J Community Health (2011) 36:895–902

DOI 10.1007/s10900-011-9465-4

ORIGINAL PAPER

Acute Coronary Syndrome: Factors Affecting Time to Arrival

in a Diverse Urban Setting
Mrualini Deshmukh • Michael A. Joseph •

Niko Verdecias • Edmond S. Malka •

Judith H. LaRosa

Published online: 30 August 2011

Ó Springer Science+Business Media, LLC 2011

Abstract This study seeks to better understand how
individuals of different cultural/ethnic backgrounds in an
urban setting assess the signs and symptoms of Acute
Coronary Syndrome (ACS) and the ensuing decision to
take urgent action. Few studies exist which examine these
differences and enhance understanding of how to address
these differences and, ultimately, reduce morbidity and
mortality from ACS. Face-to-face interviews were con-
ducted with a convenience sample of urban patients of
different cultural and socioeconomic backgrounds regard-
ing their actions upon recognition of ACS signs and
M. Deshmukh
Section of Endocrinology and Metabolism, Reading Hospital
Medical Center, 1991 State Hill Road, Wyomissing,
PA 19610, USA
e-mail: mrunalini.deshmukh@gmail.com
M. A. Joseph
Department of Epidemiology and Biostatistics, SUNY
Downstate Medical Center School of Public Health,
450 Clarkson Avenue, Box 43, Brooklyn, NY 11203, USA
e-mail: michael.joseph@downstate.edu
N. Verdecias
Department of Family and Social Medicine, Albert Einstein
College of Medicine/Montefiore Medical Center,
1300 Morris Park Avenue, Bronx, NY 10461, USA
e-mail: RNVMD@aol.com
E. S. Malka
Institute for Health, Health Care Policy and Aging Research,
Rutgers, The State University of New Jersey,
112 Paterson Street, New Brunswick, NJ 08901, USA
e-mail: emalka@ifh.rutgers.edu
J. H. LaRosa (&)
SUNY Downstate Medical Center School of Public Health,
450 Clarkson Avenue, Box 43, Brooklyn, NY 11203, USA
e-mail: judie.larosa@downstate.edu
symptoms. Patients (423) with presumed or diagnosed ACS
were interviewed within 12 h of arrival at the urban
emergency rooms. Among the different cultural groups,
Haitians delayed the longest (median) from symptom onset
to hospital arrival (8.24 h), followed by Caribbeans
(7.83 h), African Americans (6.62 h) and Hispanics
(6.00 h). Although these delay intervals were not statisti-
cally significant across groups, each racial/ethnic group
sought care well beyond the recommended time period of
3 h after initial recognition of ACS signs and symptoms.
Among all the cultural groups, the two key factors moti-
vating early arrival were being employed and taking
positive actions. ACS symptom perception by different
cultural groups appears to play an important role in the
decision to seek emergency treatment. This is an area that
has not been widely studied among or within different
cultural/ethnic groups. As such, further research is needed
to delineate these concepts and actions and to provide
opportunities for appropriate education.
Keywords Acute Coronary Syndrome (ACS)

Time to treatment
Cultural differences
Introduction
Time interval is a crucial factor in the initiation of defini-
tive treatment and prevention of morbidity and mortality of
Acute Coronary Syndrome (ACS). Of the three major
components of delay—pre-hospital or patient delay,
Emergency Medical Services (EMS) delay, and hospital
delay—patient delay is the major contributor [1, 2].
Yet, despite public education campaigns over the past
two decades, little significant change has been measured in
the delay period. In the United States, median delay time

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from symptom onset to arrival ranges from 1.5 to 6 h [2].
Fifty percent of the American population still tends to
delay an average of 4 or more hours in seeking medical
care for ACS symptom [3].
Some previously studied factors affecting patient delay
include: female sex, older age, a history of diabetes mel-
litus, non-white race, and lower socioeconomic status [4–
9]. Perception of symptoms also plays an important role in
decision to seek treatment [10–14]. Those who perceive
their symptoms as cardiac in nature are more likely to
respond early, whereas those who attribute their symptoms
to indigestion, muscle pain, fatigue, or another cause tend
to respond later [15]. A Japanese study considered an
individual’s independence as an important factor in the
decision to seek care, i.e., the more independent the indi-
vidual, the more likely he or she was to seek treatment [16].
A few studies have investigated perceptions of ACS
symptoms among diverse urban groups and the effect on
immediate actions taken and time to emergency room (ER)
arrival [4, 15–17]. These studies underscored that symptom
perception varied, particularly among individuals of dif-
ferent racial and ethnic backgrounds. In the United States,
more Blacks appear to attribute their symptoms to non-
cardiac causes than do Whites [17, 18].
Yet, in none of these studies is there a focus on the vast
diversity found within various cultural groups, which is
often an important measure of how an individual sees him
or herself. Thus, this study considers factors affecting the
decision to seek treatment and the arrival at an emergency
room among different cultural groups in an urban setting.
The objective of the study was to determine factors
affecting: (1) time from the first ACS signs and symptoms
to departure for emergency treatment, and (2) time from
departure to arrival at the ER among patients from different
cultural backgrounds and socioeconomic status.
Methods
The participants in this study represented a convenience
sample of culturally and socio-economically diverse
patients with presumed or confirmed diagnosis of Acute
Coronary Syndrome (ACS) who presented to ERs in
Central Brooklyn from September 2006 through May 2007.
This study was approved by the SUNY Downstate Medical
Center Institutional Review Board for the protection of
human subjects. The ERs chosen for this study serve a
widely diverse racial/ethnic and socio-economic popula-
tion. Data were obtained by interviewing stable patients
with a presumed or confirmed diagnosis of ACS. The
diagnosis of confirmed or presumed ACS was made by ER
physicians. Five hundred twenty (520) patients with such
diagnosis were screened by attending or resident physicians
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J Community Health (2011) 36:895–902
upon entry to the ERs. Patients who were included in the
study tended to be older than 18 years of age; able to
understand the study and their role in it; signed the consent
form; and had arrived at the ER less than 12 h at the time
of interview.
Survey Instrument Development and Testing
The survey instrument was developed and tested in three
phases: (1) an employee survey to initially test a newly
formulated questionnaire (2) a pilot test of the newly for-
mulated questionnaire, and (3) final testing of completed
questionnaire.
Phase 1 A basic questionnaire was developed based on
validated questionnaires used in previous studies [15, 17,
19]. The questions focused on what individuals perceived
their symptoms were related to, what they did initially after
the onset of symptoms, which symptoms brought them to
the hospital, and what mode of transportation they used to
arrive at the ER. Time of onset of symptoms and time of
departure to the ER, as reported by the subjects was
recorded.
Two different time intervals were calculated based on
subjects responses or ER documentation: (1) time from
onset of symptoms to departure, and (2) time from depar-
ture to hospital arrival. Time from onset of symptoms to
hospital arrival was categorized by less than 3 h or more
than 3 h, for the purpose of analysis. The cut-point of 3 h
was chosen based on the recommendations of the Ameri-
can College of Cardiology guidelines, during which
patients with a confirmed Myocardial Infarction (MI)
should be treated [20]. Variables—age, sex, race/ethnicity,
education status, employment status, insurance status,
immigration status, perception of symptoms and actions
taken (active vs. passive)—were considered as potentially
affecting time intervals (less than 3 h or more than 3 h).
Time of arrival at the ER was included as reported on the
ER documentation sheet.
Perception of symptoms is an important factor in the
decision to take action. As such, patients were asked an
open-ended question: What do you think your symptoms
are related to? If the patient’s answer matched the prede-
termined list of options—which included heart, muscle
pain, stress, fatigue, indigestion—that answer was entered
for that specific question. If the patient’s answer did not
match the predetermined list of options, the answer was
written as text in an option marked ‘‘Other’’.
Actions were categorized into active and passive for
purpose of analysis. Active actions included: called 911,
called family physician, took aspirin. Passive actions
included: took prescribed medicine, took over the counter
pain medicine or medicine for ‘‘gas’’, drank hot tea/herbal
J Community Health (2011) 36:895–902
tea, laid down, called family members/neighbors/friends,
waited to see if the symptoms would go away, ignored
symptoms, tried to relax, wished or prayed that symptoms
would go away.
Based on the number of medical problems, each patient
was assigned a co-morbidity index of 1–15 for the purpose
of analysis, with 15 being the highest level. For example; if
a patient had three (3) medical problems from the option
list, the co-morbidity index would be three [21].
Final discharge diagnosis of the patients was categorized
into cardiac versus non-cardiac related discharge. Cardiac
diagnoses included: hypertensive heart disease, athero-
sclerotic heart disease, unstable angina, angina pectoris,
non-ST elevation MI, and syncope. Non-cardiac causes
included: gastritis, peptic ulcer disease, musculoskeletal
pain, atypical chest pain, gastro-esophageal reflux disease,
and pulmonary embolism.
Questions also gathered information on education, eco-
nomic status, insurance status, occupation, medical prob-
lems, place of birth and, if the individual (patient) was
foreign born and how long they had been living in United
States.
Phase 2 To pilot test the revised questionnaire, we
worked with a Downstate Medical Center employee group.
This group was selected, with their approval, because of
their cultural/ethnic similarity to the patient population
delineated for study. A total of 70 employees from dif-
ferent cultural/ethnic backgrounds were asked about: (1)
symptoms of ACS or Heart Attack, (2) immediate actions
that they would take if they had such symptoms, (3) what
would affect their decision to seek emergency treatment,
and (4) mode of transportation to the hospital. The original
questionnaire was modified based on the responses and
feedback from this employee group.
Phase 3 The final questionnaire was pilot tested on 25
patients in the ERs. After minor adjustments, the final
revised questionnaire was used for all patient interviews.
Patient Interviews
Interviews were conducted by the primary investigator and
a research assistant in 4 h shifts from 8:00 am to 8:00 pm,
Monday through Saturday. The primary investigator and
research assistant went through intensive training on con-
ducting patient interviews. The primary investigator and
research assistant were observed by Dr. LaRosa several
times during interviews to insure consistency in data
collection.
Each shift covered is referred to as a ‘‘period’’. There
were a total of 18 periods during a week for potential
interviewing, comprised of three time periods per day
897
(8 am to 12 noon; 12 noon to 4 pm; and, 4 to 8 pm). Given
the impracticality of interviewing 24 h a day, 7 days a
week, a block randomization scheme was developed to
ensure coverage of all time periods and all days equally
throughout the study period. The block randomization
interview schedule was generated using SAS software. In
each week, a total of six periods were covered and at the
end of the study all periods were covered equally thus
providing a homogenous representative sample. The
approximate interview time was 15–20 min per subject.
The interviewers asked patients to choose their ethnicity
from the option list. Ultimately, race was categorized into
subgroups, which included, African American, Caribbean/
West Indian, Haitian, Indian, Mexican, Puerto Rican, Other
Hispanics, Russian, Middle Eastern and Other. However,
because of the small sample size within some racial/ethnic
groups, only four major ethnic groups—African American,
Caribbean, Haitian, and Hispanic—were analyzed. Note
that ‘‘Hispanic’’ in this study, was predominantly com-
prised of Puerto Rican and Mexican ethnicity.
A total of 520 patients were screened in the ER, of
which 423 (81.3%) signed informed consent. Ninety-seven
subjects (18.7%) were ineligible for the study. The primary
reasons for ineligibility were: time interval from arrival at
ER greater than 12 h at the time of interview (n = 28),
inability to understand consent form or inability to speak
English (n = 24), unstable medical condition (n = 1), and
refusal to participate in the study or refused to sign a
consent form (n = 44).
To assess associations between categorical variables,
Chi-square analyses were performed. The median and
interquartile range (IQR) were used to describe time
elapsed from first symptoms to ER arrival. Because of the
asymmetric distribution of the delay times (i.e., time from
first symptoms to departure; time from departure to ER
arrival; and total time from first symptoms to ER arrival)
and the presence of outliers, the nonparametric Kruskal–
Wallis test was used to evaluate statistically significant
differences in the distribution of delay times across groups.
All analyses were performed using the statistical package
SPSS, version 17 (SPSS Inc., Chicago, IL). Statistical
significance was set at a two-tailed alpha level of 0.05.
Results
A total of 423 eligible patients (Female: 262, Male: 161,
mean age 60 years) were interviewed. Of those 423, 384
(91%) were included in the analysis. Of the remaining 39
patients, 32 were excluded because of inadequate infor-
mation and 7 who identified themselves as ‘‘other’’ among
the ethnic categories.
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Table 1 Patient characteristics

Patient characteristics Ethnicity (%) P value
African American Caribbean Haitian Hispanic
N = 97 N = 235 N = 16 N = 36

Mean age (years) 58.79 60.33 60 57.8 0.058

Education in number of years
\12 years 74.9 67.5 73.0 74.0 0.003
[12 years 18.8 18.0 20.0 24.0
No answer 6.3 14.5 7.0 2.0
Household income
\20 K 71.0 67.4 80.0 77.0 0.010
[20 K 15.0 19.6 14.0 15.0
Dependent 4.0 13.0 6.0 8.0
Immigration status
US born 93.8 2.1 0 23.5 \0.001
Not US born 06.3 97.9 100 76.5
Employment status
Yes 36.5 53.0 67.0 44.1 0.021
No 63.5 47.0 33.0 55.9
Insurance status
Yes 93.0 85.0 87.0 85.0 0.343
No 7.0 15.0 13.0 15.0
Clinical history
DM type 2 37.5 34.2 53.3 20.6 0.132
CHD 20.8 13.2 6.7 5.9 0.108
Angina 22.9 15.8 13.3 11.8 0.073
Hypertension 77.1 71.4 66.7 58.8 0.063
Hyperlipidemia 52.1 45.3 46.7 35.3 0.043
Heart attack 19.8 6.8 6.7 2.9 0.003
CABG 7.3 4.7 0 5.9 0.540
Stomach complaints 12.5 6.0 20.0 8.8 0.52
Active smoker 49.0 23.5 13.3 35.3 0.002
Coronary 9.4 9.4 0 2.9 0.213
Angioplasty/stent

Table 1 presents the demographics of the study popu-
lation. Subjects self-identified as: African American
(25.3%), Caribbean (61.2%), Haitian (4.2%), and Hispanic
(9.4%). The majority of African Americans were US born
(94%), while the majority of Caribbeans (98%), Hispanics
(76%), and Haitians (100%) were foreign born. Among the
different ethnic groups there were statistically significant
differences in employment, annual household income,
education, and immigration status. For example, the
majority of Haitians and Caribbeans were employed, 67
and 53% respectively, compared with African Americans
and Hispanics. The majority of households among all
racial/ethnic groups earned less the $20,000 per year. The
majority (ranging from 85 to 97%) of individuals had some
form of health insurance.
Review of medical history showed that hypertension,
hyperlipidemia and Diabetes Mellitus (DM) Type 2 were
the most prevalent medical problems across all cultural
groups. In comparison to the other racial/ethnic groups,
African Americans had a statistically significantly higher
prevalence of hyperlipidemia, heart attack, and active
smoking. These risk factors clearly set the stage for ensuing
coronary heart disease. The prevalence of other risk factors
varied among the cultural/ethnic groups.
When exploring the steps taken by subjects upon rec-
ognition of the signs and symptoms, we found that Haitians
delayed the longest time (median) from symptom onset to
hospital arrival [8.24 (IQR 1.9–18.69) hours], followed by
Caribbeans [7.83 (IQR 3.33–14.60) hours], African
Americans [6.62 (IQR 2.92–15.58) hours] and Hispanics

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Table 2 Median (interquartile range) time elapsed (in hours) from first symptoms to emergency room (ER) arrival
Cultural group N From first symptoms to departure From departure to ER arrival From first symptoms to ER arrival

African American 81 4.91 (1.13–12.52) 1.00 (0.48–1.95) 6.62 (2.92–15.58)

Caribbean 204 6.25 (1.88–12.49) 1.32 (0.75–1.99) 7.83 (3.33–14.6)
Haitian 14 6.88 (1.25–14.63) 0.92 (0.70–1.63) 8.24 (1.9–18.69)
Hispanic 30 4.00 (1.00–12.67) 1.33 (0.69–2.70) 6.00 (2.64–14.28)
P value* 0.505 0.639 0.616
* Kruskall-Wallis test

[6.00 (IQR 2.64–14.28) hours]. Differences across groups Table 3 Perception of sign and symptoms of ACS among different
were not statistically significant, however (all P values ethnic groups
[0.05 in Kruskal–Wallis test). Symptom Cultural group (%)
Of all the potential delay periods among all cultural/ perception
African Caribbean Haitian Hispanic P value
ethnic groups, the most prolonged delays occurred from
American
time of symptom onset to departure for the hospital
(Table 2); the shortest duration (median (IQR)) of Heart 51.0 42.0 20.0 41.0 0.126
patient delay was observed among Hispanics [4.00 Gas pain/ 19.3 29.2 59.6 18.0
(IQR 1.00–12.67) hours] and African-Americans [4.91 indigestion
(IQR 1.13–12.52) hours], whereas Caribbeans [6.25 (IQR Muscle pain 4.0 3.4 6.0 6.0
1.88–12.48) hours] and Haitians [6.88 (IQR 1.25–14.63) Fatigue/ 7.0 18.5 0 17.6
stress
hours] exhibited the longest delays.
Stroke/BP 3.0 6.0 0 9.0
Among all the cultural groups, the two key factors
associated with early departures and arrivals were, being Others 13.5 16.3 13.0 8.8
employed and taking active action, i.e., within 3 h of
symptom onset. Of those who took active action there were
Table 4 Relationship between symptom perception and action taken
no differences among the cultural/ethnic groups based on
age, sex, education, insurance status, immigration status, Symptom perception Actions taken (%)
and symptom perception. Those who were employed Active Passive P value
(30%) and those taking active action (33%) were, however,
Cardiac 23.6 76.4 0.014
in the minority.
Non-cardiac 13.8 86.2
More African Americans (51%) attributed their symp-
toms to the heart, in comparison to Caribbeans (42%),
Hispanics (41%), and Haitians (20%), although these and Hispanics (79%) adopted a passive response to the
findings were not statistically significant. Alternately, per- symptoms.
ception of symptoms, such as ‘‘gas’’ pain, occurred among The most commonly used mode of transportation was
the majority of Haitians (60%), followed by a minority of private vehicle among all ethnic groups, except African
Caribbeans (29%), African Americans (19%) and Hispan- Americans. Fifty percent of African Americans came by
ics (18%) (Table 3). ambulance compared with 33% or less of Caribbeans,
Perception of symptoms was further categorized into Haitians, and Hispanics. Haitians (46%) and Hispanics
cardiac and non-cardiac. Patients who perceived their (39%) were most likely to choose a private vehicle com-
symptoms as cardiac were more likely to take active action, pared to African Americans and Caribbeans. More than
but they, too, were in the minority (24%). (Table 4) The 30% of patients from all cultural/ethnic groups believed
majority of the patients presented with chest pain, 61–80%, that emergency services (ambulance) had the appropriate
as the primary symptom followed by shortness of breath, equipment for life resuscitation and thus chose to use
11–21%. Less than six percent of all patients presented emergency services (Table 5).
with nausea, vomiting, dizziness/giddiness. The reasons for not choosing emergency services
Forty-four percent of African Americans took active transportation for many African Americans (24%) and
action such as chewing aspirin, calling 911 or their family Caribbeans (25%) was their economic/insurance situation
doctor, compared with other groups. Only 32% of patients (poor coverage for ambulance services) and the sense that
among all ethnic groups called 911 at some point after they could obtain faster access to the hospital by other
onset of symptoms. The majority of Haitians (80%) means such as a private vehicle.

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Table 5 Mode of transportation used
Ethnicity Mode of transportation (%)
Private Ambulance Public Walk P value
vehicle transport
African 35.2 50.0 9.0 5.6 0.564
American
Caribbean 42.0 31.0 19.0 7.7
Haitian 46.0 33.0 6.0 13.0
Hispanic 39.4 30.0 13.0 6.0
Patients were asked what influenced their final decision
to visit the ER. More than 40% of patients from all ethnic
groups decided to go to the ER because of unbearable chest
pain. The only exception were Haitians, where 60% deci-
ded to go to the ER because of shortness of breath. ‘‘Car-
diac’’ related diagnoses at hospital discharge were present
in 52% of African Americans, 61% of Caribbeans, 50% of
Haitians and 34% of Hispanics.
Discussion
In a racially and ethnically diverse sample of patients with
presumed or confirmed ACS, no statistically significant
differences in delay between groups from recognition of
first symptoms to hospital arrival were found. However,
each racial/ethnic group reported pre-hospital delays that
were well beyond the recommended time period of 3 h
after initial recognition of ACS signs and symptoms.
Reducing time to treatment in cases of ACS saves lives.
Yet, despite health professional and public education
campaigns over the past two decades, little significant
change has been measured in the delay period. The ques-
tion that persists is why individuals delay seeking treat-
ment. Of particular interest is the issue of how different
cultural and ethnic groups respond.
Several factors have been shown to influence delay:
female sex, older age, a history of diabetes mellitus, non-
white race, and lower socioeconomic status [4–9]. A critical
factor has always been perception of symptoms [10–14]. Yet,
one issue that has not been addressed in many studies is that
of cultural/ethnic perceptions of ACS signs and symptoms.
One should ask if symptoms are perceived differently and
might this affect seeking treatment? Therefore, this study
sought to explore and better understand how individuals of
different cultural/ethnic backgrounds in an urban setting
assess their signs and symptoms of ACS and their ensuing
decision to take action.
The study data demonstrate that there was no apparent
relationship among older age, gender, insurance status, or
lower socio-economic status with pre-hospital delay.
However, differences were noted among the different
cultural/ethnic groups in the perception of ACS signs and
symptoms and the decision to act.
A strong component of this study was allowing patients
to choose their ethnicity. Having the interviewer presume
the race or ethnicity of an individual can create errors and
may miss the nuances of cultural differences among races
and ethnicities. The term Black, like White or Asian, is a
broad category that includes many ethnicities and cultural
groups. For example, when interviews were conducted
among the culturally diverse employees at the medical
center, 60% who were born in Haiti categorized themselves
as Haitian and not Caribbean or African American.
While this study was not designed to completely detail
cultural differences among the different groups, it does
indicate that such differences do exist and do have an effect
on health actions. The majority of African Americans
perceived their symptoms as related to the heart, while
other cultural groups generally perceived their symptoms
as related to gas pain: Haitians and Hispanics followed by
Caribbeans. More African Americans, compared to
Caribbeans, Haitians and Hispanics, took active actions
such as chewing aspirin, calling 911, or a family doctor.
Fifty percent of African Americans chose to come by
ambulance compared with 30–35% of patients from other
groups. Overall, African Americans were more actively
responsive compared to the other groups. Haitians were
most likely to delay ER arrival from onset of ACS symp-
toms. What has emerged from these findings is that
symptom perception varies among different cultural groups
and has an impact on ensuing action which in turn can
contribute to differences in adverse outcomes.
There were no statistically significant differences in
insurance status among the different ethnic/cultural groups,
which may be due to the small sample sizes. Others have
found that the ability to pay for emergency services plays
an important role in the decision to seek emergency ser-
vices [20].
We acknowledge several limitations to our study. Our
study population consisted of a convenience sample of
patients with a presumed or confirmed diagnosis of ACS
who presented to ER’s in Central Brooklyn that serve a
highly diverse minority population. Thus, any generaliza-
tions from this population are limited by the sociodemo-
graphic composition of our sample and the potential
selection bias imposed by this sampling approach.
Another issue that must be taken into consideration
concerns the validity of self-reported information; the
sensitive nature of some questionnaire items might have
influenced the probability of respondents providing honest,
accurate responses. In addition, non-English speaking
patients, less than five percent of all excluded patients,
were excluded from the study.

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Finally, the data analysis did not, for the most part,
indicate any statistically significant differences among the
different cultural/ethnic groups on a variety of risk factors,
probably due to the small sample sizes. Even though many
of these differences were not statistically significant, they
do have clinical relevance in terms of the need to obtain
urgent care at the first ACS signs and symptoms. For
instance, each of the racial/ethnic groups examined in our
study reported seeking care well beyond the recommended
cutoff period of 3 h upon initial recognition/onset of
symptoms.
Though the time delays among racial/ethnic groups were
not statistically significantly different, the prolonged delay
times noted for each group suggest the need for culturally
appropriate education to shorten delay patterns in seeking
care.
There could be several factors contributing to the lack of
statistically significant findings. This was conducted as a
pilot study with a convenience sample and, as such, the
number of participants was relatively small in each racial/
ethnic group leading to low power to detect a difference.
Further, potentially inaccurate self-reporting of times from
symptom onset to departure for hospital may contribute if
they were differentially over or under estimated among the
different racial/cultural groups. Additionally, the different
misperceptions of the ACS signs and symptoms tended to
be fairly extensive across the different groups, thus leading
to many distinct categories for statistical analysis.
Conclusions
Our results suggest that differences in treatment-seeking
behavior in this richly diverse racial/ethnic population may
be attributed to cultural differences in the knowledge,
perception and interpretation of the signs and symptoms of
ACS. Symptom perception by different cultural groups
appears to play an important role in the decision to take
appropriate treatment action by patients with Acute Coro-
nary Syndrome. This is an area that has not been fully
appreciated nor studied. As such, further research is needed
to elaborate these concepts, to clarify cultural perceptions,
and to provide culturally appropriate education.
Acknowledgments Special Appreciation and Recognition go to
Clinton Brown, MD, Luther Clark, MD, Samy McFarlane, MD, MPH,
Stephen Rinnert, MD, Wanda Torres.
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