Nearly half of patients with a history of heart disease have poor knowledge about the symptoms of a heart attack and do not perceive themselves to have an elevated cardiovascular risk.

Individuals with heart disease have five to seven times the risk of having a heart attack or dying as the general population, according to background information. Survival rates improve following heart attack if treatment begins within one hour. However, most patients are admitted to the hospital 2.5 to three hours after symptoms begin. "Barriers to seeking appropriate care quickly are both cognitive and emotional." If patients do not know the symptoms of acute myocardial infarction/heart attack and other acute coronary syndromes including nausea and pain in the jaw, chest or left arm, they will not seek treatment for them. If they do not perceive themselves to be at risk for heart attack, they will look for another explanation when they experience these symptoms.

Kathleen Dracup, D.N.Sc., of the University of California, San Francisco, School of Nursing, and colleagues surveyed 3,522 patients (average age 67) who had a history of heart attack or an invasive procedure for treating narrowed arteries. The patients were asked to identify possible symptoms of heart attack and responded to true-false questions about heart disease. Participants also were asked whether they were more or less likely than other individuals their age to have a heart attack in the next five years.

The average cardiac knowledge score was 71 percent. Despite their history of heart disease, 44 percent of the patients had low knowledge levels, as documented by scores of less than 70 percent. Women, individuals who had participated in cardiac rehabilitation, those with higher education levels, younger individuals and those who received care from a cardiologist as opposed to a family practitioner or internist tended to score higher.

"In this group of patients, who were all at high risk for a future acute myocardial infarction, 43 percent inappropriately assessed their risk as less than or the same as other people their age," the authors write. "More men than women perceived themselves as being at low risk (47 percent vs. 36 percent, respectively)."

Changes in the health care delivery system have led to less hospital time for heart disease patients, reducing the amount of time available for education about heart disease symptoms, the authors note. "Patients require continued reinforcement about the nature of cardiac symptoms, the benefits of early treatment and their risk status," they write. "Our findings suggest that men, elderly individuals, those with low levels of education and those who have not attended a cardiac rehabilitation program are more likely to require special efforts during medical office visits to review symptoms of acute myocardial infarction and to learn the appropriate actions to take in the face of new symptoms of acute coronary syndromes."

The researchers "found two modifiable factors identified with increased knowledge about coronary artery disease: participation in cardiac rehabilitation and receiving care by a cardiologist," writes Robert A. Phillips, M.D., Ph.D., of the UMass Memorial Medical Center, Worcester, in an accompanying editorial."These findings should help to fuel the recent focus on the barriers, benefits and methods to improve participation in cardiac rehabilitation by coronary artery disease patients," he continues.

"Health care theory suggests that the highest level of care is provided when payments and best health care practices are aligned. To this end, payers such as Centers for Medicare and Medicaid Services and private insurers should develop a tiered approach to payment for cardiac care, providing higher reimbursements for those hospitals that offer cardiac rehabilitation and higher reimbursement to physicians and hospitals who consistently refer eligible patients for cardiac rehabilitation," Dr. Phillips concludes.