Document Type : Original Article


1 Department of Nursing, School of Nursing, Qom University of Medical Sciences, Qom, Iran

2 Department of Midwifery, School of Medicine, Qom University of Medical Sciences, Qom, Iran

3 Department of Family and Community Medicine, School of Medicine, Neuroscience Research Center Qom University of Medical Sciences, Qom, Iran

4 Department of Nursing, School of Nursing and Midwifery, Shahed University, Tehran, Iran


BACKGROUND: Delay in seeking medical help in patients with acute myocardial infarction (AMI) 
challenges the patients in terms of diagnosis and treatment. This study aimed to evaluate the outcomes 
of delay referral (≥12 h) in patients with AMI.
MATERIALS AND METHODS: In this retrospective cohort study, the medical records of 252 patients 
with AMI (2017–2019) admitted to Shahid Beheshti Hospital, Qom, Iran, was reviewed. Data 
collection tool was a researcher‑made data sheet that included demographic characteristics, times, 
hospitalization costs, risk factors, history of heart disease, results of paraclinical tests, clinical 
information at the time of admission, and outcomes of delayed referral. Data were analyzed using t‑test, 
Chi‑square, Kaplan–Meier estimator, log‑rank test, Cox regression by STATA, and SPSS (version 25).
RESULTS: The levels of troponin, creatine phosphokinase, lactate dehydrogenase were 
significantly higher in the delayed referral group (P < 0.05). After treatment, the cardiac ejection 
fraction was significantly different in the nondelayed referral (41.56 ± 9.16) and the delayed referral 
group (38.39 ± 11.01) (P < 0.001). There was no significant difference in the percentage of hospital 
deaths in the groups (P = 0.078).
CONCLUSION: Delayed referral of patients with AMI is associated with decreased physiological 
cardiac function, which complicates recovery for these patients.


1. Mohebbi B, Tafaghodi B, Sadeghi R, Tol A, Yekanenejad MS. 
Factors predicting nutritional knowledge, illness perceptions, 
and dietary adherence among hypertensive middleaged women: Application of transtheoretical model. J Educ Health 
Promot 2021;10:212.
2. Shakibazadeh E, Sabouri M, Mohebbi B, Tol A, Yaseri M. Validity 
and reliability properties of the Persian version of perceived health 
competence scale among patients with cardiovascular diseases. 
J Educ Health Promot 2021;10;19.
3. Ioacara S, PopescuAC, Tenenbaum J, DimulescuDR, PopescuMR, 
Sirbu A, Fica S. Acute myocardial infarction mortality rates and 
trends in Romania between 1994 and 2017. Int. J. Environ. Res. 
Public Health 2020;17 (1):285.
4. Reed GW, Rossi JE, Cannon CP. Acute myocardial infarction. The 
Lancet 2017 14;389 (10065):197‑210 Acute myocardial infarction. 
The Lancet. 2017 Jan 14;389 (10065):197‑210.
5. Chai LS, Putit Z, Siop S. Barriers to timely treatment‑seeking 
in patients with acute myocardial infarction in Malaysia: 
A qualitative study. BMC nursing 2016;15 (1):1‑0.
6. Lim SC, Rahman A, Yaacob NM. Pre‑hospital factors influencing 
time of arrival at emergency departments for patients with 
acute ST‑elevation myocardial infarction. Malays J Med Sci 
2019;26 (1):87.
7. Ibañez EL, López RR, Palavecino JA, Amicone NC. Evaluation of 
Strategies to Reduce Reperfusion Times in ST‑Segment elevation 
acute Myocardial infarction. Mobile health experience (mhealth). 
Rev Argent Cardiol 2019;87:314‑8.
8. Rafi A, Sayeed Z, Sultana P, Aik S, Hossain G. Pre‑hospital delay 
in patients with myocardial infarction: An observational study 
in a tertiary care hospital of northern Bangladesh. BMC Health 
Serv Res 2020;20 (1):1.
9. Soltani L, Ravari A, Sabzevari S. Relationship between 
prodromal (warning) symptoms and referring time in patients 
with myocardial infarction. Iran J Cardiovasc Nurs 2016;4:22‑31.
10. Xie L, Huang SF, Hu YZ. Factors influencing pre‑hospital patient 
delay in patients with acute myocardial infarction. Chin Nurs Res 
11. Balk M, Gomes HB, Quadros AS, Saffi MA, Leiria TL. 
Comparative analysis between transferred and self‑referred 
STEMI patients undergoing primary angioplasty. Arq Bras 
Cardiol 201915;112:402.
12. Lassen JF, Bøtker HE, Terkelsen CJ. Timely and optimal treatment 
of patients with STEMI. Nat Rev Cardiol 2013;10 (1):41‑8.
13. Hochberg CP, Jacobs AK. Prehospital delay in patients with 
ST‑segment elevation myocardial infarction: Time for change. 
Coron Artery Dis 2018;29 (5):368‑70.
14. Maruhashi T, Ishihara M, Inoue I, Kawagoe T, Shimatani Y, 
Kurisu S, Nakama Y, Kagawa E, Dai K, Matsushita J, Ikenaga H. 
Effect of prodromal angina pectoris on the infarct progression in 
patients with first ST‑elevation acute myocardial infarction. Circ 
J 2010:1006150773.
15. Nguyen HL, Saczynski JS, Gore JM, Goldberg RJ. Age and sex 
differences in duration of prehospital delay in patients with acute 
myocardial infarction: A systematic review. Circ Cardiovasc Qual 
Outcomes 2010;3 (1):82‑92.
16. McNair PW, Bilchick KC, Keeley EC. Very late presentation in 
ST elevation myocardial infarction: Predictors and long‑term 
mortality. IJC Heart & Vasculature 2019;22:156‑9.
17. O’gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, 
De Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, 
Granger CB. 2013 ACCF/AHA guideline for the management 
of ST‑elevation myocardial infarction: A report of the 
American College of Cardiology Foundation/American Heart 
Association Task Force on Practice Guidelines. J Am Coll Cardiol 
2013;61 (4):e78‑140.
18. Ängerud KH, Sederholm Lawesson S, Isaksson RM, Thylén I, 
Swahn E. Differences in symptoms, first medical contact and 
pre‑hospital delay times between patients with ST‑ and 
non‑ST‑elevation myocardial infarction. Eur Heart J Acute 
Cardiovasc Care 2019;8 (3):201‑7.
19. Dianati M, Mosavi GA, Hajibagheri A, Alavi NM. The pre‑hospital 
delay in seeking treatment in patients with acute myocardial 
infarction referring to a central hospital in Kashan, Iran. Indian J 
Med Sci2010;64 (10):448‑54.
20. Rad M, Bidi A, Khaligh RG, Rad M. Causes of late referral to the 
Emergency Department in patients with myocardial infarction in 
Iran. Acta Facult Med Naissensis 2018;35:105‑13.
21. CerratoE, FornoD, FerroS, ChinagliaA. Characteristics, in‑hospital 
management and outcome of late acute ST‑elevation myocardial 
infarction presenters. J Cardiovasc Med 2017;18 (8):567‑71.
22. Nymark C, Henriksson P, Mattiasson AC, Saboonchi F, 
Kiessling A. Inability to act was associated with an extended 
delay prior to care‑seeking, in patients with an acute myocardial 
infarction. Eur J Cardiovasc Nurs 2019;18 (6):512‑20.
23. Jäger B, Farhan S, Rohla M, Christ G, Podczeck‑Schweighofer A, 
SchreiberW, LaggnerAN, Weidinger F, StefenelliT, Delle‑KarthG, 
Kaff A. Clinical predictors of patient related delay in the VIENNA 
ST‑elevation myocardial infarction network and impact on 
long‑term mortality. E Eur Heart J Acute Cardiovasc Care 
2017;6 (3):254‑61.
24. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli‑Ducci C, 
Bueno H, 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). European Heart Journal 
2017;39 (2):119‑77.