title: Factors associated with presenting >12 hours after symptom onset of acute myocardial infarction among Veteran men.
abstract: BACKGROUND
  Approximately 2/3 of Veterans admitting to Veterans Health Administration (VHA) facilities present >12 hours after symptom onset of acute myocardial infarction (AMI) ("late presenters"). Veterans admitted to VHA facilities with AMI may delay hospital presentation for different reasons compared to their general population counter parts. Despite the large descriptive literature on factors associated with delayed presentation in the general population, the literature describing these factors among the Veteran AMI population is limited. The purpose of this analysis is to identify predictors of late presentation in the Veteran population presenting with AMI to VHA facilities. Identifying predictors will help inform and target interventions for Veterans at a high risk of late presentation.
  
  
  METHODS
  In our cross-sectional study, we analyzed a cohort of 335 male Veterans from nine VHA facilities with physician diagnosed AMI between April 2005 and December 2006. We compared demographics, presentation characteristics, medical history, perceptions of health, and access to health care between early and late presenting Veterans. We used standard descriptive statistics for bivariate comparisons and multivariate logistic regression to identify independent predictors of late presentation.
  
  
  RESULTS
  Our cohort was an average of 64 ± 10 years old and was 88% white. Sixty-eight percent of our cohort were late presenters. Bivariate comparisons found that fewer late presenters had attended at least some college or vocational school (late 53% vs. early 66%, p = 0.02). Multivariate analysis showed that presentation with ST-elevation myocardial infarction (STEMI) was associated with early presentation (OR = 0.4 95%CI [0.2, 0.9]) and ≥2 angina episodes in the prior 24 hours (versus 0-1 episode) was associated with late presentation (OR = 7.5 95%CI [3.6,15.6]).
  
  
  CONCLUSIONS
  A significant majority of Veterans presenting to VHA facilities with AMI were late presenters. We found few differences between early and late presenters. Having a STEMI was independently associated with early presentation and reporting ≥2 angina episodes in the 24 hours prior to hospital admission was independently associated with late presentation. These independent predictors of early and late presentation are similar to what has been reported for the general population. Despite these similarities to the general population, there may be untapped opportunities for patient education within the VHA to decrease late presentation.
authors.affiliation: Osher Center for Integrative Medicine, University of California, San Francisco, 1545 Divisadero St,, 3rd Floor, Box 1726, San Francisco, CA 94115, USA. mcdermottk@ocim.ucsf.edu
authors.forename: Kelly
authors.initials: K
authors.lastname: McDermott
authors.forename: Charles
authors.initials: C
authors.lastname: Maynard
authors.forename: Ranak
authors.initials: R
authors.lastname: Trivedi
authors.forename: Elliott
authors.initials: E
authors.lastname: Lowy
authors.forename: Stephan
authors.initials: S
authors.lastname: Fihn
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis*; D010353:Patient Education as Topic; D013997:Time Factors; D014728:Veterans