Findings shed new light on factors contributing to heart attack mortality

Cardiovascular disease causes nearly 650,000 deaths per year in the United States and leads to annual costs of more than $200 billion. One of the many conditions under this umbrella is heart attacks. Although heart attack deaths have been decreasing in recent years—in part due to timely medical care—many patients delay care, putting them at risk for serious, and costly, complications. Previous research suggests this delay in care is possibly because patients are unaware of common heart attack symptoms; however, few studies have investigated the possible sociodemographic characteristics associated with this lack of awareness.

In a new study published in JAMA Network Open and presented at an American Heart Association scientific session, Bita Kash, PhD, FACHE, professor in the Department of Health Policy and Management at the Texas A&M School of Public Health and director of the Center for Outcomes Research, a partnership between Houston Methodist and the School of Public Health, investigated heart attack symptom awareness and sociodemographic factors associated with lower awareness. Data was used from a nationally representative health statistics dataset from 2017 that included approximately 25,000 American adults. Additional researchers included cardiologist Khurram Nasir, MD, co-director of the Center for Outcomes Research, along with colleagues from Houston Methodist Research Institute, Baylor College of Medicine, Yale University and other institutions.

The researchers collected responses to questions about whether participants considered five symptoms—chest pain, shortness of breath, arm or shoulder pain, feeling faint and jaw, neck or back pain—to be heart attack signs. They then used the responses to assess awareness of all five symptoms and of the three most common symptoms: chest pain, shoulder or arm pain and shortness of breath. The researchers also analyzed answers about what action to take when someone is having a heart attack, which they categorized as calling 911 or not calling. Their analysis also included information on factors such as age, gender, race, socioeconomic status, education level, insurance status, geographic location and immigration status, which included country of birth, length of residence in the United States and English proficiency.

Kash and colleagues found that 92 percent of the respondents considered chest pain a sign of a heart attack and smaller numbers also knew that shortness of breath and arm or shoulder pain were additional symptoms. Only 53 percent of the respondents were aware of all five symptoms, 20 percent were unaware of the three most common and 6 percent were unaware of any symptoms. Their analysis found that awareness was highest in U.S.-born non-Hispanic white respondents with higher income and education levels and private insurance, whereas black and Hispanic respondents, those living in the south, people with lower income or education levels or without insurance and people not proficient in English had the lowest awareness. The researchers also noted that around 4 percent of respondents chose an action other than calling 911, which was skewed mainly toward uninsured respondents over the age of 65.

This research builds on previous research by identifying respondents most likely to be unaware of heart attack symptoms and determining groups that would most benefit from targeted interventions. This was also the first study to investigate symptom awareness in immigrant groups and focus on duration in the United States and English proficiency.

“Our findings reemphasized the importance of medicine and public health working together in order to improve health outcomes for all Americans, regardless of socioeconomic status. Public health outreach interventions that use culturally appropriate health education curricula and communication strategies can make a big difference among underserved populations as identified in this study,” Kash said.

Although these findings shed new light on factors contributing to heart attack mortality, the study had some limitations that indicate avenues for future research. The closed-ended (yes or no) nature of the questions may have biased responses. An open-ended question asking respondents to list heart attack symptoms without cueing could yield even lower awareness rates. Additionally, the study’s dataset did not contain information on personal factors such as whether respondents or family members have had a heart attack before, which could affect symptom awareness. There may have also been a bias in answers on responding to a heart attack, as calling 911 could be seen as socially desirable. Thus, the proportion of people not calling 911 in a real situation could be even higher. Further study on heart attack symptom responses and reasons for not responding, such as cost concerns or perceived loss of control, will be needed to explore possible barriers to timely care.

Despite these limitations, this study clearly shows how various sociodemographic factors correlate with heart attack symptom awareness. Despite overall awareness increasing in recent years, there is room for improvement and a need for interventions that reach disadvantaged groups and attempt to understand and overcome barriers to receiving the timely care that is crucial for surviving a heart attack.