Journal of Behavioral Medicine

, Volume 31, Issue 6, pp 498–505 | Cite as

Causal beliefs, cardiac denial and pre-hospital delays following the onset of acute coronary syndromes

  • Linda Perkins-PorrasEmail author
  • Daisy L. Whitehead
  • Philip C. Strike
  • Andrew Steptoe


Reducing pre-hospital delay is crucial in reducing mortality from acute coronary syndrome (ACS). Patient’s causal beliefs and coping styles may affect symptom appraisal and help-seeking behavior. We examined whether patient’s beliefs about the causes of their ACS and denial of impact were associated with pre-hospital delay. Pre-hospital delay data were collected from 177 patients with ACS. Retrospective causal beliefs and cardiac denial of impact were assessed using questionnaires. Factor analysis of causal beliefs produced 3 factors; beliefs in stress and emotional state, behavioral and clinical risk factors, and in heredity as causal influences. Patients with strong beliefs that stress and emotional state caused their ACS were more likely to have long pre-hospital delays (>130 min). There were no significant associations between pre-hospital delay and the other two causal belief factors. Patients with greater denial scores were also more likely to have long delays than those with low scores. These effects were independent of age, gender, education, previous myocardial infarction, history of depression and negative affectivity. Cognitive and emotional factors including patient’s beliefs about causes and avoidant coping help to explain variations in pre-hospital delay.


Causal beliefs Denial Acute coronary syndrome Pre-hospital delay 



This study was supported by the British Heart Foundation, Economic and Social Research Council and Medical Research Council. We are grateful to Dr Susan Edwards for participation in data collection, and the staff and patients of University College Hospital, St. George’s Hospital, Southend and Kingston Hospitals.


  1. Aalto, A. M., Heijmans, M., Weinman, J., & Aro, A. R. (2005). Illness perceptions in coronary heart disease. Sociodemographic, illness-related, and psychosocial correlates. Journal of Psychosomatic Research, 58, 393–402. doi: 10.1016/j.jpsychores.2005.03.001.PubMedCrossRefGoogle Scholar
  2. Affleck, G., Tennen, H., Croog, S., & Levine, S. (1987). Causal attribution, perceived benefits, and morbidity after a heart attack: An 8-year study. Journal of Consulting and Clinical Psychology, 55, 29–35. doi: 10.1037/0022-006X.55.1.29.PubMedCrossRefGoogle Scholar
  3. Anon, (2000). Myocardial infarction redefined–a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. European Heart Journal, 21, 1502–1513. doi: 10.1053/euhj.2000.2305.CrossRefGoogle Scholar
  4. Berglin-Blohm, M., Hartford, M., Karlsson, T., & Herlitz, J. (1998). Factors associated with pre-hospital and in-hospital delay time in acute myocardial infarction: A 6-year experience. Journal of Internal Medicine, 243, 243–250. doi: 10.1046/j.1365-2796.1998.00296.x.PubMedCrossRefGoogle Scholar
  5. British Heart Foundation. (2007). British heart foundation statistics database 2007. Accessed on 21 March 2008.
  6. Buckley, T., McKinley, S., Gallagher, R., Dracup, K., Moser, D. K., & Aitken, L. M. (2006). The effect of education and counselling on knowledge, attitudes and beliefs about responses to acute myocardial infarction symptoms. European Journal of Cardiovascular Nursing, 6, 105–111. doi: 10.1016/j.ejcnurse.2006.05.005.PubMedCrossRefGoogle Scholar
  7. Bunde, J., & Martin, R. (2006). Depression and prehospital delay in the context of myocardial infarction. Psychosomatic Medicine, 68, 51–57. doi: 10.1097/01.psy.0000195724.58085.f0.PubMedCrossRefGoogle Scholar
  8. Carney, R., Fitzsimons, D., & Dempster, M. (2002). Why people experiencing acute myocardial infarction delay seeking medical assistance. European Journal of Cardiovascular Nursing, 1, 237–242. doi: 10.1016/S1474-5151(02)00049-X.PubMedCrossRefGoogle Scholar
  9. Chambless, L., Keil, U., Dobson, A., Mahonen, M., Kuulasmaa, K., Rajakangas, A. M., et al. (1997). Population versus clinical view of case fatality from acute coronary heart disease: Results from the WHO MONICA Project 1985–1990. Multinational monitoring of trends and determinants in cardiovascular disease. Circulation, 96, 3849–3859.PubMedGoogle Scholar
  10. Denollet, J. (1998). Personality and coronary heart disease: The Type D Scale-16 (DS16). Annals of Behavioral Medicine, 20, 209–215. doi: 10.1007/BF02884962.PubMedCrossRefGoogle Scholar
  11. Dracup, K., McKinley, S. M., & Moser, D. K. (1997). Australian patients’ delay in response to heart attack symptoms. The Medical Journal of Australia, 166, 233–236.PubMedGoogle Scholar
  12. Fibrinolytic Therapy Trialists’ Collaborative Group. (1994). 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. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Lancet, 343, 311–322.Google Scholar
  13. Fowers, B. J. (1992). The Cardiac Denial of Impact Scale: A brief, self report research measure. Journal of Psychosomatic Research, 36, 469–475. doi: 10.1016/0022-3999(92)90007-O.PubMedCrossRefGoogle Scholar
  14. French, D. P., Maissi, E., & Marteau, T. M. (2005). The purpose of attributing cause: Beliefs about causes of myocardial infarction. Social Science and Medicine, 60, 1411–1421. doi: 10.1016/j.socscimed.2004.08.008.PubMedCrossRefGoogle Scholar
  15. French, D. P., Senior, V., Weinman, J., & Marteau, T. M. (2001). Causal attributions for heart disease: A systematic review. Psychology & Health, 16, 77–98. doi: 10.1080/08870440108405491.CrossRefGoogle Scholar
  16. GISSI. (1986). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction: Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico. Lancet, 1, 397–402.Google Scholar
  17. Goff, D. C, Jr, Feldman, H. A., McGovern, P. G., Goldberg, R. J., Simons-Morton, D. G., Cornell, C. E., et al. (1999). Prehospital delay in patients hospitalized with heart attack symptoms in the United States: The REACT trial. Rapid Early Action for Coronary Treatment (REACT) Study Group. American Heart Journal, 138, 1046–1057. doi: 10.1016/S0002-8703(99)70069-4.PubMedCrossRefGoogle Scholar
  18. Goldberg, R. J., Steg, P. G., Sadiq, I., Granger, C. B., Jackson, E. A., Budaj, A., et al. (2002). Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry). The American Journal of Cardiology, 89, 791–796. doi: 10.1016/S0002-9149(02)02186-0.PubMedCrossRefGoogle Scholar
  19. Goldberg, R. J., Yarzebski, J., Lessard, D., & Gore, J. M. (2000). Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: The Worcester Heart Attack study. Archives of Internal Medicine, 160, 3217–3223. doi: 10.1001/archinte.160.21.3217.PubMedCrossRefGoogle Scholar
  20. Gudmundsdottir, H., Johnston, M., Johnston, D., & Foulkes, J. (2001). Spontaneous, elicited and cued causal attributions in the year following a first myocardial infarction. British Journal of Health Psychology, 6, 81–96. doi: 10.1348/135910701169070.PubMedCrossRefGoogle Scholar
  21. Gurwitz, J. H., McLaughlin, T. J., Willison, D. J., Guadagnoli, E., Hauptman, P. J., Gao, X., et al. (1997). Delayed hospital presentation in patients who have had acute myocardial infarction. Annals of Internal Medicine, 126, 593–599.PubMedGoogle Scholar
  22. Horne, R., James, D., Petrie, K., Weinman, J., & Vincent, R. (2000). Patients’ interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction. Heart (British Cardiac Society), 83, 388–393. doi: 10.1136/heart.83.4.388.Google Scholar
  23. ISIS-2. (1988). Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17, 187 cases of suspected acute myocardial infarction: ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet, 2, 349–360.Google Scholar
  24. ISIS-3. (1992). A randomised comparison of streptokinase vs tissue plasminogen activator vs anistreplase and of aspirin plus heparin vs aspirin alone among 41,299 cases of suspected acute myocardial infarction. ISIS-3 (Third International Study of Infarct Survival) Collaborative Group. Lancet, 339, 753–770.CrossRefGoogle Scholar
  25. Kainth, A., Hewitt, A., Sowden, A., Duffy, S., Pattenden, J., Lewin, R., et al. (2004). Systematic review of interventions to reduce delay in patients with suspected heart attack. Emergency Medicine Journal, 21, 506–508.PubMedCrossRefGoogle Scholar
  26. Kentsch, M., Rodemerk, U., Muller-Esch, G., Schnoor, U., Munzel, T., Ittel, T. H., et al. (2002). Emotional attitudes toward symptoms and inadequate coping strategies are major determinants of patient delay in acute myocardial infarction. Zeitschrift fur Kardiologie, 91, 147–155.PubMedCrossRefGoogle Scholar
  27. King, R. (2002). Illness attributions and myocardial infarction: The influence of gender and socio-economic circumstances on illness beliefs. Journal of Advanced Nursing, 37, 431–438.PubMedCrossRefGoogle Scholar
  28. Leslie, W. S., Fitzpatrick, B., Morrison, C. E., Watt, G. C., & Tunstall-Pedoe, H. (1996). Out-of-hospital cardiac arrest due to coronary heart disease: A comparison of survival before and after the introduction of defribrillators in ambulances. Heart, 75, 195–199.PubMedCrossRefGoogle Scholar
  29. Leslie, W. S., Urie, A., Hooper, J., & Morrison, C. E. (2000). Delay in calling for help during myocardial infarction: Reasons for the delay and subsequent pattern of accessing care. Heart, 84, 137–141.PubMedCrossRefGoogle Scholar
  30. Luepker, R. V., Raczynski, J. M., Osganian, S., Goldberg, R. J., Finnegan, J. R., Jr., Hedges, J. R., et al. (2000). Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial. Journal of the American Medical Association, 284, 60–67.PubMedCrossRefGoogle Scholar
  31. Martin, R., Johnsen, E. L., Bunde, J., Bellman, S. B., Rothrock, N. E., Weinrib, A., et al. (2005). Gender differences in patients’ attributions for myocardial infarction: Implications for adaptive health behaviors. International Journal of Behavioral Medicine, 12, 39–45.PubMedCrossRefGoogle Scholar
  32. Meischke, H., Eisenberg, M. S., & Larsen, M. P. (1993). Pre-hospital delay interval for patients who use emergency medical services: The effect of heart-related medical conditions and demographic variables. Annals of Emergency Medicine, 22, 1597–1601.PubMedCrossRefGoogle Scholar
  33. Moser, D. K., Kimble, L. P., Alberts, M. J., Alonzo, A., Croft, J. B., Dracup, K., et al. (2006). Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: A scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council. Circulation, 114, 168–182.PubMedCrossRefGoogle Scholar
  34. O’Carroll, R. E., Smith, K. B., Grubb, N. R., Fox, K. A., & Masterton, G. (2001). Psychological factors associated with delay in attending hospital following a myocardial infarction. Journal of Psychosomatic Research, 51, 611–614.PubMedCrossRefGoogle Scholar
  35. Pattenden, J., Watt, I., Lewin, R. J., & Stanford, N. (2002). Decision making processes in people with symptoms of acute myocardial infarction: Qualitative study. British Medical Journal, 324, 1006–1009.PubMedCrossRefGoogle Scholar
  36. Perkins-Porras, L., Whitehead, D. L., & Steptoe, A. (2006). Patients’ beliefs about the causes of heart disease: Relationships with risk factors, sex and socio-economic status. European Journal of Cardiovascular Prevention and Rehabilitation, 13, 724–730.Google Scholar
  37. Perkins-Porras, L., Whitehead, D. L., Strike, P. C., & Steptoe, A. (2008). Pre-hospital delay following symptom onset in patients with acute coronary syndrome: Factors associated with patient decision time and home to hospital delay. European Journal of Cardiovascular Nursing. doi: 10.1016/j.ejcnurse.2008.05.001.
  38. Petrie, K. J., Cameron, L. D., Ellis, C. J., Buick, D., & Weinman, J. (2002). Changing illness perceptions after myocardial infarction: An early intervention randomized controlled trial. Psychosomatic Medicine, 64, 580–586.PubMedGoogle Scholar
  39. Scharloo, M., Kaptein, A. A., Weinman, J., Bergman, W., Vermeer, B. J., & Rooijmans, H. G. (2000). Patients’ illness perceptions and coping as predictors of functional status in psoriasis: A 1-year follow-up. British Journal of Dermatology, 142, 899–907.PubMedCrossRefGoogle Scholar
  40. Stenstrom, U., Nilsson, A. K., Stridh, C., Nijm, J., Nyrinder, I., Jonsson, A., et al. (2005). Denial in patients with a first-time myocardial infarction: Relations to pre-hospital delay and attendance to a cardiac rehabilitation programme. European Journal of Cardiovascular Prevention and Rehabilitation, 12, 568–571.PubMedCrossRefGoogle Scholar
  41. Strike, P. C., Perkins-Porras, L., Whitehead, D. L., McEwan, J. R., & Steptoe, A. (2006). Triggering of acute coronary syndromes by physical exertion and anger: Clinical and sociodemographic characteristics. Heart, 92, 1035–1040.PubMedCrossRefGoogle Scholar
  42. Weiner, B. (1985). “Spontaneous” causal thinking. Psychological Bulletin, 97, 74–84.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Linda Perkins-Porras
    • 1
    • 2
    Email author
  • Daisy L. Whitehead
    • 2
  • Philip C. Strike
    • 2
  • Andrew Steptoe
    • 2
  1. 1.Department of Community Health Sciences, Cranmer TerraceSt. George’s University of LondonLondonUK
  2. 2.Department of Epidemiology & Public HealthUniversity College LondonLondonUK

Personalised recommendations