Disparities in Adult Awareness of Heart Attack Warning Signs and Symptoms --- 14 States, 2005

In 2005, approximately 920,000 persons in the United States had a myocardial infarction (i.e., heart attack); in 2004, approximately 157,000 heart attacks were fatal (1). One study indicated that approximately half of cardiac deaths occur within 1 hour of symptom onset, before patients reach a hospital (2). Timely access to emergency cardiac care, receipt of advanced treatment, and potential for surviving a heart attack all depend on 1) early recognition of warning signs and symptoms of a heart attack by persons who are having a heart attack and bystanders and 2) immediately calling 9-1-1. Healthy People 2010 includes an objective to increase from 46% to 50% the proportion of adults aged >20 years who are aware of the early warning signs and symptoms of a heart attack and the importance of accessing rapid emergency care by calling 9-1-1 (objective 12-2) (3,4). To update estimates of public awareness of heart attack warning signs and symptoms and knowledge of the importance of calling 9-1-1, CDC analyzed 2005 Behavioral Risk Factor Surveillance System (BRFSS) data from the 14 states that included questions on signs and symptoms of a heart attack. This report describes the results of that analysis, which indicated that although the awareness of certain individual warning signs was as high as 93% (i.e., for shortness of breath), awareness of all five warning signs was 31%, underscoring the need for public health measures to increase public awareness of heart attack warning signs and symptoms. In addition, disparities in awareness were observed by race/ethnicity, sex, and level of education, suggesting that new public health measures should target populations with the lowest levels of awareness.

BRFSS is a state-based, random-digit--dialed telephone survey of the U.S. civilian, noninstitutionalized population aged >18 years. The survey is administered in all 50 states, the District of Columbia (DC), and the three U.S. territories (Guam, Puerto Rico, and the U.S. Virgin Islands). In 2005, 13 states and DC included modules on heart attack and stroke in their surveys. The median response rate for the 13 states and DC was 54.5% (range: 45.1%--61.3%). Data were weighted according to 2005 state population estimates. Nonoverlapping 95% confidence intervals were used to identify statistically significant prevalence differences.

A total of 71,994 respondents answered questions* regarding signs and symptoms of heart attack (with response options of "yes," "no," and "don't know/not sure"). An incorrect symptom (i.e., sudden trouble seeing in one or both eyes) was included to assess whether respondents would answer "yes" to all the items in a series of closed-ended questions. Respondents also were asked to choose the one action that they would take first, from the following list of actions, if they thought that a person was having a heart attack or stroke: take the person to the hospital, advise the person to call a doctor, call 9-1-1, call a spouse or family member, or do something else.

In 2005, respondent awareness of each of the five major warning signs and symptoms of heart attack varied: pain or discomfort in the jaw, neck, or back (48%); feeling weak, lightheaded, or faint (62%); chest pain or discomfort (92%); pain or discomfort in the arms or shoulder (85%); and shortness of breath (93%). A total of 86% of respondents reported that they would call 9-1-1 if they thought someone was having a heart attack or stroke.

Awareness of each of the five major heart attack warning signs and symptoms varied by race/ethnicity, sex, and level of education. Non-Hispanic whites, women, and those with higher levels of education were significantly more likely to be aware of heart attack warning signs and symptoms and more likely to call 9-1-1 if they thought someone was having a heart attack than non-Hispanic blacks, Hispanics, men, and persons with a lower level of education (Table 1). Awareness of the signs and symptoms also varied by state: pain or discomfort in the jaw, neck, or back ranged from 34% in DC to 59% in West Virginia; feeling weak, lightheaded, or faint ranged from 53% in DC to 70% in Iowa; chest pain or discomfort ranged from 86% in Tennessee to 96% in West Virginia; pain or discomfort in the arms or shoulder ranged from 77% in DC to 92% in West Virginia; and shortness of breath ranged from 90% in DC to 96% in West Virginia. The proportion of respondents who reported they would call 9-1-1 if they thought that someone was having a heart attack or stroke ranged from 78% in Mississippi to 89% in Minnesota (Table 1).

Awareness of all five heart attack warning signs and symptoms was low among respondents (Table 2); 31% of the respondents knew all five signs, 18% were aware of all five signs and the one incorrect symptom, and 27% were both aware of all heart attack warning signs and symptoms and indicated that they would first call 9-1-1 if they thought someone was having a heart attack or stroke. In addition, 16% of respondents were both aware of all five heart attack warning signs and symptoms but also knew that sudden trouble seeing in one or both eyes was not a warning sign and also indicated that they would call 9-1-1 if they thought someone was having a heart attack or stroke.

Awareness of all five heart attack warning signs and symptoms and calling 9-1-1 was significantly higher among non-Hispanic whites (30.2%), women (30.8%), and those with a college education or more (33.4%) than among non-Hispanic blacks and Hispanics (16.2% and 14.3%, respectively), men (22.5%), and those with less than a high school education (15.7%), respectively. By state, awareness of all five signs and symptoms and calling 9-1-1 was highest in West Virginia (35.5%) and lowest in DC (16.0%).

Reported by: J Fang, MD, N Keenan, PhD, S Dai, MD, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion; C Denny, PhD, Div of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, CDC.

Editorial Note:

Persons who have a heart attack can benefit from new treatments, such as thrombolytic drugs that can stop certain heart attacks in progress. However, to be effective, these drugs ideally should be administered within 1 hour of symptom onset (5). In 2001, the American Heart Association and the National Heart, Lung, and Blood Institute launched the Act in Time campaign to increase awareness of heart attack warning signs and symptoms and the importance of calling 9-1-1 immediately at the onset of such symptoms. In addition, certain states with heart disease and stroke prevention programs are conducting activities to increase public awareness of the signs and symptoms of heart attack and the importance of calling 9-1-1 (6).

The disparities observed in this report by race/ethnicity, sex, and education level, with higher levels of awareness among whites, women, and persons with a college education, suggest that public health measures should target blacks, Hispanics, men, and persons with less education. In addition, the state and local departments of health in states with lower awareness should collaborate to implement general public awareness campaigns to increase the percentage of persons aware of all five heart attack signs and symptoms and the percentage of persons who are both aware of all five signs and symptoms and who know to call 9-1-1 immediately if a person is having a heart attack or stroke.

BRFSS data from 2001 indicated that the proportion of respondents who were aware of all five heart attack signs and symptoms and the one incorrect heart attack warning signs and symptoms and who indicated that they would to call 9-1-1 as their first action, also was low (11%) (7). However, the states participating in the heart attack and stroke module from BRFSS differed in 2001 and 2005; therefore, the data cannot be compared directly.

The findings in this report are subject to at least four limitations. First, BRFSS data are based on self-reports and subject to recall bias. Second, BRFSS excludes households without landline telephones, so the results might not be representative of certain segments of the U.S. population. Third, only 13 states and DC included the BRFSS question on heart attack warning signs and symptoms in 2005, so the results might not be generalizable to the entire U.S. population. Finally, although the Healthy People 2010 objective (i.e., to increase from 46% to 50% the proportion of adults aged >20 years who are aware of the early warning signs and symptoms of a heart attack and the importance of calling 9-1-1) is being used as a gauge of current levels of awareness, the BRFSS findings in this report cannot be compared with baseline data of Healthy People 2010 from the 2001 National Health Interview Survey (NHIS) (4). NHIS is conducted with in-person interviews of a representative U.S. population, whereas BRFSS is a telephone survey that only includes households with telephones, and the heart attack module questions were asked in only 13 states and DC.

Mortality from heart attack would decrease if patients received medical assistance more quickly (8). The time between symptom onset and treatment depends on several factors, including actions taken by the patient or bystanders, prehospital emergency care, transport systems, and in-hospital systems. Research suggests that patient delays in seeking help are a major factor related to delay in care (9). Although emergency care and medical therapies for acute events have improved, studies have shown that the time from symptom onset to treatment overall has not decreased (10). Because only approximately one third of the surveyed population knew all five correct heart attack signs and symptoms, and only 16% of the population knew 1) all five signs and symptoms, 2) the one incorrect symptom, and 3) to call 9-1-1 immediately, state and local public health measures should be developed to improve public awareness of heart attack warning signs and symptoms.

References

1. American Heart Association. Heart disease and stroke statistics---2008 update. Dallas, TX: American Heart Association; 2008. Available at http://www.americanheart.org/downloadable/heart/1200078608862HS_Stats%202008.final.pdf.
2. Zheng ZJ, Croft JB, Giles WH, et al. Sudden cardiac death in the United States, 1989 to 1998. Circulation 2001;104:2158--63.
3. US Department of Health and Human Services. Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov.
4. US Department of Health and Human Services. Healthy people 2010 midcourse review. Washington, DC: US Department of Health and Human Services; 2006. Available at http://www.healthypeople.gov/data/midcourse.
5. Avorn J, Knight E, Ganz DA, Schneeweiss S. Therapeutic delay and reduced functional status six months after thrombolysis for acute myocardial infarction. Am J Cardiol 2004;94:415--20.
6. CDC State Heart Disease and Stroke Prevention Program. Available at http://www.cdc.gov/dhdsp/state_program/index.htm.
7. Greenlund KJ, Keenan NL, Giles WH, et al. Public recognition of major signs and symptoms of heart attack: seventeen states and the U.S. Virgin islands, 2001. Am Heart J 2004;147:1010--6.
8. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994;343:311--22.
9. Dracup K, Moser DK, Eisenberg M, et al. Causes of delay in seeking treatment for heart attack symptoms. Soc Sci Med 1995;40:379--92.
10. Goldberg RJ, Yarzebski J, Lessard D, et al. Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: the Worcester Heart Attack study. Arch Intern Med 2000;160:3217--23.

* "Do you think pain or discomfort in the jaw, neck, or back are symptoms of a heart attack?" "Do you think feeling weak, lightheaded, or faint are symptoms of a heart attack?" "Do you think chest pain or discomfort are symptoms of a heart attack?" "Do you think pain or discomfort in the arms or shoulder are symptoms of a heart attack?" "Do you think shortness of breath is a symptom of a heart attack?"

Table 1


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Table 2


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Date last reviewed: 2/20/2008