Archives of Academic Emergency Medicine. 2019; 7 (1): e29 OR I G I N A L RE S E A RC H Pre-Hospital Delay and Its Contributing Factors in Pa- tients with ST-Elevation Myocardial Infarction; a Cross sectional Study Hamidreza Poorhosseini1, Mohammad Saadat2, Mojtaba Salarifar1, Seyedeh Hamideh Mortazavi2, Babak Geraiely1∗ 1. Interventional Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. 2. Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. Received: March 2019; Accepted: April 2019; Published online: 29 May 2019 Abstract: Introduction: The outcome of ST-elevation myocardial infarction (STEMI) is significantly influenced by the to- tal tissue ischemic time. In spite of efforts for reducing the in-hospital delay by full-time provision of primary percutaneous coronary intervention (P-PCI) in the 24/7 program, pre-hospital delay still persists. As a first re- port in Iran, we aimed to assess the duration of pre-hospital delay and its contributing factors in STEMI patients in the P-PCI era. Methods: The present cross-sectional study evaluated 2103 STEMI patients who underwent primary PCI from 2016 to 2018. Demographic, personal and socioeconomic factors, index event characteris- tics, past medical history, pain onset and door times of patients were recorded and independent factors of pre- hospital delay were calculated. Results: Median (IQR) of pain to door (P2D) time was 279 (120-630) minutes. In multivariate analysis, female gender [Beta=0.064 (95%CI: 0.003-0.125); p=0.038], being uneducated [Beta=0.213 (95%CI: 0.115-0.311); p<0.001], the onset of chest pain between 00:00 to 6:00 [Beta=0.130 (95%CI: 0.058-0.202); p<0.001] or 7:00 to 12:00 [Beta=0.119 (95%CI: 0.049-0.190); p=0.001], self-transportation [Beta=0.098 (95%CI: 0.015-0.181); p=0.020] or referral from another hospital [Beta=0.253 (95%CI: 0.117-0.389); p<0.001], atypical chest pain [Beta=0.170 (95%CI: 0.048-0.293); p=0.006], history of hypertension [Beta=0.052 (95%CI: 0.002-0.102); p=0.041], and opium abuse [Beta=0.076 (95%CI: 0.007-0.146); p=0.031] were associated with significantly higher log(P2D), while history of CABG was associated with shorter P2D. Conclusion: Our study showed that P2D is still very high in Iran and revealed the high-risk groups associated with longer P2D. Effective actions should be implemented to increase the public awareness about the symptoms of STEMI, and the importance of immediate appropriate help-seeking. Keywords: ST-elevation myocardial infarction; myocardial infarction, STEMI; time-to-treatment Cite this article as: Poorhosseini H, Saadat M, Salarifar M, Mortazavi S H, Geraiely B. Pre-Hospital Delay and Its Contributing Factors in Patients with ST-Elevation Myocardial Infarction; a Cross sectional Study. Arch Acad Emerg Med. 2019; 7(1): e29. 1. Introduction Ischemic heart disease is still the most common cause of death worldwide (1-3). Several studies have shown that the morbidity and mortality of patients with ST-elevation my- ocardial infarction (STEMI) is significantly influenced by the total tissue ischemic time, which consists of pre-hospital and/or in-hospital delays (4-7). High expenditure strategies like primary percutaneous coronary intervention (P-PCI) for ∗Corresponding Author: Babak Geraiely; Tehran Heart Center, North Kar- gar Street, Tehran-Iran, P.O: 1411713138, Tel & Fax: +98 21 88029600, Email: bgeraiely@sina.tums.ac.ir STEMI and early invasive strategy for Non-STEMI are devel- oped to reduce the in-hospital component of ischemic time; while a huge amount of golden time is lost in the pre-hospital phase. Efforts have been made in different countries to re- duce the total ischemic time. While in-hospital delay has been reduced in many countries, even developing ones (8, 9), only developed countries have been able to reduce the pre- hospital delay by focusing on total ischemic time through in- creasing the general population’s awareness via public edu- cational programs in social media (10, 11). Due to the implementation of full-time (24/7) provision of P-PCI services in our country by the ministry of health and medical education, the in-hospital delay has been reduced in This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem H. Poorhosseini et al. 2 recent years (12). However, as long as the pre-hospital delay remains too long, the benefits of 24/7 P-PCI will be limited. There is no large-scale study evaluating the accurate duration of pre-hospital delay in STEMI patients in our country. Given this lack of information, we aimed to assess the duration of prehospital delay and it’s contributing factors in STEMI pa- tients undergoing P-PCI. 2. Methods 2.1. Study design and setting In the present cross-sectional study, we enrolled 2407 con- secutive STEMI patients who underwent P-PCI between Jan- uary 2016 and December 2018 at a tertiary cardiac center (Tehran Heart center)(13), Tehran, Iran. The hospital’s local review board and Ethics Committee approved the study pro- tocol (Ethics number: IR.TUMS.MEDICINE.REC.1397.954). 2.2. Participants The study population consisted of all STEMI patients who were referred to the mentioned hospital during the study period and underwent P-PCI. Patients were excluded if the STEMI had occurred in the hospital (n=23). In addition, pa- tients with missed data on pain or door times were excluded from the analysis (n=281). Finally, 2103 STEMI patients were included. 2.3. Data gathering Data on the patients’ demographic information, personal and socioeconomic factors, marital status, educational level, ethnicity, place of longest stay, insurance type, physical ac- tivity level, mode of transfer to hospital, pain characteristics, pain onset time, door times, cardiovascular risk factors, and patients’ past medical history, as well as the infarct related artery were extracted from ischemic heart disease, angiog- raphy and angioplasty registries of the hospital, which have been described in details before (14). Physical activity level was defined as high in professional ath- letes, intermediate in those who do usual daily activities and low in patients with the least or lack of physical activity. 2.4. Statistical Analysis Continuous variables were presented as mean ± standard de- viations (SDs) if they assumed normal distributions and as medians (25t h – 75t h interquartile ranges: IQR) if they failed to assume normal distributions. Discrete variables were pre- sented as numbers (percentages). Pain to door (P2D) was compared between groups using Mann–Whitney test and Kruskal–Wallis test as appropriate. The predictors exhibiting a borderline statistical relationship with pain to door time in the univariate analysis (P ≤ 0.15) were taken for a multivari- ate logistic regression analysis to investigate their indepen- dence. Backward elimination regression analysis was used to remove insignificant variables and log(P2D) was consid- ered as a dependent variable. A P ≤ 0.05 was considered statistically significant. All the statistical analyses were con- ducted using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp, Armonk, NY). 3. Results 3.1. Baseline characteristics of participants 2407 consecutive patients were studied out of which 23 cases were excluded due to occurrence of STEMI within the hospi- tal and 281 were excluded because of missed data on pain or door times. Finally, 2103 STEMI patients with the mean age of 59.49±11.79 years were enrolled for analysis (76.4% male). Table 1 and 2 summarize the baseline characteristics of stud- ied patients. 94.3% of the patients were married, 79.0% had a diploma or university level education, 77.1% were of Fars eth- nicity. Self-transport was the most common form of transfer (86%). Table 3 shows the index event’s characteristics. Me- dian (IQR) of P2D time of patients was 279 (120-630) minutes. 3.2. Contributing factors of P2D delay (univari- ate analysis) The results of univariate analysis are presented in table 1- 3. Based on these analyses, female gender was associated with longer median of P2D time (p<0.001) and higher educa- tional level was associated with shorter P2D time (p<0.001). Age had a significant relationship (r=0.036, p=0.095) with log(P2D), while the association was insignificant for BMI (r=0.004, p=0.865). The P2D time was significantly shorter in those who were transferred to the hospital by EMS (p<0.001). Despite the presence of some meaningful patterns, statistical signifi- cance was not observed regarding marital status (p=0.137) and physical activity status (p=0.507). Description of symp- toms as atypical or typical chest pain (p=0.005) and also epigastric pain (p=0.007) was significantly associated with longer P2D. In addition, the history of diabetes (p=0.029) and hypertension (p=0.004) were associated with longer P2D. Although P2D was not different among those with and without the history of coronary stenting (p=0.924), the his- tory of coronary artery bypass graft (CABG) was associated with shorter P2D with borderline significance [191.0 (97.50- 425.50) vs. 280.0 (120.0-630.0), p=0.085]. 3.3. Contributing factors of P2D delay (multi- variate analysis) After nine steps of the backward elimination method, eight variables remained in the final model (table 4). Female gender (Beta-Coefficient: 0.064, 95%CI: 0.003 - 0.125, p= 0.038), being uneducated (Beta: 0.213, 95%CI: 0.115 - 0.311, This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e29 Table 1: Demographic and socioeconomic characteristics Variables Number (%) Prehospital Delay (minute) P Median IQR 25% - 75% Gender Male 1607(76.4) 255.00 110.00 - 595.00 <0.001 Female 496 (23.6) 337.00 160.00 - 790.00 Marital status Married 1983 (94.3) 270.50 117.00 - 619.75 0.173 Single 17 (0.8) 314.00 122.50 - 625.50 Divorced 18 (0.9) 227.50 83.00 - 1020.25 Widowed 85 (4.0) 349.00 172.50 - 858.00 Education University 279 (13.4) 206.00 90.00 - 465.00 <0.001 High school diploma 1362 (65.6) 265.00 115.00 - 606.75 Elementary education 175 (8.4) 310.00 136.00 - 662.00 Uneducated 260 (12.5) 400.50 184.25 - 1014.00 Ethnicity Fars 1622 (77.1) 270.00 117.00 - 603.75 Turk 299 (14.2) 303.00 130.00 - 730.00 0.267 Other 182 (8.7) 318.00 120.00 - 806.00 Longest linger Tehran 1507 (71.7) 260.00 110.00 - 603.25 0.011 Main Cities 162 (7.7) 355.00 141.00 - 732.50 Small Cities 161 (7.7) 312.00 140.25 - 689.75 Village 273 (13.0) 300.00 138.00 - 659.50 Insurance Social security 843 (40.1) 273.00 120.00 - 648.50 0.609 Health facilities 704 (33.5) 285.00 120.25 - 625.75 Other companies 390 (18.5) 289.00 120.00 - 600.00 No insurance 166 (7.9) 239.00 90.75 - 601.50 Physical activity level High 49 (2.3) 206.00 128.75 - 574.00 Intermediate 1986 (94.4) 279.00 118.50 - 624.50 0.507 Low 68 (3.2) 310.00 129.00 - 790.00 p<0.001), the onset of chest pain in 00:00 to 6:00 (Beta: 0.130, 95%CI: 0.058 - 0.202, p<0.001) or 7:00 to 12:00 (Beta: 0.119, 95%CI: 0.049 - 0.190, p=0.001), self-transportation (Beta: 0.098, 95%CI: 0.015 - 0.181, p=0.020) or referral from another hospital (Beta: 0.253, 95%CI: 0.117 - 0.389, p<0.001), descrip- tion of symptoms as atypical chest pain (Beta: 0.170, 95%CI: 0.048 - 0.293, p=0.006), history of hypertension (Beta: 0.052, 95%CI: 0.002 - 0.102, p=0.041), and opium abuse (Beta: 0.076, 95%CI: 0.007 - 0.146, p=0.031) were associated with longer P2D and the history of CABG (Beta: -0.124, 95%CI: -0.252 - -0.004, p=0.048) was associated with shorter P2D time. 4. Discussion Based on the findings of the present study, female gender, being uneducated, the onset of chest pain in 00:00 to 6:00 or 7:00 to 12:00, self-transportation or referral from another hospital, description of symptoms as atypical chest pain, history of hypertension and opium abuse were associated with longer P2D while history of CABG was associated with shorter P2D time. Several studies have been performed in different countries to estimate the interval between pain onset and hospital ar- rival time. Table 5 demonstrates the median of prehospi- tal delay in STEMI patients in various countries. As is evi- dent grossly, developed countries have succeeded in reduc- ing P2D to around 2 hours, while India as a developing coun- try hasn’t shown any obvious progress during these years. Limited studies with small sample sizes have been conducted regarding prehospital delay in Iran (Table 6). As is evident, all of them were performed before implementation of 24/7 pro- gram. Except for one study, all of them have small sample sizes and their results are greatly discordant. To the best of our knowledge, this is the first study to evaluate predictors of prehospital delay in Iran in a large population of STEMI patients undergoing P-PCI. In the current study, using mul- tivariate analysis, pain to door time was found to be signif- icantly higher in female gender, uneducated patients, those with onset of chest pain between 00:00 to 6:00 or 7:00 to 12:00, self-transported patients or individuals who were re- ferred from other hospitals, patients with atypical chest pain This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem H. Poorhosseini et al. 4 Table 2: Past medical history of the patients Variables Number (%) Prehospital Delay (minute) P Median IQR 25% - 75% Diabetes mellitus Yes 657 (31.2) 309.50 123.25 - 629.25 0.029 No 1446 (68.8) 264.00 115.25 - 628.00 Hypertension Yes 852 (40.5) 315.50 130.75 - 670.00 0.004 No 1251 (59.5) 250.00 110.00 - 596.25 Hyperlipidemia Yes 880 (41.8) 266.50 116.25 - 612.00 0.383 No 1223 (58.2) 285.50 120.00 - 640.25 Smoking Yes 739 (35.1) 252.00 111.50 - 612.00 0.235 No 1364 (64.9) 290.00 120.00 - 649.00 Opium abuse Yes 303 (14.4) 340.00 133.00 - 663.00 0.081 No 1800 (85.6) 270.00 117.00 - 618.00 Family history of CAD Yes 354 (16.8) 253.00 102.00 - 607.50 0.066 No 1749 (83.2) 285.00 120.00 - 642.00 Cerebrovascular event Yes 78 (3.7) 266.00 111.00 - 547.50 0.852 No 2025 (96.3) 279.00 120.00 - 630.00 Chronic kidney disease Yes 46 (2.2) 350.50 157.00 - 679.50 0.324 No 2057 (97.8) 274.00 119.75 - 627.75 History of CABG Yes 77 (3.7) 191.00 97.50 - 425.50 0.085 No 2026 (96.3) 280.00 120.00 - 630.00 History of myocardial infarc- tion Yes 153 (7.3) 330.00 125.00 - 890.00 0.053 No 1950 (92.7) 270.00 119.00 - 610.00 History of coronary stenting Yes 122 (5.8) 266.00 110.00 - 733.75 0.924 No 1981 (94.2) 279.50 120.00 - 621.25 Infarct related artery LAD 1144 (54.4) 270.00 120.00 - 642.50 0.621 LCX 297 (14.1) 310.00 119.25 - 583.25 RCA 612 (29.1) 287.00 120.00 - 645.75 SVG 50 (2.4) 162.00 98.75 - 898.00 Hx, history; CAD, coronary artery disease; CABG, coronary artery bypass graft; LAD, left anterior descending; LCX, left circumflex; RCA, right coronary artery; SVG, saphenous vein graft. and history of hypertension and opium abuse; while history of CABG was associated with shorter pain to door time. In a study by Noorani et al. (15), prehospital delay has been shown to be associated with long distance from hospital, lower socioeconomic status and using ambulance. In a study by Moser el al. (11) several factors have been men- tioned to be associated with prehospital delay including fe- male gender, older age, worse socioeconomic status, history of angina, having cardiovascular risk factors and poor knowl- edge of the individual. In the current study we found that pa- tients with chest pain between 00:00 to 6:00 or 7:00 to 12:00 had higher prehospital delays. On the contrary, patients transferred by EMS and educated individuals had lower pain to door time. Infarct related artery had no significant effect in pain to door time in our study population. Our findings are in line with those of Peng et al. (16) who assessed 1088 STEMI patients. They demonstrated that prehospital delay was neg- atively correlated with high educational level, previous his- tory of MI, transportation by ambulance, onset of pain dur- ing the daytime (6:00-18:00) and anterior and posterior MI. In our study, the level of education was negatively correlated with pain to door time. Similar to our work, the study of Heo et al. (17), reported a pain to door time of 144, 76 and 68 min- utes in STEMI patients with low, moderate and high educa- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2019; 7 (1): e29 Table 3: Index event’s characteristics Index Number Prehospital Delay (minute) P Median IQR 25% - 75% Mode of transfer Ambulance 196 (9.3) 209.00 91.25 - 458.00 Self-transport 1808 (86.8) 280.00 120.00 - 650.00 <0.001 Referral 99 (4.7) 364.00 208.50 - 684.00 Pain onset time 0 to 6 554 (26.4) 345.00 112.00 - 872.00 <0.001 7 to 12 617 (29.4) 324.00 135.00 - 677.50 13 to 18 519 (24.7) 264.00 120.00 - 462.00 19 to 24 412 (19.6) 205.00 106.25 - 549.50 Pain description Typical chest pain 1984 (94.3) 270.00 117.00 - 613.00 Atypical chest pain 84 (4.0) 488.00 176.00 - 895.75 0.005 No chest pain 35 (1.7) 307.00 99.00 - 705.00 Pain duration >30 min 1183 (56.3) 300.00 120.00 - 663.00 0.022 11-30 min 801 (38.1) 248.00 112.50 - 581.50 1-10 min 84 (4.0) 324.00 142.00 - 847.00 No chest pain 35 (1.7) 307.00 99.00 - 705.00 Back pain Yes 26 (1.2) 377.50 149.25 - 904.50 0.146 No 2077 (98.8) 275.50 119.00 - 620.25 Epigastric pain Yes 277 (13.2) 335.50 144.25 - 701.75 0.007 No 1826 (86.8) 270.00 115.00 - 615.00 Jaw pain Yes 14 (0.7) 221.50 131.25 - 553.75 0.640 No 2089 (99.3) 278.50 120.00- 630.00 Left precordial pain Yes 1022 (48.6) 265.00 113.50 - 612.00 0.162 No 1081 (51.4) 289.00 120.00 - 645.00 Retro-sternal pain Yes 1400 (66.6) 270.00 115.00 - 630.00 0.223 No 703 (33.4) 285.00 127.50 - 616.00 Right precordial pain Yes 11 (0.5) 345.00 205.00 - 610.00 0.495 No 2092 (99.5) 276.00 119.50 - 630.00 Arm & shoulder pain Yes 71 (3.4) 227.50 140.25 - 574.00 0.815 No 2032 (96.6) 279.50 117.25 - 630.75 tional levels, respectively. In MEDEA Study (18) on 486 acute MI patients, prehospital delay was higher in patients with low MI-knowledge. They also found that patients with atypical symptoms had higher prehospital delays, which corresponds to our findings. Our study showed that P2D is still very high in Iran and re- vealed the high-risk groups associated with longer P2D. We assume that effective actions should be implemented to in- crease the general population’s knowledge about the presen- tations of acute MI in order to decrease the time to seek treat- ment. 5. Limitations and Strengths Being single-centered and retrospective design of the current work can be considered as our study limitations. We had missing values in pain or door times in 281 patients and thus we excluded them from the final analysis. We had no infor- mation regarding the patients’ place of living and could not retrieve the data on their distance from the hospital. Mean- while, the present study is the largest study that has been done to evaluate P2D in Iranian patients and the first study that has published after starting the 24/7 program. Unlike IPACE2 study, only STEMI patients, for whom P2D is appli- cable and can be defined, were included in our study. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem H. Poorhosseini et al. 6 Table 4: Multivariate analysis for prediction of log (p2d) Variable Beta Coefficient 95% Confidence Interval P Lower Upper Gender Male - - - - Female 0.064 0.003 0.125 0.038 Education University - - - - High school diploma 0.070 -0.002 0.143 0.058 Elementary education 0.082 -0.025 0.189 0.135 Uneducated 0.213 0.115 0.311 <0.001 Pain Onset Time 19 to 24 - - - - 13 to 18 0.043 -0.030 0.116 0.243 7 to 12 0.119 0.049 0.190 0.001 0 to 6 0.130 0.058 0.202 <0.001 Mode of Transfer Ambulance - - - - Self-transfer 0.098 0.015 0.181 0.020 Referral 0.253 0.117 0.389 <0.001 Pain Description Typical chest pain - - - - Atypical chest pain 0.170 0.048 0.293 0.006 No chest pain 0.066 -0.121 0.253 0.491 Hypertension No - - - - Yes 0.052 0.002 0.102 0.041 Opium No - - - - Yes 0.076 0.007 0.146 0.031 CABG No - - - - Yes -0.124 -0.252 -0.004 0.048 CABG: coronary artery bypass graft. Table 5: Median of prehospital delay in ST-elevation myocardial infarction patients in various countries according to published reports Country Prehospital delay (minute) Year United Stated (10, 19) 290 1990 84 in males 2002 121 in females 59 in males 2006 81 in females Denmark (20) 125 1998 Australia and New Zealand (21) 145 2008 South Korea (22) 130 2012 India (23, 24) 310 2003 290 2016 6. Conclusion In the present study female gender, transfer via vehicles other than ambulance, atypical chest pain, low level of education, late night and morning onset of pain, history of hyperten- sion and opium abuse were associated with higher prehos- pital delay while history of CABG was associated with short- ened P2D. 7. Appendix 7.1. Acknowledgements The present work was supported by Tehran Heart Center, Tehran University of Medical Sciences. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2019; 7 (1): e29 Table 6: Iranian studies on prehospital delay Study Year City Number* ACS forms P2D Momeni (25) 2011 Rasht 162 STEMI 120 Khosravi (26) 2011 Isfahan 103 STEMI 255 Farshidi (27) 2012 Hormozgan 227 STEMI & NSTEMI N/A IPACE2 (28) 2012 Tehran, Mashhad, Isfahan, Shiraz, Tabriz 1997 UA & NSTEMI & STEMI 265 Taghadosi (29) 2013 Kashan 117 STEMI & NSTEMI 129 *: number of patients, P2D: pain to door time (minutes), ACS: acute coronary syndrome. 7.2. Author contribution All the authors met the criteria of authorship based on the recommendations of the international committee of medical journal editors. Authors ORCIDs Hamidreza Poorhosseini: 0000-0002-5733-9588 Mohammad Saadat: 0000-0003-4950-8334 Mojtaba Salarifar: 0000-0001-9062-3495 Seyedeh Hamideh Mortazavi: 0000-0002-8167-2241 Babak Geraiely: 0000-0001-6695-7751 7.3. Funding/Support None. 7.4. Conflict of interest None. References 1. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2013;380(9859):2197- 223. 2. Finegold JA, Asaria P, Francis DP. Mortality from is- chaemic heart disease by country, region, and age: statis- tics from World Health Organisation and United Nations. Int J Cardiol. 2013;168(2):934-45. 3. Mendis S. Global progress in prevention of cardiovascu- lar disease. Cardiovasc Diagn Ther. 2017;7(Suppl 1):S32- s8. 4. Avorn J, Knight E, Ganz DA, Schneeweiss S. Therapeu- tic delay and reduced functional status six months after thrombolysis for acute myocardial infarction. The Amer- ican journal of cardiology. 2004;94(4):415-20. 5. Cullen L, Greenslade JH, Menzies L, et al. Time to presen- tation and 12-month health outcomes in patients pre- senting to the emergency department with symptoms of possible acute coronary syndrome. Emergency Medicine Journal. 2016;33(6):390-5. 6. Nilsson G, Mooe T, Soderstrom L, Samuelsson E. Pre- hospital delay in patients with first time myocar- dial infarction: an observational study in a north- ern Swedish population. BMC cardiovascular disorders. 2016;16(1):93. 7. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angio- plasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004;109(10):1223-5. 8. Akimbaeva Z, Ismailov Z, Akanov AA, Radisauskas R, Padaiga Z. Assessment of coronary care management and hospital mortality from ST-segment elevation my- ocardial infarction in the Kazakhstan population: Data from 2012 to 2015. Medicina (Kaunas). 2017;53(1):58-65. 9. Beig JR, Tramboo NA, Kumar K, et al. Components and determinants of therapeutic delay in patients with acute ST-elevation myocardial infarction: A tertiary care hospital-based study. J Saudi Heart Assoc. 2017;29(1):7- 14. 10. Kaul P, Armstrong PW, Sookram S, Leung BK, Brass N, Welsh RC. Temporal trends in patient and treatment de- lay among men and women presenting with ST-elevation myocardial infarction. Am Heart J. 2011;161(1):91-7. 11. Moser DK, Kimble LP, Alberts MJ, et al. Reducing delay in seeking treatment by patients with acute coronary syn- drome and stroke: a scientific statement from the Ameri- can Heart Association Council on cardiovascular nursing and stroke council. Circulation. 2006;114(2):168-82. 12. Salarifar M, Askari J, Saadat M, et al. Strategies to Reduce the Door-to-Device time in ST-Elevation Myocardial In- farction Patients. The Journal of Tehran University Heart Center. 2019;14(1):18-27. 13. Poorhosseini H, Abbasi SH. The Tehran Heart Center. Eur Heart J. 2018;39(29):2695-6. 14. Salarifar M, Mousavi MR, Saroukhani S, et al. Percuta- neous coronary intervention to treat chronic total occlu- sion: predictors of technical success and one-year clini- cal outcome. Tex Heart Inst J. 2014;41(1):40-7. 15. Noorani F, Runge M, Tripathi S, et al. Pre-Hospital Delays in Care for STEMI Patients in Mumbai: Challenges and Opportunities. Am Heart Assoc; 2016. 16. Peng YG, Feng JJ, Guo LF, et al. Factors associated with This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem H. Poorhosseini et al. 8 prehospital delay in patients with ST-segment elevation acute myocardial infarction in China. Am J Emerg Med. 2014;32(4):349-55. 17. Heo JY, Hong KJ, Shin SD, Song KJ, Ro YS. Associ- ation of educational level with delay of prehospital care before reperfusion in STEMI. Am J Emerg Med. 2015;33(12):1760-9. 18. Albarqouni L, Smenes K, Meinertz T, et al. Patients’ knowledge about symptoms and adequate behaviour during acute myocardial infarction and its impact on de- lay time: Findings from the multicentre MEDEA Study. Patient Educ Couns. 2016;99(11):1845-51. 19. Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal trends and factors associated with extent of delay to hos- pital arrival in patients with acute myocardial infarction: the Worcester Heart Attack Study. American heart jour- nal. 1994;128(2):255-63. 20. Rasmussen CH, Munck A, Kragstrup J, Haghfelt T. Patient delay from onset of chest pain suggesting acute coro- nary syndrome to hospital admission. Scand Cardiovasc J. 2003;37(4):183-6. 21. McKinley S, Aitken LM, Marshall AP, et al. Delays in pre- sentation with acute coronary syndrome in people with coronary artery disease in Australia and New Zealand. Emerg Med Australas. 2011;23(2):153-61. 22. Lee MR, Yun KH, Kim DH, et al. Factors Related to Pre- hospital Delay in Korean Patients with ST-segment Ele- vation Myocardial Infarction: A Data from the Province of Jeonbuk Regional Cardiovascular Center. Journal of Lipid and Atherosclerosis. 2016;5(1):21-6. 23. Malhotra S, Gupta M, Chandra KK, Grover A, Pandhi P. Prehospital delay in patients hospitalized with acute my- ocardial infarction in the emergency unit of a North In- dian tertiary care hospital. Indian Heart J. 2003;55(4):349- 53. 24. George L, Ramamoorthy L, Satheesh S, Saya RP, Subrah- manyam DK. Prehospital delay and time to reperfusion therapy in ST elevation myocardial infarction. J Emerg Trauma Shock. 2017;10(2):64-9. 25. Momeni M, Salari A, Shafighnia S, Ghanbari A, Mirbolouk F. Factors influencing pre-hospital delay among patients with acute myocardial infarction in Iran. Chin Med J. 2012;125(19):3404-9. 26. Khosravi AR, Hoseinabadi M, Pourmoghaddas M, et al. Primary percutaneous coronary intervention in the Isfa- han province, Iran; A situation analysis and needs assess- ment. ARYA Atheroscler. 2013;9(1):38-44. 27. Taghaddosi M, Dianati M, Fath Gharib Bidgoli J, Ba- honaran J. Delay and its related factors in seeking treat- ment in patients with acute myocardial infarction. ARYA Atheroscler. 2010;6(1):35-41. 28. Kassaian SE, Masoudkabir F, Sezavar H, et al. Clinical characteristics, management and 1-year outcomes of pa- tients with acute coronary syndrome in Iran: the Iranian Project for Assessment of Coronary Events 2 (IPACE2). BMJ open. 2015;5(12):e007786. 29. Farshidi H, Rahimi S, Abdi A, Salehi S, Madani A. Fac- tors Associated With Pre-hospital Delay in Patients With Acute Myocardial Infarction. Iran Red Crescent Med J. 2013;15(4):312-6. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations and Strengths Conclusion Appendix References