease. Participants were assessed on enrollment and at 3 months using the Multiple Adjective Affect Checklist and the Brief Symptom Inventory for depressive and anxious symptoms, respectively. Results: At 3 months, 608 individuals (61.7%) reported persistent symptoms of depression, anxiety, or both. Three hundred seventy-nine (42.5%) and 1056 (45.4%) had persistent anxious and depressive symptoms, respectively. Those with persistent, comorbid symptoms had higher mortality compared to others (p = .029). The combined presence of anxious and depressive symptoms contributed significantly to mortality when compared to symptom-free participants (OR 2.35, 95% CI 1.23-4.47, p = .010). The presence of persistent depressive symptoms only and persistent anxious symptoms only were not associated with death, when other demographic and clinical variables were considered. Conclusions: Persistent symptoms of anxiety and depression increased substantially the risk of death in patients with ischemic heart disease. Future research into shared and unique pathways and treatments is needed. © 2009 Elsevier Ireland Ltd.

Background: The timely and accurate identification of symptoms of acute coronary syndrome (ACS) is a challenge for patients and clinicians. It is unknown whether response times and clinical outcomes differ with specific symptoms. We sought to identify which ACS symptoms are related-symptom clusters-and to determine if sample characteristics, response times, and outcomes differ among symptom cluster groups. Methods: In a multisite randomized clinical trial, 3522 patients with known cardiovascular disease were followed up for 2 years. During follow-up, 331 (11%) had a confirmed ACS event. In this group, 8 presenting symptoms were analyzed using cluster analysis. Differences in symptom cluster group characteristics, delay times, and outcomes were examined. Results: The sample was predominately male (67%), older (mean 67.8, S.D. 11.6 years), and white (90%). Four symptom clusters were identified: Classic ACS characterized by chest pain; Pain Symptoms (neck, throat, jaw, back, shoulder, arm pain); Stress Symptoms (shortness of breath, sweating, nausea, indigestion, dread, anxiety); and Diffuse Symptoms, with a low frequency of most symptoms. Those in the Diffuse Symptoms cluster tended to be older (P = .08) and the Pain Symptoms group was most likely to have a history of angina (P = .01). After adjusting for differences, the Diffuse Symptoms cluster demonstrated higher mortality at 2 years (17%) than the other 3 clusters (2%-5%, P < .001), although prehospital delay time did not differ significantly. Conclusion: Most ACS symptoms occur in groups or clusters. Uncharacteristic symptom patterns may delay diagnosis and treatment by clinicians even when patients seek care rapidly. Knowledge of common symptom patterns may facilitate rapid identification of ACS. © 2010 Mosby, Inc. All rights reserved.

Background. Incident anxiety and depression are associated separately with cardiac events and mortality in patients after acute coronary syndromes, but the influence of persistent comorbid depression and anxiety on mortality remains unknown. The purpose of this study was to determine the prevalence of comorbid persistent depressive and anxious symptoms in individuals with ischemic heart disease and to evaluate effects on mortality. Methods. Prospective, longitudinal cohort design in the context of a randomized trial to decrease patient delay in seeking treatment for ischemic heart symptoms (PROMOTION trial) was used, with twelve-month follow-up of 2325 individuals with stable ischemic heart disease. Participants were assessed on enrollment and at 3 months using the Multiple Adjective Affect Checklist and the Brief Symptom Inventory for depressive and anxious symptoms, respectively. Results. At 3 months, 608 individuals (61.7%) reported persistent symptoms of depression, anxiety, or both. Three hundred seventy-nine (42.5%) and 1056 (45.4%) had persistent anxious and depressive symptoms, respectively. Those with persistent, comorbid symptoms had higher mortality compared to others (p = .029). The combined presence of anxious and depressive symptoms contributed significantly to mortality when compared to symptom-free participants (OR 2.35, 95% CI 1.23–4.47, p = .010). The presence of persistent depressive symptoms only and persistent anxious symptoms only were not associated with death, when other demographic and clinical variables were considered. Conclusions. Persistent symptoms of anxiety and depression increased substantially the risk of death in patients with ischemic heart disease. Future research into shared and unique pathways and treatments is needed.

Background: The timely and accurate identification of symptoms of acute coronary syndrome (ACS) is a challenge forpatients and clinicians. It is unknown whether response times and clinical outcomes differ with specific symptoms. We sought toidentify which ACS symptoms are related 'symptom clusters' and to determine if sample characteristics, response times, and outcomes differ among symptom cluster groups. Methods: In a multisite randomized clinical trial, 3522 patients with known cardiovascular disease were followed up for 2 years. During follow-up, 331 (11%) had a confirmed ACS event. In this group, 8 presenting symptoms were analyzed using cluster analysis. Differences in symptom cluster group characteristics, delay times, and outcomes were examined. Results: The sample was predominately male (67%), older (mean 67.8, S.D. 11.6 years), and white (90%). Four symptom clusters were identified: Classic ACS characterized by chest pain; Pain Symptoms (neck, throat, jaw, back, shoulder, arm pain); Stress Symptoms (shortness of breath, sweating, nausea, indigestion, dread, anxiety); and Diffuse Symptoms, with a low frequency of most symptoms. Those in the Diffuse Symptoms cluster tended to be older (P = .08) and the Pain Symptoms group was most likely to have a history of angina (P = .01). After adjusting for differences, the Diffuse Symptoms cluster demonstrated higher mortality at 2 years (17%) than the other 3 clusters (2%-5%, P b .001), although prehospital delay time did not differ significantly. Conclusion: Most ACS symptoms occur in groups or clusters. Uncharacteristic symptom patterns may delay diagnosis and treatment by clinicians even when patients seek care rapidly. Knowledge of common symptom patterns may facilitate rapid identification of ACS.

Background-Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time. Methods and Results-Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67±11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%). Conclusions-The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge. Clinical Trial Registration- clinicaltrials.gov. Identifier NCT00734760. © 2009 American Heart Association, Inc.

Background: Coronary heart disease (CHD) and acute coronary syndrome (ACS) remain significant public health problems. The effect of ACS on mortality and morbidity is largely dependent on the time from symptom onset to the time of reperfusion, but patient delay in presenting for treatment is the main reason timely reperfusion is not received. Objectives: We tested the effect of an education and counseling intervention on knowledge, attitudes and beliefs about ACS symptoms and the appropriate response to symptoms, and identified patient characteristics associated with changes in knowledge, attitudes and beliefs over time. Methods: We conducted a two-group randomized controlled trial in 3522 people with CHD. The intervention group received a 40 min, one-on-one education and counseling session. The control group received usual care. Knowledge, attitudes and beliefs were measured at baseline, 3 and 12 months using the ACS Response Index and analyzed with repeated measures analysis of variance. Results: Knowledge, attitudes and beliefs scores increased significantly from baseline in the intervention group compared to the control group at 3 months, and these differences were sustained at 12 months (p = .0005 for all). Higher perceived control over cardiac illness was associated with more positive attitudes (p < .0005) and higher state anxiety was associated with lower levels of knowledge (p < .05), attitudes (p < .05) and beliefs (p < .0005). Conclusion: A relatively short education and counseling intervention increased knowledge, attitudes and beliefs about ACS and response to ACS symptoms in individuals with CHD. Higher perceived control over cardiac illness was associated with more positive attitudes and higher state anxiety was associated with lower levels of knowledge, attitudes and beliefs about responding to the health threat of possible ACS. © 2009 Elsevier Ltd. All rights reserved.

Background: Perceived control is a construct with important theoretical and clinical implications for healthcare providers, yet practical application of the construct in research and clinical practice awaits development of an easily administered instrument to measure perceived control with evidence of reliability and validity. Objective: To test the psychometric properties of the Control Attitudes Scale-Revised (CAS-R) using a sample of 3,396 individuals with coronary heart disease, 513 patients with acute myocardial infarction, and 146 patients with heart failure. Methods: Analyses were done separately in each patient group. Reliability was assessed using Cronbach's alpha to determine internal consistency, and item homogeneity was assessed using item-total and interitem correlations. Validity was examined using principal component analysis and testing hypotheses about known associations. Results: Cronbach's alpha values for the CAS-R in patients with coronary heart disease, acute myocardial infarction, and heart failure were all greater than. 70. Item-total and interitem correlation coefficients for all items were acceptable in the groups. In factor analyses, the same single factor was extracted in all groups, and all items were loaded moderately or strongly to the factor in each group. As hypothesized in the final construct validity test, in all groups, patients with higher levels of perceived control had less depression and less anxiety compared with those of patients who had lower levels of perceived control. Conclusion: This study provides evidence of the reliability and validity of the 8-item CAS-R as a measure of perceived control in patients with cardiac illness and provides important insight into a key patient construct.

Background: Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomised trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time. Methods and Results: Participants (n=3522) with documented coronary heart disease were randomised to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67 +/- 11 years, and 68% were male. over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%). Conclusions: The education and counselling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge. Clinical Trial Registration: clinicaltrials.gov. Identifier NCT00734760.(Circ Cardiovasc Qual Outcomes. 2009;2:525-532).

Background: The effectiveness of therapy for an acute coronary syndrome (ACS) is dependent on patients' quick decision to seek treatment. We surveyed patients' level of knowledge about heart disease and self-perceived risk for a future acute myocardial infarction (AMI) in patients with documented ischemic heart disease. Methods: Patients (N = 3522) had a mean age of 67 years, 68% were male, and all had a history of AMI or invasive cardiac procedure for ischemic heart disease. Data were gathered using a 26-item instrument focusing on ACS symptoms and appropriate steps to seeking treatment. Patients were asked to identify their level of perceived risk for a future AMI. Results: Forty-six percent of patients had low knowledge levels (ie, <70% of answers were correct). The mean score was 71%. Higher knowledge scores were significantly related to female sex (P = .001), younger age (P = .001), higher education (P = .001), participation in cardiac rehabilitation (P = .001), and receiving care by a cardiologist rather than an internist or general practitioner (P = .005). Clinical history (eg, AMI [P = .24] and cardiac surgery [P = .38]) were not significant predictors of knowledge. Most (57%) identified themselves as being at higher risk for a future AMI compared with an age-matched individual without heart disease with 1 exception. Namely, patients who had undergone coronary artery bypass surgery felt significantly less vulnerable for a future AMI than other individuals of the same age. Conclusions: Even following diagnosis of ACS and numerous interactions with physicians and other health care professionals, knowledge about ACS symptoms and treatment on the part of patients with cardiac disease remains poor. Patients require continued reinforcement about the nature of cardiac symptoms, the benefits of early treatment, and their risk status. ©2008 American Medical Association. All rights reserved.

Knowledge, attitudes, and beliefs of persons with ischemic heart disease are important predictors of delay in seeking treatment. We tested the psychometric profile of the Acute Coronary Syndrome (ACS) Response Index, a measure assessing patient knowledge, attitudes and beliefs about ACS symptoms and response, in 3,522 patients. On factor analysis, 21 dichotomous knowledge items loaded onto four factors (alpha .82). In a separate factor analysis, another five items loaded on two attitude factors, and seven items loaded on two belief factors (alpha .76). The scales discriminated between patients previously exposed to medical experts. Scale scores were significantly correlated but without evidence of multicolinearity. Initial tests of reliability and validity support further testing of this new instrument. © 2007 Wiley Periodicals, Inc.