Factors leading to delayed presentation among patients presenting with ST-elevation Myocardial Infarction in Emergency Department of a tertiary care hospital.


  • Imran Zameer Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan.
  • Adnan Baig Rawalpindi Institute of cardiology, Rawalpindi, Pakistan.
  • Zubair Ahmed Rawalpindi Institute of cardiology, Rawalpindi, Pakistan.
  • Junaid Qayyum Medicine Department, Benazir Bhutto Hospital, Rawalpindi, Pakistan
  • Asad Amir Department of General Surgery, Holy Family Hospital, Rawalpindi, Pakistan.
  • Saima Rauf Royal Bolton Hospital, United Kingdom
  • Adam Umair Ashraf Butt Medicine Department, Benazir Bhutto Hospital, Rawalpindi, Pakistan
  • Muhammad Sarfraz Khan Medicine Department, Benazir Bhutto Hospital, Rawalpindi, Pakistan
  • Abdur Rehman Malik Medicine Department, Benazir Bhutto Hospital, Rawalpindi, Pakistan
  • Areeb Khalid Medicine Department, Benazir Bhutto Hospital, Rawalpindi, Pakistan




ST-Elevation Myocardial Infarction, Thrombolytic Therapy, Percutaneous Coronary Intervention, Electrocardiography


The duration between the onset of myocardial infarction and first intervention plays a pivotal role in saving the life of the patients. Objective: To determine the frequency of various pre-hospital factors causing delay among patients presenting with STEMI in the emergency department of a teaching hospital. Methods: This is a descriptive observational study conducted at the Cardiology Department, Rawalpindi Institute of Cardiology (RIC), Rawalpindi from March to August 2019. A total of 142 patients presenting with ST-elevation myocardial infarction (STEMI) to the Emergency Department (ED) of RIC were enrolled. Electrocardiograms (ECGs) were reviewed for confirmation of STEMI and find the type of MI. Echo-cardiography was done to find out the ejection fraction (EF) of the left ventricle. Type of reperfusion therapy either thrombolytic therapy or primary percutaneous coronary intervention (PCI), time of symptom onset, and time of presentation in ED of RIC were noted.  Patients were divided into four major groups depending upon the possible factors for delayed presentation: 1) Misinterpretation of symptoms, 2) Ignorance Of reporting urgently or waiting for symptoms to resolve, 3) Transportation problem and 4) First presentational facility where thrombolytic unavailable. Data were analyzed using the Statistical Package for Social Sciences (SPSS) v.23.0 (IBM, Armonk, U.S.). Results: The mean age was 53.2(SD=15.5). Out of 142 patients, most of them were males 130(91.5%). In our study, the majority 46.5% had a primary level of education.  Transportation problems were the main reason for delayed presentation accounting for 45(34.5%), followed by misinterpretation of symptoms 40(28.2%), patients first presented at a facility where thrombolytic therapy was unavailable 27(19%) and patients were either ignorant of reporting urgently to a hospital or they waited for symptoms to resolve 26(18.3%). There was a significant difference in point of the first consultation, MI type, and time duration of delayed presentation among groups (P<.05). Conclusion: Transportation problems and misinterpretation of symptoms are the main reasons for the delay in getting reperfusion treatment for ST-elevation MI. Providing better primary care facilities available to rural areas as well as targeted awareness campaigns will greatly help in this regard.


Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol. 2017 Jul 4; 70(1): 1-25. https://doi.org/10.1016/j.jacc.2017.04.052

Rodrigues JA, Melleu K, Schmidt MM, Gottschall CAM, Moraes MAP, Quadros AS: Independent Predictors of Late Presentation in Patients with ST-Segment Elevation Myocardial Infarction. Arq Bras Cardiol. 2018, 111:587-93. https://doi.org/10.5935/abc.20180178

Albrahim M ,Amjad M. Ahmed , Alwakeel AR , Hijji F , Al-Mallah MH. Predictors of delayed pre-hospital presentation among patients with ST-segment elevation myocardial infarction. .Qatar Med J. 2016; 2016(1): 7. https://doi.org/10.5339/qmj.2016.7

Choudhary R, Sharma SM, Kumar V, Gautam DK. An Observational study of prehospital and hospital delay in reperfusion for acute myocardial infarction at a University Hospital in India. J Pract Cardiovasc Sci 2016;2:163-8. https://doi.org/10.4103/2395-5414.201378

Shah, G. F., Memon, S. H., Shaikh, A. A., Memon, A. G., Kumar, J., & Almas, T. (2020). Factors Responsible for Late Presentation of STEMI Patients in our Population. Journal of Pharmaceutical Research International, 32(30), 6-10. https://doi.org/10.9734/jpri/2020/v32i3030895

Ibanez B, James S, Agewall S, et al.: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018, 39:11977.https://doi.org/10.1093/eurheartj/ehx393

Boersma E, Maas AC, Deckers JW, et al.: Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996, 348:771-775. https://doi.org/10.1016/S0140-6736(96)02514-7

Langer A, Goodman SG, Topol EJ, et al.: Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6-24 hours after onset of acute myocardial infarction. Lancet. 1993, 342:759-766. https://doi.org/10.1016/0140-6736(93)91538-W

Mohan B, Bansal R, Dogra N, et al.: Factors influencing prehospital delay in patients presenting with ST-elevation myocardial infarction and the impact of prehospital electrocardiogram. Indian Heart J. 2018, 70 Suppl 3:S194-8. https://doi.org/10.1016/j.ihj.2018.10.395

Denktas AE, Anderson HV, McCarthy J, Smalling RW: Total ischemic time: the correct focus of attention for optimal ST-segment elevation myocardial infarction care. JACC Cardiovasc Interv. 2011, 4:599-604. https://doi.org/10.1016/j.jcin.2011.02.012

Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013 Sep 5;369(10):901-9. https://doi.org/10.1056/NEJMoa1208200

Flynn A, Moscucci M, Share D, Smith D, LaLonde T, Changezi H, Riba A, Gurm HS. Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Arch Intern Med. 2010 Nov 8;170(20):1842-9.https://doi.org/10.1001/archinternmed.2010.381

JA khan. Factors causing delayed presentation of patients with acute myocardial infarction to the hospital. Pak Armed Forces Med J 2011; 61 (4): 511-5. https://www.pafmj.org/index.php/PAFMJ/article/download/1081/912/

Khalid SH, Liaqat I, Mallhi TH, Khan AH, Ahmad J, Khan YH. Impact of diabetes mellitus on clinico-laboratory characteristics and in-hospital clinical outcomes among patients with myocardial infarction. J Pak Med Assoc. 2020 Dec;70(12(B)):2376-2382. https://doi.org/10.47391/JPMA.370

Blohm MB, Hartford M, Karlson BW, Luepker RV, Herlitz J. An evaluation of the results of media and educational campaigns designed to shorten the time taken by patients with acute myocardial infarction to decide to go to hospital. Heart. 1996 Nov;76(5):430-4. https://doi.org/10.1136/hrt.76.5.430

Ali, Zafar, and Iftikhar Ahmad. "FACTORS RESPONSIBLE FOR LATE PRESENTATION OF PATIENTS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION." Journal of Postgraduate Medical Institute (Peshawar-Pakistan) 34.2 (2020). https://jpmi.org.pk/index.php/jpmi/article/view/2531

Koc, Sema, Durna, Zehra & Akin, Semiha. (‎2017)‎. Interpretation of symptoms as a cause of delays in patients with acute myocardial infarction, Istanbul, Turkey. EMHJ-Eastern Mediterranean Health Journal, 23 (‎4)‎, 287 - 294. World Health Organization, Regional Office for the Eastern Mediterranean. https://apps.who.int/iris/handle/10665/260386


Miedema, M. D., Newell, M. C., Duval, S., Garberich, R. F., Handran, C. B., Larson, D. M., Mulder, S., Wang, Y. L., Lips, D. L., & Henry, T. D. (2011). Causes of delay and associated mortality in patients transferred with ST-segment-elevation myocardial infarction. Circulation, 124(15), 1636-1644. https://doi.org/10.1161/CIRCULATIONAHA.111.033118

Pereira H, Calé R, Pinto FJ, Pereira E, Caldeira D, Mello S, Vitorino S, de Sousa Almeida M, Mimoso J. Factors influencing patient delay before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: The Stent for life initiative in Portugal. Revista Portuguesa de Cardiologia (English Edition). 2018 May 1;37(5):409-21. https://doi.org/10.1016/j.repc.2017.07.014

Eagle KA, Nallamothu BK, Mehta RH, et al.: Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go. Eur Heart J. 2008, 29:609-17. https://doi.org/10.1093/eurheartj/ehn069



DOI: 10.54393/pbmj.v5i1.261
Published: 2022-01-31

How to Cite

Zameer, I., Baig, A. ., Ahmed, Z., Qayyum, J. ., Amir, A., Rauf, S. ., Ashraf Butt, A. U. ., Khan, M. S., Malik, A. R., & Khalid, A. . (2022). Factors leading to delayed presentation among patients presenting with ST-elevation Myocardial Infarction in Emergency Department of a tertiary care hospital. Pakistan BioMedical Journal, 5(1), 207–211. https://doi.org/10.54393/pbmj.v5i1.261



Original Article