The demographics of participants are presented in Table 1. The mean age of participants was 60 ± 5.2 years, ranging from 51 to 83 years. They were mainly married (71.79%), housewives (64.10%), had health insurance (79.48%), and presented to the emergency department with an accompanying family member (89.74%). A considerable number of participants (30.76%) were illiterate.

Table 1 Demographic characteristics of the study participants (n = 39)

The analysis of the interview data revealed four main themes and 11 subthemes. The classifications of the themes and example statements are presented in Table 2.

Table 2 Summary of the study themes and sub-themesThe onset of the ACS symptoms

The onset of ACS symptoms was wide-ranging in terms of the onset time, severity, and type of symptoms. The onset of the symptoms could be day or night time. Only one woman experienced the symptoms while sleeping, and all other women were awake when their symptoms started. The onset of symptoms was sudden in some participants (n = 21) but gradual in others (n = 18). In the sudden onset of symptoms, the severity was high from the start, but in participants with gradual symptoms onset, the severity of the symptoms increased progressively over time.

Sudden onset of symptoms

In participants whose symptoms had developed abruptly and acutely, the sudden presentation caused them to focus on symptom relief more than symptom attribution. The following are excerpts from participant interviews.

I was lying down at night; I felt like the weight of a mountain on my chest. I thought my chest was going to blow up from the pressure anytime (p:17)

I was so confused; I didn’t know what was going on. I wasn't sure…should I focus on finding out why I have this pain or just find a solution. Like a cat jumping down from a wall, I was out of breath and shocked (p:7).

Gradual development of the symptoms

Some participants, however, developed the symptoms gradually over time. They experienced symptoms such as shortness of breath, heartburn, or high blood pressure for a couple of days. The gradual and progressive development of the symptoms allowed these women time to analyze and interpret their symptoms. Nevertheless, most women attributed their symptoms to a non-cardiac cause, such as fluctuations in blood glucose level, acid reflux, heavy food, stress, COVID-19, lung problems, muscle overuse, or aging. Acid reflux was the most commonly attributed cause.

After eating, I had this terrible heartburn, as if a needle was piercing my chest. I said (to my sister): I have a stomach problem; my sister said: no, this is a gallstone problem because it hurts after eating. (P: 15)

That day I had cold sweats; my head felt dizzy and heavy; I asked my daughter to check my sugar; I thought my sugar had dropped again. She said my sugar was fine. I thought she had not done it correctly, or perhaps the machine was broken. I said: no, get me some sugar water; I know my sugar has dropped. (P: 35)

The types of symptoms

Most women experienced chest symptoms (n = 28), including chest pain, which radiated to the jaw or left arm with or without shortness of breath. However, several women presented with non-chest pain symptoms (n = 8), such as sweating, indigestion, nausea and vomiting, palpitation, and the feeling of numbness. Three participants were symptomless.

Experience of chest symptoms

Most women experienced chest symptoms, such as chest pain or chest discomfort with or without shortness of breath. Chest pain was radiating to the jaw or left arm. Participants described their chest symptoms as ‘feeling a pressure and heaviness on the chest, or a crushing pain.’ Some participants described their chest symptoms as a feeling of tightness or pressure in the chest. The most common phrases that women used to describe their chest symptoms included: ‘like a rock on the chest,' 'felt like a mountain’, ‘a very heavy object on the chest,' 'squeezing the heart tightly in the fist', and "as if someone was pressing my heart with his fist.” Almost all participants who had experienced chest symptoms illustrated their feeling by fisting their hand or pressing their chest with a fist hand and described its severity as ‘very severe’ or ‘deadly.' Some participants described their chest symptoms as ‘sharp pain.' They used phrases like 'sticking large needles into my chest’ or ‘stabbing in the chest’ to articulate their symptoms.

Imagine simultaneously scratched by thousands of long nails (p: 33)!

The intensity of the chest symptoms and shortness of breath created a sense of imminent death or a death wish. Participants commonly used phrases, such as ‘I saw death in front of my eyes’ or ‘I would rather die than endure the pain,’ to describe the severity of their pain. Shortness of breath was also a chest symptom, presented in isolation or with other symptoms. Breathlessness mainly occurred at night or during or after physical activity, such as doing house chores.

For a few days, as soon as I was lying down or doing a chore, I would feel like I was drowning in the sea. That day (the day she came to the hospital), I could barely breathe (p: 11).

Experience of non-chest symptoms

Several women presented with non-chest symptoms. Sweating was the most common non-chest symptom, described as a sudden episode of heavy cold sweating. Pain in the epigastric area, upper back, or wrist, feeling of indigestion, nausea, and vomiting were other symptoms. Some women experienced palpitations. A woman described how she became aware of her heart beating, which trigged her that something was wrong with her heart. Several women developed numbness in different body parts, such as the back, shoulders, neck, or jaw, but the numbness was more common in the left hand. In addition, a limited number of women reported feeling lightheaded, lethargic, dizzy, unusual fatigue, or pale.

I could not explain how I was feeling. It felt as if I was no longer on the earth, I do not know how to explain it… like dizziness, severe fatigue, lightheadedness, or something like that (p: 39).

Symptomless

In three participants, the ACS condition was detected only by accident; participant No. 19 had had pain in her leg for an extended period and rested because of it. While in the hospital for knee surgery, clinicians detected some abnormal changes in the electrocardiogram and referred her to the emergency department of the participating heart hospital. In addition, two participants were visiting their cardiologists for their hypertension problem when their ACS was detected, and they were referred to the hospital for an emergency angiography.

My cardiologist called the ambulance himself; he said you should go to the hospital immediately. He spoke with the cardiologist in the hospital himself. I was just confused (p: 14).

Response to the symptoms

Participants responded to their symptoms differently, but none of them took their symptoms seriously if the symptoms were not sudden and severe.

Using home remedies

Most women attempted to relieve their symptoms by using home remedies (n = 10) if their symptoms were not sudden and severe or they did not think of a cardiac origin. These participants did not consider their symptoms serious enough, which needed immediate medical attention. They assumed that they could treat the symptoms by using some home remedies. For example, women who had attributed their pain to muscular tension used a warm compress or massage as a remedy. They used emollients such as olive oil or blood-boosting oils to ease the pain, like black sesame oil or pepper oil. Women who attributed their symptoms to overeating or having heavy food used yogurt, lemon juice, mint, and horseradish to relieve the symptoms. One participant said:

I felt like all the food I had eaten was pounding in my esophagus, so I hung from a horizontal bar to let the food down (p: 22).

Another participant with a similar feeling swallowed large pieces of bread to push down the food (p: 32). Women, who attributed their symptoms to low blood sugar levels, tried something sweet, like sugar water or dates.

I thought my heartburn was because of food…. I was thinking like I shouldn’t have had that meal…I tried mints to remedy the symptoms…. (P: 1)

Ignoring the symptoms

Participants who did not have severe pain or what they considered serious symptoms tended to ignore their symptoms (n = 3). For some women, the pain was part of their life; thus, when ACS occurred, they did not take the symptoms seriously that needed medical care. They expected that the symptoms would resolve if they ignored them.

I always have pain somewhere… my legs, knees, hands, and now my chest is an overplus (p: 12).

In older age, you should not pay too much attention to pain; otherwise, you gotta be in the hospital every day. You always have pain somewhere (p: 27).

Hiding the symptoms

Some participants hid their symptoms from others (n = 4). They expressed various reasons for not disclosing their ACS symptoms. One participant shared that she was ashamed, as her children had to take her to the doctor frequently due to her ill health (p: 2). Similarly, another participant did not want to burden the family (p: 3).

One participant described that she had visited the doctor several times in the past for various reasons, and each time was told that her symptoms did not have a physical origin and were mental health-related. Therefore, the participant was concerned that doctors might have related her symptoms to mental issues again, leading to losing the family’s trust (p: 36).

I was ashamed to tell them (my sons). They might have said in their hearts that mum is always sick; she is old (she smiles). They wouldn’t say it to be fair, they get along very well, but I do not like to burden (p: 9).

Deciding to seek medical help

A decision to seek medical help was made almost only when women experienced severe symptoms (n = 22). In other words, the main factor that triggered seeking care from health facilities was the severity of the symptoms, especially chest pain.

I could not even stand my husband putting my clothes on. I was just shouting, hurry up, hurry up (p: 5).

“I knew that nothing and no one could help me remedy that deadly pain except the hospital (p: 4).

Nevertheless, women, who were familiar with the ACS symptoms because they had seen them in a family member before, decided to seek medical care quickly, even if their symptoms were not severe. Two women shared seeking immediate medical help, although their pain was at a moderate level. These women had previously witnessed similar symptoms in their husbands and were aware of the importance of the symptoms and the necessity of early medical interventions.

Although sudden onset, severe pain, and severe symptoms triggered participants to rush to a health center, in cases where the symptoms were mild or bearable, there was a delay from the onset of symptoms to deciding to seek medical help. Seeking medical treatment was delayed until the person could no longer endure the pain or symptoms.

Delay in seeking medical help occurred due to initial hesitation about the necessity of visiting an emergency department; barriers such as living in rural and remote areas also caused a significant delay in accessing timely treatment. As the participating hospital is the primary referral public specialized heart hospital in northwest Iran, some participants had to travel hours to arrive; therefore, they missed the standard gold time for primary interventions. Having negative attitude towards staff in the EDs and patients' reluctance to visit the hospital during the COVID-19 pandemic emerged as other reasons for delaying medical care. These women delayed seeking medical help until their condition became unbearable.

I said if I go to the hospital, they'll just give me some painkillers; I'll wait to see a specialist after the Corona (p: 20)

It was hurting, I knew that something was wrong, but I told myself that I should not go to the hospital in this situation (COVID-19 pandemic)…with my high blood pressure and diabetes, I wouldn’t survive it (if I caught COVID-19) (p: 13).

Arriving at the hospital

Participants were brought to the hospital by ambulance or personal vehicle.

Arriving by ambulance

Participants brought to the hospital by an ambulance (n = 18) were either referred from a small hospital/medical center or had previous experience using the ambulance service for themselves, a family member, or a relative. Participant No. 6, whose son had passed away only a few days before the interview, had used the ambulance a few times over the preceding days due to her ill health:

My husband called the ambulance, and they arrived pretty fast. They know our home. During those three days (after her son's death), I frequently felt sick, so we called them several times (p: 6).

Some patients used the ambulance service because they were familiar with the service. They had called an ambulance for a family member in the past or had heard about using the ambulance for a relative or friend. They knew how the ambulance service operated in Iran and thus felt comfortable calling the ambulance when they experienced ACS symptoms.

When my son had a (car) accident, bystanders immediately called the ambulance. In the hospital, a nurse told us he would have died of bleeding if you had brought him late. Since then, we have decided to call an ambulance when there is a problem... When I became like that (experienced ACS symptoms), my husband called them immediately (p: 8).

Some participants used an ambulance because they had regretted not using it in the past and learned from experience to use the ambulance service in medical emergencies.

When my husband had a stroke, we took her to the hospital ourselves. There, I saw patients brought in by ambulance were receiving quicker care. Since then, we have realized that using an ambulance is very important (p: 10).

In addition, some participants called an ambulance as they evaluated their condition as ‘critical’, needing immediate medical attention. They believed that the ambulance was a safer option for medical emergencies due to the presence of paramedics and necessary equipment.

It would be dangerous to come (to the hospital) by ourselves. In an ambulance, you are with a health team member, equipment,….(p: 37)

Using a personal vehicle

Some patients were brought to the hospital by a personal vehicle (n = 21). The participants in this category were two groups; the first group consisted of patients who were unfamiliar with the ambulance service, as they had not used it previously. Therefore, when they experienced ACS symptoms, they did not consider the ambulance an option. Below are excerpts from two participants:

While I was there, my husband said to my son, help put your mum in the car; it looks like her condition is serious " (p: 19).

“We did not think about it (calling the ambulance) at all. Ummu…, they (the family) were so frightened to see me like that (lethargic with frequent vomiting)” (p: 16).

The second group included patients who held negative attitudes towards the ambulance service. They assumed the ambulance would arrive late and it would be faster if they brought the patient to the hospital by a personal vehicle. Further, some women did not call the ambulance, as they had this wrong assumption that the ambulance service would be costly, while this service is free in Iran. Another reason for not calling an ambulance was the the participants’ uncertainty about their eligibility for the service. Participant 26 said they did not call the ambulance because they were unsure if the ambulance service would evaluate her condition as critical, requiring an ambulance. She recalled when a relative called the ambulance for her Covid-19 condition, but her request was refused for not being critical enough.

My sister said, "call an ambulance," but my husband said no, by the time the ambulance arrives, we’ll get her to the hospital ourselves (p; 31).