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

Su6mittetf as a partia( fulfilCment of tfie requirements for tfie _ CDipComa in CardlovascuCar and %oracic :Nursing

MANIKANDA PRASAD.M.R. CODE NO: 5887

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY

TRIVANDRUM

2009

CERTIFICATE FROM SUPERVISORY GUIDE

This is to certify that Mr.MANIKANDA PRASAD.M.R has completed the project

work 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, 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

·nr. Saramma.P.P, MN, PhD

Senior Lecturer in Nursing SCTIMST . ~

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

guidance of Dr.Saramma.P.P, M.N, PhD, Senior Lecturer in Nursing, SCTIMST,

Thiruvananthapuram. It is also certified that this work has not been presented previously

to any other University for award of degree, diploma or other recognition.

Trivandrum,

November 2009.

Mr.MANIKANDA PRASAD.M.R.

CODE NO: 5887 SCTIMST

APPROVAL SHEET

This is to certify that Mr.MANIKANDA PRASAD.M.R, bearing code no: 5887,

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

Medical Sciences and Technology, Trivandrum and it is found satisfactory.

EXAMINERS

(!) .................... . (2) .....•.........••...•

GUIDE

(1 ) ................... . (2) ...••......•...•..•••

Trivandrum

November 2009

.. ~ ~ ~ t4 de LO!td /lud~~wdt~~"

-Proverb 16:3

Investigator owes sincere thanks to God Almighty, who accompanied and directed

him to achieve success throughout this study.

The present study has been completed under the expert guidance of

Dr.Saramma.P.P, Senior Lecturer in Nursing, SCTIMST, Trivandrum. Investigator

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.

The researcher expressess his sincere thanks to Dr.A. V. George, Registrar,

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

John, Ward Sister, CCU,for which he is extremely grateful.

Investigator would also like to acknowledge the contribution of all participants

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

department of Cardiology, for their timely help.

The researcher expresses his gratitude to Dr. Sankara Sarma, Additional

professor, SCTIMST, for his guidance in statistical analysis.

The researcher inscribes his sincere thanks to all friends, who were helpful

directly and indirectly for the successful completion of this study.

A word of thanks to the library staff of SCTIMST, for their co-operation and help.

He remains ever indebted to his beloved parents, sister Remya, and Abi, for their

unconditional love, prayerful support and constant encouragement in his life.

ABSTRACT

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

selected variables. Method: A survey was conducted in 50 consecutive samples with a

. 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

risk factors and warning signs of ACS.

CONTENTS

Chapter No TITLE Page No

I INTRODUCTION 1

1.1 Introduction 1

1.2 Background of the study 2

1.3 Need and significance of the study 8

1.4 Statement of the problem 9

1.5 Objectives ofthe study

9

1.6 Operational definitions 10

1.7 Limitations 11

1.8 Summary 11

II REVIEW OF LITERATURE 12

2.1 Introduction 12

2.2 Studies on risk factors and warning signs of ACS 12

2.3 Studies on knowledge about risk factors and 16

warning signs of ACS

III METHODOLOGY 23

3.1 Introduction 23

3.2 Research approach 23

3.3 Research design 23

3.4 Setting of the study 24

-3.5 Study population 24

3.6 Sample 25

3.7 Criteria for sample selection 25

3.8 Sampling technique 25

3.9 Data collection tool 25

3.10 Description of the tool 26

3.11 Pilot study 27

3.12 Data collection procedure 27

3.13 Plan for analysis 27

3.14· Protection of human subjects 28

. 3.15 Summary 28 -

IV ANALYSIS AND INTERPRETATION OF 29 DATA

v SUMMARY, CONCLUSION, DISCUSSION 42

AND RECOMMENDATIONS

BIBLIOGRAPHY 46

ANNEXURES 53

LIST OF TABLES

Table No TITLE Page No

1 Distribution of samples according to demographic

30 variables

2 Distribution of samples according to knowledge

35 about risk factors of ACS

3 Distribution of samples according to knowledge

36 about warning signs of ACS

4 Distribution of samples according to the total

37 knowledge score

5 Mean and standard deviation of knowledge score

by age group. 40

6 Mean and standard deviation of knowledge score 41

by sex

7 Mean and standard deviation of-knowledg~ score

41 by educational status

LIST OF FIGURES

Fig No TITLE Page No

1 Deaths in millions from Cardiovascular Causes 2

2 Distribution of samples according to age 32

3 Distribution of samples according to sex 32

4 Distribution of samples according to educational

33 status

5 Distribution of samples according to the source of 33 information -

6 Distribution of samples according to the knowledge

34 about risk factors

7 Distribution of samples a~cording to the knowledge

38 wammg signs

Distribution of samples according to the total 38 8 knowledge score

ACC

ACS

AHA

AMI

CAG

ccu

CHD

CI

CVD

ED

HDL

ICMR

LDL

MI

NSTEMI

PTCA

SCR

SCTIMST

Technology

SD

UA

WHO

ABBREVIATIONS

American College of Cardiology

Acute Coronary Syndrome

American Heart Association

Acute Myocardial Infarction

Coronary Angiogram

Coronary Care Unit

Coronary Heart Disease

Confidence Interval

Cardiovascular Disease

Emergency Department

High Density Lipoprotein

Indian Council for Medical Research

Low Density Lipoprotein

Myocardial Infarction

Non ST Elevation Myocardial Infarction

Percutaneous Trans Coronary Angioplasty

Standard Cardiac Rehabilitation

Sree Chitra Tirunal Institute for Medical Sciences and

Standard Deviation

Unstable Angina

World Health Organization

CHAPTER 1

INTRODUCTION

"Jfearyour lieart. Jfeart your liealtli. ,..,Paitli Seeliill''

1.1 Introduction

Coronary Heart Disease (CHD) is the leading cause of mortality and

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

disease every year by 2015. (Okrainee, 2007).

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

Disease (CHD) in India was estimated to be 3 - 4 percent in rural areas and 8 - 10

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 CHD in India, and the number is expected to

almost double to 2.03 million by 2010. The huge burden of CVD in Indian subcontinent

is the consequence of the large population and high prevalence of CVD risk factors.

(Goenka et al, 2009).

1.2 Background of the study

Globally, second half of the 20 t h century has witnessed a high spread of CHD

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

increase, mostly in developing countries. (Fig 1)

Fig I. Deaths in millions from Cardiovascular Causes, world wide, in 1990 and

estimated for 2020. Data from Reddy (2007)

• 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

Cardiovascular dise~. Extrapolating the Varkala ICDS Block data, it can be

summarized that at least 38,000 people die of heart attack every year. Otherwise

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

surprising when one understands the preponderance of risk factor of cardiovascular

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).

1.2.1 Coronary Heart Disease

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

ftrst presentation ofCHD.

1.2.2 Acute Coronary Syndrome (ACS):

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 .

. The term ACS encompasses Myocardial Infarction (MI), Non-ST Elevation MI

(NSTEMI), and Unstable Angina (UA).

Myocardial Infarction:

Rupture of atheromatous plaque may result in complete occlusion of the coronary

artery by thrombus or other aggregates. This leads to necrosis of the area of myocardium

subtended by the affected artery and is labeled as Myocardial Infarction. MI is typically

associated with ST segment elevation on the Electro Cardiograph (ECG) and the release

ofbiochemical markers of necrosis. (Fox, 2000).

Unstable Angina:

Where less obstructive thrombi exist or where spontaneous dissolution of the

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,

this is described as Unstable Angina.

Ntm-ST Elevation MI:

Episodes of occlusion may occur where release of biochemical markers of

necrosis occurs but where ST elevation is not evident on the ECG. This is termed as Non-

ST Elevation MI. (Fox, 2000) ~

Mortality risks vary between the syndromes and the treatment indicated for each

is different. In particular emergency reperfusion treatment is indicated for acute MI but

not for the remainder of the syndrome.

Symptoms associated with ACS:

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

of discomfort whilst resting is also suggestive of ACS (Braunwald, et al, 2002).

IdentifYing symptoms of A CS:

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

typical. However, there is evidence to suggest that a substantial proportion of patients

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 and the warning signs of ACS are as follows:

Risk factors:

• Age:

* In men after the age of 45

* In women after menopause, usually after the age of 50.

• A previous history of heart attack or procedure to open up the coronary arteries.

• Family history of early heart disease

*Father or brother diagnosed before the age of 55.

*Mother or sister diagnosed before the age of 65.

• Diabetes mellitus

• High blood cholesterol

6

• High blood pressure

• Cigarette smoking

• Over weight

• Physical inactivity

Heart attack warning(signs:

• 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

uncomfortable pressure, squeezing, or fullness.

• Discomfort in other areas of upper body:

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

before chest discomfort.

• Other signs:

These may include breaking out in cold sweat, nausea, or light-headedness. Some

patients report a sense of impending doom. (Omato, 2009).

7

1.3 Need and significance of the study

Studies have shown that -knowledge has an impact on prevention of heart disease.

Significant correlations between patient's specific knowledge about risk factors of

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.

Definitive treatment for MI is early reperfusion. It may be either with angioplasty or

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

'knowledge ofheart attack symptoms may prolong delay. (Zhang, 2007).

Sree Chitra Tirunal Institute for Medical Scie~ces and Technology (SCTIMST) is an

institute of national importance by an act of the Indian parliament. It is an autonomous

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

economic status as per hospital records).

1.4. Statement of the problem

A study to assess the knowledge about risk factors and warning signs of Acute

Coronary Syndrome among patients admitted in Cardiac Medial Unit at SCTIMST,

Trivandrum.

1.5. Objectives

• To assess the knowledge of patients about risk factors of Acute Coronary

Syndrome (ACS).

• To assess the knowledge of patients about warning signs of Acute Coronary

Syndrome (ACS).

• To assess the relationship between patients knowledge about risk factors and

warning signs of Acute Coronary Syndrome (ACS) and selected variables.

9

1.6. Operational definitions

Knowledge:

A state of awareness or understanding with conscious mind.

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

questionnaire on knowledge about risk factors and warning signs of ACS.

Risk factors:

A factor that causes a person/group of people to be particularly

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,

high blood pressure, stress, and fatty diet.

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

pain, indigestion/ gastric discomfort and suddn dizziness.

Acute Coronary Syndrome (ACS):

An umbrella term used to cover any group of clinical symptoms

compatible with acute myocardial ischemia. Acute myocardial ischemia is considered to

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

mentioned clinical conditions.

Cardiac Medical Unit:

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.

(Department of Human Services, Victoria, 1999f

1.7. Limitatiol!s

• The study is limited only to Malayalam speaking patients.

• The study area is limited only in Coronary Care Unit (Cardiac Medical Unit).

• The data collection period is limited to one month.

1.8. Summary

This chapter included the introduction, background of the study, need

and significance of the study, statement of the problem, objectives, operational

definitions, and limitations of the study.

11

2.1 Introduction

CHAPTER II

REVIEW OF LITERATURE

Review of literature is the key step in research process, which helps to

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

build upon existing know ledge.

The literature review relevant to this study is presented in the following

sections.

• Studies on risk facfors, warnmg s1gns and symptoms of Acute Coronary

Syndrome.

• Studies on knowledge about risk factors and warning signs of Acute Coronary

Syndrome.

2.2 Studies on risk factors, warning signs and symptoms of ACS

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

sweat, nausea or light-headedness. The American College of Cardiology (ACC) defined

atypical symptoms as epigastric, arm, shoulder, and wrist, jaw or back pain without

complaints of chest pain. (Alpert et al, 2000;0rnato et al, 2009).

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.

Milner et al (2001) conducted a prospective study at the Yale-New Haven

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

investigators interpreted that smoking cessation, treatment of hypertension and reduction

in blood glucose and central obesity (through dietary modification) is important in

preventing ischemic heart disease in Asian Indians.

Studies show that coronary risk factors are more common m lower soc1o

economic strata. Gupta et al (2003) conducted an epidemiological survey in urban Indian

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

increase in educational status, a significant increase of obesity, total cholesterol, LDL

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

hypertension. Increase in smoking, diabetes and dyslipidaemias were observed n less

educational groups. The investigator concluded that there is a significant increase in

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,

diabetes and dislipidaemias increased more in lower educational groups.

McSweeney et al(2003) conducted a study in the University of Arkansan for

Medical sciences, USA, to describe prodromal and early waming symptoms of acute

myocardial infarction in women. 515 women were surveyed after 4- 6 months of

discharge with McSweeney Acute and Prodromal Myocardial Infarction Symptom

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

women had prodromal symptoms before AMI.

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

Rajasthan also performed urban-rural comparisons in coronary risk factor prevalence.

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

Knowledge is an important pre-requisite for implementing primary as well as

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

warning signs/ symptoms of ACS.

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

part of cardiac patients remained poor.

Ponti et al (2006) conducted a survey on knowledge and lifestyle of patients admitted

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

incorrect or insufficient knowledge on illness and risk factors at discharge. The

investigators concluded that the results were worrying and called for systematic adoption

of secondary prevention strategies with effective interventions aimed at increasing

knowledge and modifying lifestyles.

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

targeted educational strategies in the Pakistani population.

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

education is needed for the cardiac patients.

Baberg et al (2000) assessed the knowledge of the inpatients of an acute coronary

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

3 patients mentioned diabetes mellitus as a risk factor. There was no change in

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

better health information for patients.

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

cardiac rehabilitation (NCR), with a group about to commence standard cardiac

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

about to commence cardiac rehabilitation.

19

Memis et al (2009) conducted a study to determine the level of knowledge and

awareness of warning signs of heart attack in the samples of Turkish population. A

population based cross sectional survey was carried out with people over the age of 40

years by multiple sampling methods using a questionnaire. The percentage of participants

who did not know what a heart attack is and its warning signs were 42.3% and 23.2%,

respectively. Overall, 11.8% were unaware of risk factors. Loss of consciousness/

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.

Zhang et al (2007) documented the knowledge about heart attack symptoms

among Beijing residents and to identify the characteristics associated with increased

knowledge of heart attack. A structured survey was conducted in 18 communities in

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

respondents reported chest pain or discomfort (common symptoms) as a symptom of

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.

Noureddine et al (2008) in the American University of Beirut, Lebanon, explored

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

coronary care in a tertiary center by using Response to Symptoms questionnaire. The

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

differ between Lebanese men and women.

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

investigator conducted an interview and a questionnaire study of 171 ACS patients

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

disease to smoking, compared to 0% never smokers. 90.4% of hypertensives attributed

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

with risk factors.

Key words for related search and number of articles

Keywords Free Articles Total Articles

Patient knowledge 14359 95955

Acute coronary syndrome 2032 9439

Heart attack wariiing signs 21 129

Risk factors of ACS 538 2300

Coronary heart disease risk 9519 45068

22

CHAPTER III

METHODOLOGY

"erne fastest, most efficient, easiest and 6est way of aoing anytliing incfuding tliin/Ung is tlie organize£ way"

3.1 Introduction

Research methodology is the systematic way to solve problem. It includes the

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

· data for an investigation.

This chapter provides a brief description of the method adopted by the

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.

3.2 Research approach

Survey approach was selected for this study. Survey approach is more suitable for

educational fact finding in a relatively small sample.

3.3 Research design

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

design. The framework for the study is as follows.

23

Attribute variables

Age, Sex, Educational status, Source of information 9

3.4 Setting of the study

Framework for the study

Population Tool

Patients admitted in Structured

Cardiac questionnaire Medical on risk factors

Unit 9 and warning

signs of ACS Study

sample= 50 patients

Outcome

Knowledge about risk

factors and

9 warning signs of

ACS

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.

SCTIMST is an institute of national importance, where there is a separate department for

Cardiology, which includes Cardiology medical ward and Comprehensive Acute

Coronary Care Unit.

3.5 Study population

The target population of the study was both male and female patients admitted in

Cardiology medical unit.

24

3.6 Sample

The sample consisted of 50 patients. 10 samples were selected for pilot study.

3.7 Criteria for sample selection

Inclusion criteria:

• Patients who can understand and read Malayalam/ or English.

• Patients who are willing to participate.

Exclusion criteria:

• Patients on ventilator and who cannot respond are excluded from the study.

3.8 Sampling technique

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

consecutive sampling technique.

3.9 Data collection tool

Data collection tool refers to the instrument, which was used by the investigator to

obtain relevant data. The investigator prepared a structured questionnaire after an

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

The structured questionnaire consists of two sections.

Section I:

General information or Demographic data.

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:

It consists of a total of 24 questions regarding risk factors and warning signs of

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

calculated with percentage of marks scored by the samples.

• <40% ~POOR

• 41-60% ~AVERAGE

• 61-80% ~FAIR

• > 80% ~GOOD

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 1 0 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.

3.12 Data collection procedure

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

October 2009, for a period of 30 days.

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

cooperative and no problems occurred during data collection.

3.13 Plan for analysis

After data colle1on, datas were organized, tabulated, summarized and analyzed.

Descriptive statistics like frequency mean and inferential statistics chi-square, test of

significance (ANOV A) was used.

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,

study population, sample, sample size, sampling technique,- selection criteria.

Description of the tool, pilot study, data gathering process, plan for data analysis, and

protection ofhuman subjects.

28

CHAPTER IV

ANALYSIS AND INTERPRETATION OF DATA

4.1 Introduction

Analysis is categorizing, ordering, manipulating and summarizing the data to an

intelligible and interpretable form, so· that research problem can be studied and tested

including relationship between variable.

Interpretation is the process of making a sense of the result and examining the

implication of finding with in broader context.

The datas in this study was arranged and analysed under the followimg sections:

(1) Distribution of samples according to demographic variables

(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

(4) Distribution of samples according to total knowledge score

(5) Relationship between patient's knowledge about risk factors and warning signs

and selected variables.

29

Table 1: Distribution of samples according to demographic variables.

N=SO

Demographic data Frequency Percentage

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:

Primary (Up to 5th std) 10 20 -

Secondary (6th- 12th std) 31 62

Graduate(> 12th std) 9 18

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

the source for 34% of the samples. (Fig 6)

31

Fig 2: Distribution of samples according to age

Percentage of samples

• MALE • FEMALE

Fig 3: Distribution of samples according to sex

32

0 10 20 30 40 50 60 70

Percentage of samples

Fig 4: Distribution of samples according to educational status

Fig 5: Distribution of samples according to occupational status

33

Percentage of samples

H M A S S M E D I A

• HEALTH W O R K E R S

H OTHERS

Fig 6: Distribution of samples according to source of information

34

Table 2: Distribution of samples according to knowledge about risk factors of ACS

N=SO Correct Incorrect

Risk factors Frequency Percentage Frequency Percentage

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 -

Table 2 represents the distribution of samples according to the knowledge about

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

factors respectively.~ 46% of the samples answered diabetes mellitus. (Fig 7)

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

Upper back pain 23 46 27 54

Shortness of breath 29 58 21 42

Neck/ jaw pain 26 52 24 48

Sudden dizziness 25 50 25 50

Indigestion/ Gastric 8 16 42 84 - discomfort

Table 3 represents the distribution of samples according to the knowledge about

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.

Knowledge in percentage Frequency Percentage

<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 FACTORS OF ACS

8 100 r -

Fig 7: Sample distribution according to the knowledge about risk factors

KNOWLEDGE ABOUT WARNING SIGNS OF ACS

8 120 -i

Fig 8: Sample distribution according to the knowledge about warning signs

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: Mean and standard deviation of knowledge score by age group.

Age group Frequency Mean Std Deviation P value

< 40 years 5 54.14 13.50

41-50 years 13 60.54 13.56

51-60 years 20 57.68 14.05 0.46

> 60 years 12 51.70 16.04

Total 50 56.63 14.33

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

Sex Frequency Mean Std deviation P value

Male 32 57.51 15.90

Female 18 55.07 11.27 0.56 .

Total 50 56.63 14.33

Table 6, an unpaired 't' test showed that there was no significant difference in the

mean total knowledge score and sex of patients. (p=0.56).

Table 7: Mean, standard deviation of knowledge score by educational status.

Edu status Frequency Mean Std deviation Pvalue

Up to 5th std 10 50.38 11.70

6th -12th std ~

31 56.01 14.17

>12th std 0.059

9 65.71 14.41

Total 50 56.63 14.33

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

statistically significant at 0.05 level (p=0.059) in the ANOV A test.

41

CHAPTERV

SUMMARY, CONCLUSION, DISCUSSION AND RECOMMENDATIONS

This chapter gives a brief account of the present study including the conclusions

drawn from the findings of the stugy, discussions and recommendations.

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.

• 50 samples were selected by consecutive sampling. Knowledge was assessed with

structured questionnaire risk factors and warning signs of ACS, prepared by the

investigator. Significant findings of the study were,

• 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

was through mass media for 58% of the samples.

• 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.

Obesity was answered by 62% of the samples. Knowledge about Diabetes

mellitus and Family history was poor, as only 46% and 52% of the samples

answered it to be a risk factor.

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

indigestion/gastric discomfort and vomiting as warning signs of ACS.

• 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

knowledge about risk factors and warning of ACS.

• In assessing the relationship between total knowledge and variables, ANOV A,

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

significant at selected alpha level (p= 0.59).

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

gastric discomfort I indigestion as a warning sign of ACS.

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

ACS were low among the population.

Pais et al (1996) interpreted that smoking cessation, treatment ofhypertension and

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

et al (2006) revealed higher educational status as an independent predictor of good

knowledge about ACS among patients. This supports the findings of the present study.

44

5.4 Recommendations

• A similar study can be conducted in a large sample.

• A similar study can be conducted in some selected group of hospitals

• An experimental study can be conducted to assess the effectiveness of health

education on ACS in patients ad1pitted in the hospital.

45

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53

ANNEXURE II

QUESTIONNAIRE TO ASSESS PATIENTS KNOWLEDGE· ABOUT RISK

FACTORS AND WARNING SIGNS OF ACUTE CORONARY SYNDROME (HEART

ATTACK)

GENERAL INFORMATION

NAME

AGE

SEX:

MARRITAL STATUS

EDUCATIONAL STATUS

OCCUPATION

CATEGORY

SOURCE OF INFORMATION

DATE

:MARRIED SINGLE

: PRIMARY SECONDARY

A B Bl C

55

FORM NO:

OTHER

DEGREE

D

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?

SL.NO RISK FACTORS YES NO DON'T KNOW

1 CIGARETTE SMOKING

2 OBESITY

3 CHRONIC HEADACHE

4 HYPERTENSION

5 SLEEPING TOO MUCH

6 DRINKING LOT OF COFFEE

7 HIGH BLOOD CHOLESTEROL

. ~

8 DIABETES MELLITUS

9 STRESS

10 FATTY DIET

11 LIVING WITH HEART PATIENT

12 ASTHMA

13 FAMILY HISTORY OF HEART DISEASE

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

6 UPPER BACK PAIN

7 SHORTNESS OF BREATH

8 NECK/ JAW PAIN

-9 SUDDEN DIZZINESS -

10 INDIGESTION/ UPPER GASTRIC DISCOMFORT

11 LOOSE STOOL

57

ANNEXURE III

INFORMED CONSENT

I, . . . . . . . . . . . . . . . . . . . hereby agree to participate in the research

study, to assess patients knowledge about risk factors and warning signs of acute

coronary syndrome (Heart attack), conducted by Mr.MANIKANDA PRASAD.M.R, 1 'st

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

confidential, and will be used only for research purpose.

Signature of the participant

Date: ............... .

58

ANNEXURE IV

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61