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A Study To Assess The Knowledge About Risk Factors and Warning Signs of Acute Coronary Syndrome Among Patients Admitted in Cardiac Medical Unit at Sctimst, Triv Andrum
A Study To Assess The Knowledge About Risk Factors and Warning Signs of Acute Coronary Syndrome Among Patients Admitted in Cardiac Medical Unit at Sctimst, Triv Andrum
A Study To Assess The Knowledge About Risk Factors and Warning Signs of Acute Coronary Syndrome Among Patients Admitted in Cardiac Medical Unit at Sctimst, Triv Andrum
PROJECT REPORT
MANIKANDA PRASAD.M.R.
CODE NO: 5887
2009
CERTIFICATE FROM SUPERVISORY GUIDE
work on 'A study to assess the knowledge about risk factors and warning signs of
SCTIMST, Trivandrum ', under my direct supervision for the partial fulfillment for the
Diploma in Cardiovascular and Thoracic Nursing in the University of Sree Chitra Tirunal
Institute for Medical Sciences and Technology. It is also certified that no part of this
report has been included in any other thesis for processing any other degree by the
candidate.
Trivandrum
November 2009
CERTIFICATE FROM THE CANDIDATE
This is to certify that the project on 'A study to assess the knowledge about risk
factors and warning signs of acute coronary syndrome among patients admitted in
cardiology medical unit at SCTIMST, T~ivandrum ', is a genuine work by me, under the
Thiruvananthapuram. It is also certified that this work has not been presented previously
Mr.MANIKANDA PRASAD.M.R.
Trivandrum,
November 2009.
APPROVAL SHEET
has been admitted to the Diploma in Cardiovascular and Thoracic Nursing, in January
2009 and he has undertaken the project entitled, "A study to assess the knowledge about
risk factors and warning signs of acute coronary syndrome among patients admitted in
cardiology medical unit of SCTIMST, Trivandrum ", which is approved for the Diploma
in Cardiovascular and Thoracic Nursing, awarded by the Sree Chitra Tirunal Institute for
EXAMINERS
GUIDE
Trivandrum
November 2009
.. ~ ~ ~ t4 de LO!td
/lud~~wdt~~"
-Proverb 16:3
Investigator owes sincere thanks to God Almighty, who accompanied and directed
The present study has been completed under the expert guidance of
expresses his sincere gratitude to Dr. Saramma, for her valuable guidance, constant
support and encouragement given from the inception to the completion of the study.
SCTIMST, Trivandrum, for giving this opportunity for conducting this study.
The researcher greatly values the favor extended by Prof Dr. Jagan Mohan
Tharakan, Head of the Department of Cardiology, Dean, SCTIMST, and Mrs. Aleyamma
who kindly agreed to take part in the study. 111ey generously gave their time and attention
to the research. This study would have been impossible without such generosity.
He wishes to extend his sincere thanks to all the doctors, nursing staff of
The researcher inscribes his sincere thanks to all friends, who were helpful
A word of thanks to the library staff ofSCTIMST, for their co-operation and help.
He remains ever indebted to his beloved parents, sister Remya, and Abi, for their
A study to assess the knowledge about risk factors and warning signs of Acute
Coronary Syndrome among patients admitted in cardiac medical unit at SCTIMST,
Trivandrum.
Background: Acute Coronary Syndrome (ACS) represents the most common cause
of morbidity and mortality worldwide. Several risk factors contribute directly to this
disease burden. Recognition of warning signs is logically tied to taking action to receive
prompt emergency care. Objectives: (i) To assess the knowledge about risk factors and
warning signs of ACS among patients admitted in cardiac medical units. (ii) To assess the
relationship between Knowledge about risk factors and warning signs of ACS and
. pre-validated questionnaire. Result: 90% of the samples answered fatty diet, 88%
answered hypertension and high blood pressure. 80% of the samples answered smoking
and 62%, 46% and 52% answered obesity, diabetes and family history as a risk factor for
ACS respectively. About warning signs, 98% and 72% answered chest discomfort and
arm discomfort respectively. Only 16% and 20% had knowledge of indigestion and
vomiting as warning signs of ACS. The educated group showed higher mean total
knowledge score though it was not statistically significant at 0.05 level (p= 0.059).
Conclusion: The study showed that the patients had average level of knowledge about
I INTRODUCTION
1
1.1 Introduction 1
1.7 Limitations 11
1.8 Summary 11
II REVIEW OF LITERATURE
12
2.1 Introduction 12
III METHODOLOGY 23
3.1 Introduction 23
3.6 Sample 25
BIBLIOGRAPHY 46
ANNEXURES 53
LIST OF TABLES
CI Confidence Interval
ED Emergency Department
MI Myocardial Infarction
Technology
SD Standard Deviation
UA Unstable Angina
1.1 Introduction
morbidity in many countries worldwide. It is estimated that it will be the single largest
cause of disease burden globally by the year 2020. (World Health Organization, 2007).
Mortality from cardiovascular disease reached 17.5 million in 2005, which is 30 percent
of all global deaths. (Wood, 2005). The World Health Organization (WHO) estimated
that if no appropriate action is taken, 20 million people would die from cardiovascular
In India, heart disease is the single largest cause of death in the country with heart
attacks being responsible for 1/3rd of all deaths caused by heart diseases. According to the
projection by the WHO and the Indian Council for Medical Research (ICMR), India will
not only be the heart attack capital but also the capital of diabetes and hypertension by
2020. According to WHO, 60 percent of the world's cardiac patients will be Indians by
2010. And according to the International Obesity Task Force, a medical NGO that
coordinates with the WHO on obesity issues, of all Asians, South Asians have the worst
problems when it comes to heart disease. In 2003, the prevalence of Coronary Heart
percent in urban areas with a total of29.8 million affected according to population-based
cross-sectional surveys. The estimate is comparable to the figure of 31.8 million affected,
1
derived from extrapolations of the Global Burden of Diseases Study. In 1990, there were
an estimated 1.17 million deaths from C H D in India, and the number is expected to
almost double to 2.03 million by 2010. The huge burden of C V D in Indian subcontinent
is the consequence of the large population and high prevalence of C V D risk factors.
epidemic in developing countries, including India. Murray & Lopez (1997) estimated that
from 1990 to 2020, worldwide deaths from Cardiovascular causes would have a two-fold
Fig I. Deaths in millions from Cardiovascular Causes, world wide, in 1990 and
• WESTERN
• NON-WESTERN
1990 2020
2
The last 30 years has seen a remarkable transition in Kerala. The state is supposed to
be in the stage III of the epidemiological transition. Cardiovascular deaths are 50 percent
of the total deaths and by 2020 it is predicted to go up to 2/3rd of the total deaths. Kerala
has the highest life expectancy, lowest infant mortality rate, and maternal mortality rate.
This social transition also has unfortunately led to the highest prevalence of CHD among
all Indian states with a rural prevalence of 7.5 percent and urban prevalence of 12
percent. It is clear that population of Kerala is at very high risk of death from
everyday about 110 people die of heart attack some where in Kerala. One may also
· conjuncture that 1.5 lakhs people develop heart attacks in Kerala every year. This is not
disease in Kerala. The ICMR I WHO study on non-communicable disease risk factors
estimate that there are 8.72 million hypertensives in Kerala. The estimated numbers of
diabetic are an astounding figure of 3.48 million. 52.1 percent males and 61.4 percent
female populations has a total cholesterol of> 200 mg/dl. (Goyal & Yousuf, 2006).
Coronary Heart disease, now the leading cause of death, strikes Indians early and
kills many in their productive mid-life years. (Reddy, 2007). Coronary Heart Disease
(CHD) refers to narrowing of the coronary arteries, usually due to atheroma. The term
atheroma is used to describe a build up of 'fatty plaques', which develop within the inner
lining of the artery. A number of factors (e.g. smoking, high blood pressure, high blood
3
cholesterol and diabetes mellitus) are associated with an increased risk of developing
atheroma and therefore CHD (Anderson et al. 1991). CHD usually develops over many
years before symptoms emerge and is characterized by phases of stability and instability
(Bertrand et al. 2002). The onset of an acute coronary syndrome (ACS) is frequently the
The term Acute ~oronary Syndrome (ACS) is used to refer the spectrum of
clinical manifestations of Coronary Heart Disease (CHD), which shares this common
underlying pathology.
Myocardial Infarction:
artery by thrombus or other aggregates. This leads to necrosis of the area of myocardium
associated with ST segment elevation on the Electro Cardiograph (ECG) and the release
Unstable Angina:
thrombus occurs and flow within the artery is restored within 20 minutes, persistent
4
changes on the ECG or release ofbiochemical markers do not usually occur. Clinically,
necrosis occurs but where ST elevation is not evident on the ECG. This is termed as Non-
Mortality risks vary between the syndromes and the treatment indicated for each
Chest pain is the classic symptom associated with ACS. (Lee & Cannon,
2005). The particular type of chest pain associated with ACS is known as Angina
Pectoris. Stable angina is usually of brief duration lasting less than few minutes and
predictability associated with exertion. (Gibbons, et al, 2003). However, the symptoms of
/ angina tend to be of longer duration (> 10 minutes). Pain is prolonged (> 30 minutes) and
associated with other symptoms, such as sweating or nausea and vomiting, is commonly
associated with MI. The pain of Myocardial Infarction may last for several hours. Onset
The symptom of ACS share many common features and are therefore
very difficult to distinguish from each other. The features of ACS could be considered
with ACS experience atypical chest pain. (Eg. sharp pain or pain induced by palpitation).
5
(Bertrand et al, 2002) or indeed other atypical symptoms such as dyspnea, nausea and
vomiting or palpitations. (Canto, et al, 2000; Gupta, et al, 2002), Furthermore there is
evidence that in patients with objective pathological evidence of MI, a proportion are
unable to recall any symptom episode they could associate with MI. Particular groups
appear to be most likely to present with atypical symptoms or silent ischemia. These
include women, the elderly and people with diabetes. (Gupta, et al. 2002; Bertrand, et al.
~
2002)
According to the American Heart Association, the most common and recognized
Risk factors:
• Age:
• Diabetes mellitus
6
• High blood pressure
• Cigarette smoking
• Over weight
• Physical inactivity
• Chest discomfort:
Most heart attacks involve discomfort in the center of the chest that lasts for more
than few minutes or that goes away and comes back. The discomfort can feel like
Symptoms can include discomfort in one or both arms or in the back, neck, jaw, or
stomach.
• Shortness ofbreath:
This symptom often accompames chest discomfort. However, it can also occur
• Other signs:
These may include breaking out in cold sweat, nausea, or light-headedness. Some
7
1.3 Need and significance of the study
Studies have shown that -knowledge has an impact on prevention of heart disease.
coronary heart disease and self reported life style changes and adherence to prescribed
drugs, was noted by Roijer (2006). Individual perception of health risk is an accepted key
·issue, when goals of primary and secondary prevention are identified. Common theories
on health behavio~r(such as the health model or the protection motivation theory support
the importance of risk perception, also called percieved susceptibility for health education
and preventive medicine. For cardiovascular diseases, primary prevention has large
potential benefits. Adequate risk perception is an important step for the change of risk
related lifestyles.
thrombolytic therapy, but the benefit is strictly time dependent. Recognition of heart
\ attack symptoms is logically tied to action to receive promt emergency care. Inadequate
Sree Chitra Tirunal Institute for Medical Scie~ces and Technology (SCTIMST) is an
institute under the administrative control of the Department of Science and Technology,
Government of India, and is situated at Trivandrum, the capital city of Kerala. It has a
239-beded tertiary referral hospital with major specialities like Cardiology, Cardiac
surgery, Neurology and Neurosurgery. About 12,000 patients get registered per month.
An average of 30- 40 patients attends cardiac new OPD every day. An average of 15-20
patients with CHD gets admitted electively every day. Number of patients attending new
8
OPD is increasing day by day. A total of 434 PTCAs and 1184 CAGs have been
performed from January 2009 to October 2009. Knowledge about risk factors of coronary
heart disease and warning signs of ACS is important for patients to prevent recurrence I
as a modality for secondary prevention. It was felt that there is a need to assess the
knowledge level and their relationship with variables in the patients admitted in
·Cardiology medical unit. Hence this study was undertaken with the objectives to assess
. the knowledge of ~cute Coronary Syndrome (ACS), and to assess the relationship
between their knowledge and selected variables. (Age, sex, educational status, socio-
A study to assess the knowledge about risk factors and warning signs of Acute
Trivandrum.
1.5. Objectives
Syndrome (ACS).
Syndrome (ACS).
• To assess the relationship between patients knowledge about risk factors and
9
1.6. Operational definitions
Knowledge:
In this study 'Knowledge' refers to awareness or understanding about risk factors and
·warning signs of Acute Coronary Syndrome, measured with the help of a self reported
Risk factors:
vulnerable to an unwanted, unpleasant, or unhealthful event. In this study the risk factors
taken are, smoking, obesity, family history, diabetes mellitus, high blood cholesterol,
Warning signs:
A warning sign -is somethi~g that makes one understand that there is a possible
danger or problem, especially one in the future. In this study warning signs are, chest
discomfort, Apn discomfort, vomiting, upper back pain, shortness of breath, neck or jaw
produce chest pain due to insufficient blood supply to the heart muscle that results from
coronary artery disease. ACS encompasses the spectrum of clinical conditions, which
may range from unstable angina to non-Q wave Myocardial Infarction (MI) and Q wave
10
Myocardial Infarction (MI). ACS is also recognized as Unstable angina, or chest pain,
and Heart attack. (American Heart Association, 2005). In this study, ACS refers to the
diagnosis of patients, who are admitted in Coronary Care Unit with any of the above-
In this study, Cardiac Medical Unit refers to the Coronary Care Unit.
The Coronary Care Unit (CCU) is a facility dedicated to acute care services for patients
with cardiac disease. This critical environment provides special facilities and utilizes the
expertise of medical, nursing, and other staff trained and experienced in management of
' patients with acute cardiac problems, such as myocardial infarction and unstable angina
and who may have undergone interventional procedures from which recovery is possible.
1.7. Limitatiol!s
• The study area is limited only in Coronary Care Unit (Cardiac Medical Unit).
1.8. Summary
11
CHAPTER II
REVIEW OF LITERATURE
2.1 Introduction
lay a foundation for the study. The literature review provides a background for
understanding current knowledge on a topic and illuminates the significance of the study.
Also literature review is important to gain better understanding and insight necessary to
sections.
Syndrome.
• Studies on knowledge about risk factors and warning signs of Acute Coronary
Syndrome.
There are a plethora of studies on warning signs and risk factors of ACS
published from 1995- till date. The AHA recognized typical symptoms of ACS to be
chest discomfort, discomfort to other areas of upper body, shortness of breath, cold
atypical symptoms as epigastric, arm, shoulder, and wrist, jaw or back pain without
12
Gupta et al (2002), conducted a retrospective, cross sectional study over a five-
year period. The study aimed to determine occurrence rates and predictors of clinical
presentation for patients reporting to an ED without complaints of chest pain who were
subsequently admitted with a diagnosis of an AMI. A data base query was performed,
selecting results of 721 patients who received a diagnosis of an AMI within the noted five
year time period. Researches hypothesized that this population of urban patients studied
would have higher rates of presentations without complaints of chest pain. 47 percent of
patient did not complain of chest pain. An estimated 17 percent of patients acknowledge
shortness of breath as their chief complaint. Other presenting symptoms noted were
cardiac arrest, which was found in 7 percent of these patients, dizziness, weakness, or
syncope (4%), and 2 percent complained of abdominal pain. The authors concluded that
atypical syriiptoms were higher in urban population than in the general ED populace.
University ED during September 1995 and august 1997. The objective of the study was
to assess the function of a set of typical and atypical symptoms as predictors of ACS in
men and women. Researchers hypothesized that the atypical symptoms would predict
ACS in males but not females. Typical symptoms were identified as chest pain or
discomfort, diaphoresis, dyspnea, and arm or shoulder pain. Fainting and dizziness were
identified as atypical symptoms. The study sample included 246 women and 276 men
who were 45 years of age or older and reported to the hospital with symptoms suggesting
ACS. The results demonstrated that 36 % women and 45% men were diagnosed with
ACS. Researchers revealed that the only statistical relevant data found in multivariate
analysis was diaphoresis (relative risk = 2.53; 95% CI (1.17%-5.48%) in women and
13
chest pain or discomfort in men (relative risk= 1.81 %; 95% CI (0.83%-3.1 0% ); p= .163).
The study revealed that atypical symptoms were strongest predictors of ACS in women:
Pais et al (1996) assessed the relative importance of risk factors for ischemic heart
disease among South Asians in Bangalore. A prospective hospital based case control
stUdy was conducted in 200 Indian patients with a first acute MI and 200 age and sex
·matched controls. They recorded the following risk factors for ischemic heart disease:
Diet, smoking, alcohol use, socio-economic status, waist to hip ratio (WHR), blood
glucose, serum insulin, oral glucose tolerance test, and lipid profile. The most common
predictor for AMI was current smoking. History of hypertension and overt diabetes
mellitus were also independent risk factors. Among all individuals fasting blood glucose
was a strong predictor of risk over the entire range. Abdominal obesity (as measured by
WHR) was also a strong independent predictor. Compared to individuals with no risk
factors, individuals with multiple risk factors had greatly increased risk of AMI. The
Studies show that coronary risk factors are more common m lower soc1o
population to determine the trends of coronary risk factors and their association with
educational level as a marker of socio economic status. Two successive coronary risk
factor surveys were performed in selected individuals. In the first study (1995), 2212
subjects and in second study (2002), 1123 subjects were studied. Details of smoking,
physical activity, hypertension, diabetes mellitus, coronary heart disease, body mass
14
waist hip ratio, blood pressure and electrocardiography were evaluated.
Educational status was classified into group 0= no formal education, group 1= 11-1 0
years, group 2= 11-15 years, and group 3 = greater than 16 years. In the first study with
cholesterol and tri-glycerides and decrease in smoking was observed. In the second study,
education was associated with decrease in smoking, leisure time physical inactivity, total
and LDL cholesterol and tri-glycerides and increase in obesity, truncal obesity and
coronary risk factors- obesity, diabetes, total LDL and low HDL cholesterol and tri-
glycerides was seen in urban Indian population over a seven-year period. Smoking,
Medical sciences, USA, to describe prodromal and early waming symptoms of acute
survey. The most frequent prodromal symptom experienced by women more than one
month before were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of
breath (57.9%), weakness (54.8%) and fatigue (42.9%). Acute chest pain was absent in
43%. Women had more acute than prodromal symptoms. Women with more prodromal
symptoms experienced more acute symptoms. The investigators concluded that most
15
Padmavati et al in 1960's and Gupta et al in 1970's performed comparison of
CHD risk factor prevalence in urban and runil populations in Delhi and Haryana
respectively. CHD prevalence in urban subjects was twice that of the rural. These studies
showed greater prevalence of hypertension, obesity, sedentary life style and total
cholesterol levels in urban subjects. Reddy et al, Chadda et al in Delhi and Gupta et al in
These studies showed that in addition to hypertension, obesity, and cholesterol levels,
factors such as glucose intolerance, diabetes, and truncal obesity were also more common
in urban subjects. Case-control studies of coronary risk factors in CHD patients confirn1
these findings.
2.3 Studies on knowledge about risk factors and warning signs of ACS
"CEvery liuman 6eing is tlie autlior of liis own lieaftli or disease"- Sivananda
secondary preventive strategies for ACS. A number of studies have been conducted by
the researches all over the world in the past decade on knowledge about risk factors and
Dracup et al (2005) surveyed patient's level of knowledge about heart disease and
self-perceived risk for a future acute MI in patients with documented heart disease in the
University of California, USA. Data was gathered from 3522 patients who had a history
of AMI or invasive cardiac procedure for ischemic heart disease with a 26 item
instrument focusing on ACS symptoms and appropriate steps for seeking treatment.
Patients were asked to identify their level of perceived risk for future AMI. 46% of
16
patients had low knowledge levels (70% of the answers were correct). The mean score
was 71%. Higher knowledge scores were significantly related to female sex (p= .001),
younger age (p= .001), higher education (p= .001), participation in cardiac rehabilitation
(p= .001), and receiving care by a cardiologist rather than internist or general practitioner
(p= .005). Most identified themselves as being at higher risk for a future AMI compared
with an age- matched individual without heart disease. The researches concluded that
even after following the diagnosis of ACS and numerous interactions with physicians and
other health care professionals, knowledge about ACS symptoms and treatment on the
with ACS in the CCU of an Italian hospital. The lifestyle before admission, knowledge
on their illness and lifestyle after acute coronary event were analyzed with
questionnaires, in three different samples of patients. (A) All patients admitted for acute
coronary event from May 2003 to May 2005, to explore lifestyles before acute coronary
event (416 patients). (B) All patients admitted from May 2003 to April 2004, to explore
knowledge on their illness and its causes (132 patients). (C) A sample of 83 patients
followed in day hospital, to explore lifestyles after coronary event. The outcome of the
study was, most (50%) patients had incorrect lifestyles before the event. Even after the
coronary event, some incorrect life styles were still present. 75% of the patients had
investigators concluded that the results were worrying and called for systematic adoption
17
Khan et al (2006) estimated the level of knowledge of modifiable risk factors and
determined the factors associated with good -level of knowledge among patients
presenting with their first AMI at the National Institute of Cardiovascular Disease, a
major tertiary care hospital in Karachi, Pakistan. A cross sectional study was performed
with a standard questionnaire in 720 subjects. Knowledge of four modifiable risk factors
of heart disease; fatty food consumption, smoking, obesity and exercise were assessed.
The participants knowing 3 out of 4 risk factors were regarded as having good level of
knowledge. The independent predictors of good level of knowledge were, more than 10
years of schooling and nuclear family system. In addition, higher level of exercise and
non-user. of tobacco were also predictors of good level of knowledge. The researchers
concluded the study by highlighting the lack of good knowledge of modifiable risk
factors of heart disease among subjects with AMI and the need for aggressive and
Assiri (2003) performed a study to assess the knowledge about coronary artery
disease among patients with ACS. A pre-tested questionnaire was used to identify the
level of education about coronary artery disease in all consecutive patients admitted to
Aseer Central Hospital for a period. (Jan 2000- Feb 2001). The investigator found that the
level of knowledge in majority of the patients was poor; the older and less educated
patients had a lower level of knowledge. Improved level of knowledge was shown during
their stay in the hospital. The investigator concluded that, improvement in the level of
unit regarding health promotion and cardiovascular risk factors. A total of 510 patients
18
hospitalized in a cardiology ward were questioned on cardiovascular risk factors using a
questionnaire. The knowledge was assessed with a score system. The result of the study
was, 1 out of 5 did not know about the consequences of obesity, high blood cholesterol or
smoking on the coronary ves~els. Over 30% did not mention hypertension. Only 1 out of
knowledge during the hospital stay. The presence of risk factors had hardly any influence
on the knowledge of these patients. The investigators concluded that there is a need for
Redfern et al (2007) documented the risk factor profile and risk factor knowledge of
patients with an ACS not attending standard cardiac rehabilitation. A cross sectional
comparison was done in patients admitted in the hospital with an ACS who did not access
rehabilitation (SCR). Of the 446 patients eligible for cardiac rehabilitation, 208 attended
. for assessment (NCR: n= 144; SCR: n= 64). The NCR group had hlgher mean low-
density lipoprotein (LDL) cholesterol levels, and were more likely than the SCR group to
have a total cholesterol level of > 4.0 mmol/L and LDL cholesterol level of > 2.5
mmol/L. Compared with SCR group The NCR group had higher risk scores (LIPID risk
score); lower quality of life and significantly poorer knowledge of risk factors. Among
patients with at least two modifiable cardiac risk factors, the NCR group were less likely
than the SCR group to be able to state at least one risk factor. The investigators
concluded that the patients not participating in cardiac rehabilitation after an ACS had
more adverse risk factor profiles and poorer knowledg~ of risk factors compared to those
19
Memis et al (2009) conducted a study to determine the level of knowledge and
population based cross sectional survey was carried out with people over the age of 40
who did not know what a heart attack is and its warning signs were 42.3% and 23.2%,
fainting, chest pain, radiation of pain was reported as the warning signs. Among risk
factors, stress was ranked as the most common, followed by smoking. It was determined
that age, place of residence, education, occupation and self reported risk factors had
effect- on the knowledge for major warning signs. The factors having negative effect on
the knowledge of warning signs were, having primary school/ lower level of education,
being older, living in urban area, being unemployed and absence of self reported risk
factors. Participants ha<J learned the information about symptoms and the risk factors
from television, neighbors and relatives. !he researc]lers concluded that there is a need
for necessary awareness, utilizing community based education programs and the mass
media.
among Beijing residents and to identify the characteristics associated with increased
Beijing from March 1 through June 10 in 2006. A total of 4627 respondents completed
the questionnaires correctly, and 50.29% of them were female. Totally 64.15% of the
heart attack. 75.38% reported at least one of the following 8 symptom of heart attack;
20
Back pain, shortness of breath, arm pain or numbness, nausea or vomiting, neck, jaw or
shoulder pain, epigastric pain, sweating, weakness (less common symptoms); 20.36%
correctly reported four or more heart attack symptoms, only 7.4% knew all the heart
attack symptoms, and 28.94% knew about reperfusion therapy for heart attack. The
investigators concluded that the public knowledge of heart attack symptoms is deficient
in Beijing residents.
the differences between Lebanese men and women in cognitive emotional and behavioral
responses to signs and symptoms of ACS. A convenience sample of 149 men and 63
women with unstable angina or AMI were interviewed within 72 hours of admission to
result of the study was, women were less educated and more women had hypertension,
but more men were current smokers. Women's signs and symptoms were rated more
severe by women than men's were by the men. Women were less likely to know the signs
and symptoms of MI than were men, and delayed coming to hospital than men did. The
researchers concluded that the factors related to promptness in seeking care for the ACS
Porras et al (2006) assessed the extend to which casual attributions relate to risk
factors, sex and socio-economic status in men and women diagnosed with ACS. The
assessed within 5 days of admission to 3 hospitals in London area. Patient rated beliefs in
the role of 16 factors in causing their heart disease were assessed. Associations between
attributions and risk factors were assessed, and differences in beliefs by sex and socio-
21
economic status were analyzed. The most common attributions were stress, smoking,
high blood pressure, chance or bad luck, and heredity. 90% of smokers attributed heart
heart disease to high blood pressure, 72.2% of patients with a positive family history,
attributed to heredity, 85% of obese patients to being overweight, and 49% sedentary
patients to lack of exercise. There were few sex differences, but higher socio-economic
status patients were more likely to attribute heart disease to heredity and genetic factors.
The investigators concluded that casual beliefs about heart disease are strongly associated
22
CHAPTER III
METHODOLOGY
"erne fastest, most efficient, easiest and 6est way ofaoing anytliing
incfuding tliin/Ung is tlie organize£way"
3.1 Introduction
steps that the researcher adopts to study his problem with logic behind. (Kothari, 1990). It
indicates the general pattern of organizing the procedure of gathering valid and reliable
investigator to conduct this study. This chapter includes the research approach, research
design, setting of the study, sample and sampling technique. It further deals with the
- development of the tool, procedure for data collection and plan for data analysis.
Survey approach was selected for this study. Survey approach is more suitable for
Research design is concerned with the overall framework for conducting the
study. The design used for fulfilling the objectives of the study is as a descriptive survey
23
Framework for the study
Patients
Age, Sex, admitted in Structured Knowledge
Educational Cardiac questionnaire about risk
status, Medical on risk factors factors and
Source of Unit and warning warning
information 9 9 signs ofACS 9 signs of
Study ACS
sample=
50 patients
This study was conducted in the Coronary care unit (Cardiac medical unit) of Sree
Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. The rationale
for selecting this institute was that the investigator was more familiar with the institution.
The target population of the study was both male and female patients admitted in
24
3.6 Sample
The sample consisted of 50 patients. 10 samples were selected for pilot study.
Inclusion criteria:
Exclusion criteria:
• Patients on ventilator and who cannot respond are excluded from the study.
Patients who are admitted in the Cardiology Medical Unit during the data
collection period and who fulfilled the inclusion criteria were selected as samples by
Data collection tool refers to the instrument, which was used by the investigator to
extensive review ofliterature. The questionnaire was then examined and content
validated by experts in SCTIMST. The research tool was finalized according to experts'
opmwn.
25
3.10 Description of the tool
Section I:
It includes, name, age, sex, marital status, educational status, and financial category
(according to hospital records). Educational status is placed under four sub headings.
Uneducated (no basic education), primary (up to 5th Std), secondary (6th to 1ih std), and
above 12th std. Occupational status and the source of information is also included.
Section II:
ACS. These questions were placed under two divisions. First division consists of 13
questions about risk factors of ACS, which includes 8 known risk factors, and 5 wrong
risk factors. The second division consists of 11 questions about warning signs of ACS,
including 8 correct and 3 incorrect warning signs. The questions were of Yes or No type .
•
Separate columns were provided for answering Yes, NO and Don't know. Each correct
answer is given '1' mark. Don't know answer is calculated as wrong answer and each
wrong answer in given '0' mark. Total knowledge about risk factors and warning signs is
• <40% ~POOR
• 41-60% ~AVERAGE
• 61-80% ~FAIR
26
3.11 Pilot study
A pilot study was conducted from September 25th to 30th for 5 days. The aim of
the pilot study was to find out the practicability and feasibility of the tool. The pilot study
was conducted among 10 samples. The sampling technique used was consecutive
sampling. Informed consent was taken from the samples. Then the finalized tool was
used to assess the knowledge of the samples regarding risk factors and warning signs of
ACS. The pilot study findings revealed that the study was feasible and practicable.
Since there was no problem faced during pilot study, the same method of data
collection was used for the final study. The final study was done during the month of
The sample collection was done on the 2nd or 3rd day of admission in CCU. The
researcher first introduced himself to the subjects and then explained the need and·
purpose for the study. Informed consent was taken from the patients. The research tool
was given to the patients and then 15 minutes was given to answer the questi.ons. The
entire time taken was a maximum of 30 minutes per sample. The samples were very
After data colle1on, datas were organized, tabulated, summarized and analyzed.
Descriptive statistics like frequency mean and inferential statistics chi-square, test of
27
3.14 Protection of human subjects
The proposed study was· conducted after the approval of the guide. Permission
was obtained from the Head of the Cardiology Medical Department, and the Sister- in-
Charge. Informed consent was taken from each subject before the data collection.
Assurance was given to the study participants regarding the confidentiality of data
collected.
3.15 Summary
This chapter includes the research approach, research design, setting of the study,
Description of the tool, pilot study, data gathering process, plan for data analysis, and
28
CHAPTER IV
ANALYSIS AND INTERPRETATION OF DATA
4.1 Introduction
intelligible and interpretable form, so· that research problem can be studied and tested
Interpretation is the process of making a sense of the result and examining the
The datas in this study was arranged and analysed under the followimg sections:
(2) Distribution of samples according to the knowledge about risk factors of ACS
(3) Distribution of samples according to the knowledge about warning signs of ACS
(5) Relationship between patient's knowledge about risk factors and warning signs
29
Table 1: Distribution of samples according to demographic variables.
N=SO
AKe:
< 40 years 5 10
41 to ·so years 13 26
51 to 60 years 20 40
> 60 years 12 24
Sex:
Male 32 64
Female 18 36
Education:
Occupation:
Employed 34 68
Unemployed 16 32
Source ofinformatioll:
Mass me~ 29 58
Health workers 17 34
Others 4 8
30
Table 1 shows the demographic distribution of the samples according to variables.
40% of the samples were in between the age group of 51 - 60 years, and 10 % of the
samples were less than 40 years. 24% of the samples were greater than 60 years (Fig 2).
64% of the samples were males and the rest 36% were females (Fig 3).
62% of the samples had secondary education (5th- 12th), 18% of the samples had higher
education(> 12th std) and 20% of the samples had primary education (up to 5th std). (Fig
4).
68% of the samples were employed and 32% were unemployed. (Fig 5). Mass media was
the source of information for a maximum of 58 % of the samples. Health workers wete
31
Fig 2: Distribution of samples according to age
Percentage of samples
• MALE • FEMALE
32
0 10 20 30 40 50 60 70
Percentage of samples
33
Percentage of samples
H MASS MEDIA
• HEALTH WORKERS
H OTHERS
34
Table 2: Distribution of samples according to knowledge about risk factors of ACS
N=SO
Correct Incorrect
Risk factors Frequency Percentage Percentage
Frequency
Smoking 40 80 10 20
Obesity 31 62 19 38
Hypertension 44 88 6 12
High blood
44 88 6 12
cholesterol
Diabetes mellitus 23 46 27 54
Stress 38 76 12 24
-
Fatty diet 45 90 5 10
Family history 26 52 24 48
-
risk factors of ACS. 90% of the samples answered fatty diet as a risk factor, 80% of the
samples identified smoking, and 88% identified hypertension and high blood cholesterol
as a risk factor. 76% and 56% of the samples answered stress and family history as risk
35
Table 3: Distribution of samples according to knowledge about warning signs of ACS
N=SO
Correct Incorrect
Warning signs Frequency Percentage Frequency Percentage
Chest discomfort 49 98 I 2
Vomiting 10 20 40 80
Arm discomfort 36 72 14 28
Shortness of breath 29 58 21 42
Sudden dizziness 25 50 25 50
Indigestion/ Gastric
8 16 42 84
- discomfort
warning signs of ACS. 98% of the samples answered chest discomfort to be the mail
warning sign of ACS. 72% of the samples identified arm discomfort. 58%, 52% and 50%
of the samples answered for shortness of breath, neck/ jaw pain and sudden dizziness
respectively. 46% answered for upper back pain and only 16% and 20% of the samples
~
answered for indigestion/ gastric discomfort and vomiting respectively.(Fig 8)
36
Table 4~ Distribution of samples according to the total knowledge score.
<40% 4 8
41-60% 25 50
61-80% 18 36
> 80% 3 0
Table 4 shows the distribution of samples according to the total knowledge about risk
factors and warning signs of ACS. 50% of the samples had average knowledge and 8% of
the samples had poor knowledge. 36% had fair knowledge and only 6% of the samples
_had good knowledge about risk factors and warning signs of ACS. (Fig 9)
37
KNOWLEDGE ABOUT RISK F A C T O R S OF A C S
8 100 r-
8 120 -i
38
Fig 9: Sample distribution according to total knowledge score
39
5. Relationship between patients' knowledge about risk factors and warning signs of ACS
Table 5 shows that there was no significant statistical difference in the mean total
knowledge score of patients in the different age categories at 0.05 level in the ANOVA
test. (p=0.46). \
40
Table 6: Mean and standard deviation of knowledge score by sex
Table 6, an unpaired 't' test showed that there was no significant difference in the
Table 7 shows that there was an increase in the mean total knowledge score in the
patients with higher educational level. However this increase was not found to be
41
CHAPTERV
SUMMARY, CONCLUSION, DISCUSSION AND
RECOMMENDATIONS
This chapter gives a brief account of the present study including the conclusions
5.1 Summary
A descriptive study was undertaken to assess the knowledge about warnings and
risk factors of ACS among patients admitted in cardiac medical miit of SCTIMST,
Thiruvananthapuram.
structured questionnaire risk factors and warning signs of ACS, prepared by the
• Majotitf,60% of the samples were males, 40% of the samples were between the
age group of 51-60 years. 61% of the samples had secondary education between
5th- 12th standard. 68% of the samples were employed. Source of information
• Majority, 90% of the samples had knowledge about fatty diet as a risk factor.
Hypertension and High blood cholesterol was answered by 88% of the samples.
mellitus and Family history was poor, as only 46% and 52% of the samples
42
• Majority, 98% of the samples had knowledge about chest· discomfort as a
warning sign of ACS. Only 16% and 20% of the samples had knowledge about
• Majority 50% of the samples had a total knowledge score of between 41-60%.
Only 6% of the samples had a knowledge score of above 80%. 8% of the samples
had a knowledge score of less than 40%. Overall, the samples had low level of
showed there was no significant statistical relationship in knowledge with age and
sex of the samples. (p= 0.46 and p= 0.56 respectively). The educated group
showed higher mean total knowledge score though it was not statistically
5.2 Conclusion
A descriptive study was undertaken to assess the knowledge of the patients about
risk factors 4d warning signs of ACS. The results conveyed that the patients had lower
level of knowledge about risk factors and warning signs of ACS. The study was
conducted in a relatively small sample of 50 patients. There was an increase in the mean
total knowledge score of patients with higher educational level. This study clearly
portrays that majority of the patients had average or above average total knowledge.
However, poor knowledge was seen in 8% of the patients. It is also observed that there is
a paucity of knowledge in relation to diabetes mellitus as a risk factor and vomiting and
43
5.5 Discussion:
The findings of the study were discussed with reference to the objectives and with
the findings from other studies. The objectives of the study were, to assess the knowledge
about risk factors and warning signs of ACS and to assess the relationship between
knowledge and selected variables. Study findings revealed that majority of the patients
with ACS were unaware of the risk factors like diabete.s mellitus, obesity, stress and
family history. According to Memis et al (2009) 11.8% of the population were unaware
of the risk factors. Assiri (2003) found that the level of knowledge about risk factors of
reduction in blood glucose and central obesity is important in preventing ischemic heart
disease in Asian Indians. Study findings revealed that patients had average level of
knowledge regarding risk factors and warning signs of ACS. Dracup et al (2005), Ponti et
al (2006) also found that there is a lack of good knowledge about ACS symptoms and
risk factors among patients. These studies support the findings of the present study.
Stud~ findings also revealed that there was an increase in the mean total
knowledge score of patients with higher level of education though it was not significant
at 0.05 level (p=0.059) as the sample size was relatively small (N=50). A study by Khan
knowledge about ACS among patients. This supports the findings of the present study.
44
5.4 Recommendations
45
BIBLIOGRAPHY
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Dallas, Texas.
http://www.americanheart.org/presenter.jhtml? .identifier=3053#Heart_Attack
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review based on ECG defined coronary heart disease' Heart BMJ, July (91); 719-
46
725. http:/lheart.bmj.com/cgi/content/full/91161719, accessed on September 25,
2009 .
• Baberg et al, (2000), Health promotion and cardiovascular risk factors. The level
of know ledge among 510 inpatients of an acute coronary care unit,Med Klin
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1809-1840.
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3229.
47
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620.
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283- 288.
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II
PandeR (2004) 'Cardiovascular diseases in India and the impact of lifestyle and
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.. Reddy K.S, Cardiovascular diseases in India, WHO statQ 1993; 46: 101-107 .
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52
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~ents Chin Med J (Engl). 2007 Sep 20; 120(18): 1587-91. (Electronic version)
53
ANNEXURE II
QUESTIONNAIRE TO ASSESS PATIENTS KNOWLEDGE· ABOUT RISK
FACTORS AND WARNING SIGNS OF ACUTE CORONARY SYNDROME (HEART
ATTACK)
GENERAL INFORMATION
FORM NO:
NAME
AGE
SEX:
OCCUPATION
CATEGORY A B Bl C D
SOURCE OF INFORMATION
DATE
55
QUESTIONNAIRE
(Please mark (--J) in the box, which you think as right answer)
(1) Which of the following increases the risk ofhaving a heart attack?
DON'T
SL.NO RISK FACTORS YES NO
KNOW
CIGARETTE SMOKING
1
2 OBESITY
3 CHRONIC HEADACHE
4 HYPERTENSION
8 DIABETES MELLITUS
9 STRESS
10 FATTY DIET
12 ASTHMA
56
(2) Which of the following are the warning signs of heart attack?
- DON'T
s WARNING SIGNS YES NO
KNOW
1 CHEST DISCOMFORT
2 SEVERE HEADACHE
3 VOMITING
. i.,
4 ARM DISCOMFORT
5 FEVER
7 SHORTNESS OF BREATH
-
9 SUDDEN DIZZINESS -
INDIGESTION/ UPPER GASTRIC
10
DISCOMFORT
11 LOOSE STOOL
57
ANNEXURE III
INFORMED CONSENT
study, to assess patients knowledge about risk factors and warning signs of acute
yr Diploma in Cardiovascular and Thoracic Nursing, of Sree Chitra Tirunal Institute for
Medical ~2iences and Technology, Trivandrum. I understand that there will not be any
change in the nature of care I receive and the data's given by me will be kept
Date: ............... .
58
ANNEXURE IV
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61