Alexithymia Is Associated with Delayed Treatment Seeking in Acute Myocardial Infarction

The elapsed time between a person experiencing pain or discomfort due to an acute myocardial infarction (AMI) with ST segment elevation (STEMI) and his/her arrival at a hospital seeking care is crucial for survival. In fact, the degree of myocardial necrosis is related to the length of the ischemic episode [1], and survival depends on the early provision of reperfusion techniques. If reperfusion occurs within 2 h, some preservation of myocardial function is achieved; after this period, life expectancy or survival decreases drastically [2]. The most important factor impacting on longer time to treatment is the patient's decision to delay seeking care [1]. Thus, psychological variables such as alexithymia influencing the decision may be relevant. Unfortunately many of the findings with respect to psychosocial factors in delayed care seeking are still controversial [3]. We sought to explore psychological factors that might explain the delay in seeking care in STEMI with particular attention to alexithymia.Consecutive patients aged 18-85 years, admitted to a Cardiology Ward at Cagliari University Hospital, from April 2010 to June 2011, diagnosed with STEMI according to the European Society of Cardiology guidelines [2] were eligible for this study. The study sample was divided based on ‘time to treatment', defined as the interval between the onset of symptoms and the first diagnostic ECG: controls = early care-seeking patients (<2 h); cases = late care-seeking patients (>2 h).A form was to be filled in to record sociodemographic data, health service utilization and risk factors [4]; the study adopted the nonpatient version of the SCID-I-DSM-IV [4] and the Italian version of the 20-item Toronto Alexithymia Scale (TAS-20) [5], a self-reporting checklist measuring the ability to identify and describe feelings and to distinguish between feelings and bodily sensations. Alexithymic trait scores were characterized using established classification scores (scores ≥61). Statistical analyses were carried out in a 2-step logistic regression approach. All possible factors were entered simultaneously in a single block. All 2-way interactions between the possible risk factors were included. To select significant interactions, a backward elimination procedure with a threshold of p < 0.20 was used.The final sample included 83 patients, with 73.5% males. The mean time to treatment was 176.75 ± 239.65 min. In the analyses, 36 patients (43.4%) were allocated to the cases, 47 patients (56.6%) to the controls. Table 1 lists the frequencies of factors concerning the awareness of the disease and care-seeking behavior. None of the possible confounding factors taken into account differed between cases and controls in a statistically significant manner. However, the association between alexithymia (OR for cases 3.7, 95% CI 1.3-10.1) and contact with primary care prior to hospitalization (OR for cases 3.5, 95% CI 1.3-9.3) was statistically significant. No difference was found between cases and controls with regard to diagnosis of lifetime anxiety and depression. The multivariate analysis confirms the differences indicated by the univariate model but the two factors did not show any interaction, since the copresence of the two risk factors produced a cumulative risk without significant amplification (OR approx. 15.5, 95% CI 2.85-84.6; p < 0.0001).The study shows that low emotional awareness, measured by alexithymia, and having had contact with primary care were associated with increased time to treatment in STEMI. No interaction was found between the two factors. An early study of Kenyon et al. [6] found evidence that the presence of alexithymia predicted a delay in seeking treatment in AMI. A study of O'Carroll et al. [7], 10 years later, found some differences in alexithymia when comparing a group of patients with AMI who were prompt care seekers (<4 h), and a group of late AMI care seekers (>4 h) but these differences did not reach the threshold for statistical significance. Even so the results of such studies are partially in agreement with our data; the extension of their study sample might have biased the results since STEMI is the severest form of AMI and the only in which the delay in medical intervention is currently known to be of great danger [2]. On the other hand, ours is the first report in the literature exploring alexithymia as a potential risk factor for delay in seeking care in STEMI and also the first study to divide cases and controls with the delayed time known to be associated with a poor outcome (2 h) [2].Sociodemographic and clinical variables did not independently appear to explain the delay. These results partially confirm the previous findings [8]. However, there appears to be some contradictory findings concerning consultation with a primary care physician [8]. It may be that association between delayed time and contact with primary care may be related to specific patterns of care organization [8].The lack of a better knowledge on the psychology of care seeking by people with AMI is likely due to the fact that the high-cost community intervention with a multicomponent strategy to decrease time to treatment tested in the USA did not reach the expected goals [9]. Our work on alexithymia may therefore be an important study in this respect. Alexithymia is a deficit, inability or deficiency in emotional processing and in the skills to detect the signal of illness, rather than a defensive process [10]. Some interventions were found effective in reducing alexithymia in coronary heart disease [10]. Our data suggest a preventive use of intervention of alexithymia in people at risk for myocardial infarction.This study measures alexithymia after STEMI. The causality between alexithymia and delay must be clarified in prospective studies. The limited sample size and the single-center design do not allow subanalyses on gender and cultural factors. People with alexithymia may have a different perception and memory performance, and it may change the subjective perception of the delayed time. This hypothesis needs to be clarified.In conclusion, STEMI is responsible for 7 million deaths each year. Survival in STEMI is linked to the early availability of medical intervention. Patients capable of identifying inner emotions and bodily sensations were more likely to seek treatment earlier. An investigation of the potential preventive utility of decreasing alexithymia in improving access to care in patients with risk of STEMI is needed.