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

Sammanfattning: 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.