There is little association between prehospital delay, persistent symptoms, and post-discharge healthcare utilization in patients evaluated for acute coronary syndrome.

AIMS: Test for an association between prehospital delay for symptoms suggestive of acute coronary syndrome (ACS), persistent symptoms, and healthcare utilization (HCU) 30-days and 6-months post hospital discharge. BACKGROUND: Delayed treatment for ACS increases patient morbidity and mortality. Prehospital delay is the largest factor in delayed treatment for ACS. METHODS: Secondary analysis of data collected from a multi-center prospective study. Included were 722 patients presenting to the Emergency Department (ED) with symptoms that triggered a cardiac evaluation. Symptoms and HCU were measured using the 13-item ACS Symptom Checklist and the Froelicher's Health Services Utilization Questionnaire-Revised instrument. Logistic regression models were used to examine hypothesized associations. RESULTS: For patients with ACS (n = 325), longer prehospital delay was associated with fewer MD/NP visits (OR, 0.986) at 30 days. Longer prehospital delay was associated with higher odds of calling 911 for any reason (OR, 1.015), and calling 911 for chest related symptoms (OR, 1.016) 6 months following discharge. For non-ACS patients (n = 397), longer prehospital delay was associated with higher odds of experiencing chest pressure (OR, 1.009) and chest discomfort (OR, 1.008) at 30 days. At 6 months, longer prehospital delay was associated with higher odds of upper back pain (OR, 1.013), palpitations (OR 1.014), indigestion (OR, 1.010), and calls to the MD/NP for chest symptoms (OR, 1.014). CONCLUSIONS: There were few associations between prehospital delay and HCU for patients evaluated for ACS in the ED. Associations between prolonged delay and persistent symptoms may lead to increased HCU for those without ACS.

Symptom Profiles of Latina Breast Cancer Survivors: A Latent Class Analysis.

BACKGROUND: Symptom research among Latinas with breast cancer is limited-especially as it relates to multiple co-occurring symptoms. OBJECTIVE: The aim of the study was to identify subgroups (latent classes) of Latinas who have distinct symptom profiles while receiving radiation, chemotherapy, and/or hormonal therapy for breast cancer. METHODS: This secondary analysis included intake data from three randomized trials of supportive care psychosocial interventions for Latinas treated for breast cancer (n = 290). Prevalence of 12 symptoms-measured using the General Symptom Distress Scale-was entered into the latent class analysis to identify classes of women with different symptom profiles. RESULTS: Most of the participants had Stage II or III disease, and 81% reported receiving chemotherapy. On average, women reported 4.2 (standard deviation [SD] = 3) symptoms with an overall symptom distress score of 6.4 (SD = 2.5) on a 1-10 scale, with 10 being most distressing. Latent class analysis resulted in three classes that were labeled based on symptoms with the highest prevalence. Class 1 (n = 192) was "Disrupted Sleep and Tired," Class 2 (n = 74) was "Tired," and Class 3 (n = 24) was "Pain, Disrupted Sleep, and Tired." Depression, anxiety, and difficulty concentrating had moderate prevalence in each of the three classes. DISCUSSION: Beyond the core six symptoms (depression, anxiety, fatigue, pain, disrupted sleep, difficulty concentration), the classes differed in the prevalence of other burdensome symptoms (e.g., nausea, vomiting, constipation), which provide implications for treatment. Thus, it is important to assess for the full range of symptoms so that supportive care interventions can be tailored for the distinct symptom profiles of Latinas with breast cancer.

Stroke Survivors' Feelings and Perceptions of Their Recovery After a Tai Chi Exercise Intervention: A Qualitative Descriptive Study.

BACKGROUND: Most tai chi studies conducted among stroke survivors have focused on physical functioning, whereas inclusion of stroke survivors' feelings and perceptions of participating in tai chi is lacking. OBJECTIVE: The aim of this study was to identify stroke survivors' feelings and perceptions of participating in a tai chi intervention during their poststroke recovery. METHODS: This qualitative descriptive study examined stories from community-dwelling stroke survivors, collected as part of a larger randomized clinical trial. To examine these stories, an inductive content analysis approach was used with a priori theoretical codes (and subcodes): (1) Feelings (confidence, enjoy, hopeful, helpful, other) and (2) Perceptions of Impact (physical abilities, mental/cognitive abilities, challenges, other). Lincoln and Guba's criteria were followed to ensure trustworthiness of the study findings. RESULTS: Participants (n = 17) were on average 71 years old (range, 54-87 years), mainly men (65%), and had the option of writing their own story or having someone write it for them. Stories from these stroke survivors revealed feelings of confidence (n = 4), enjoyment (n = 7), hope (n = 1), and helpfulness (n = 15). Perceptions of the impact of tai chi on their poststroke recovery process identified improved physical abilities (n = 23), better mental/cognitive abilities (n = 12), moving forward (n = 7), and developing friendships (n = 4), with few challenges (n = 1). CONCLUSIONS: Using storytelling, healthcare providers can discuss the benefits of tai chi and then relate the feelings and perceptions of other stroke survivors' experiences to encourage engagement in regular physical activity to aid in the poststroke recovery process.

Using cognitive interviews to improve a Psychological-Social-Spiritual Healing instrument: Voices of aging African Americans with serious illness.

AIM: The purpose of this study was to contribute to content validity, by providing input into the linguistic and pragmatic validities, of a 53 item Psychological-Social-Spiritual Healing instrument. BACKGROUND: Discovery of cultural values and beliefs from African American elders' experiences of illness provides insight for development of more culturally sensitive instruments. METHODS: Through an exploratory descriptive design, this study used cognitive interviewing methods to examine linguistic and pragmatic validity of the Psychological-Social-Spiritual Healing instrument, from the perspectives of aging seriously ill AAs. Participants were recruited from urban Jackson, MS from community settings from October 2014 to January 2015. With a purposefully chosen sample of seriously ill African Americans elders (N=15), and using the method of cognitive interviewing, responses related to cultural relevance, clarity and meaning of the 53 items of the instrument were collected. This in-depth query of items was accomplished through the use of both verbal probing and think aloud methods of cognitive interviewing. RESULTS: Thirty-seven items were retained. Eight items were revised. Eight items were deleted. CONCLUSIONS: From the expert input of seriously ill African American elders, a systematic decision-making process of item retention, revision or deletion led to the development of a more culturally sensitive Psychological-Social-Spiritual Healing instrument.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

BACKGROUND: Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences. OBJECTIVE: The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS. METHODS: A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured. RESULTS: The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00-2.42), shoulder pain (OR, 1.76; CI, 1.13-2.73), and upper back pain (OR, 2.92; CI, 1.81-4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women. CONCLUSIONS: Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

African American Elders' Serious Illness Experiences: Narratives of "God Did," "God Will," and "Life Is Better".

The foundation of culturally sensitive patient-centered palliative care is formed from one's social, spiritual, psychological, and physical experiences of serious illness. The purpose of this study was to describe categories and patterns of psychological, social, and spiritual healing from the perspectives of aging seriously ill African American (AA) elders. Using narrative analysis methodology, 13 open-ended interviews were collected. Three main patterns were "prior experiences," "I changed," and "across past, present experiences and future expectations." Themes were categorized within each pattern: been through it . . . made me strong, I thought about . . . others, went down little hills . . . got me down, I grew stronger, changed priorities, do things I never would have done, quit doing, God did and will take care of me, close-knit relationships, and life is better. "Faith" in God helped the aging seriously ill AA elders "overcome things," whether their current illness or other life difficulties.

Symptom Trajectories After an Emergency Department Visit for Potential Acute Coronary Syndrome.

BACKGROUND: Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge-regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking. OBJECTIVES: The aim of this study was to identify common trajectories of symptom severity in the 6 months after an ED visit for potential ACS. METHODS: This was a secondary analysis of data from a larger observational, prospective study conducted in five U.S. EDs. Patients (N = 1005) who had electrocardiogram and biomarker testing ordered, and were identified by the triage nurse as potentially having ACS, were enrolled. Symptom severity was assessed in the hospital after initial stabilization and by telephone at 30 days and 6 months using the validated 13-item ACS Symptom Checklist. Growth mixture modeling was used for the secondary analysis. The eight most commonly reported symptoms (chest discomfort, chest pain, chest pressure, light-headedness, shortness of breath, shoulder pain, unusual fatigue, and upper back pain) were modeled across the three study time points. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices. RESULTS: The sample was 62.6% male with a mean age of 60.2 years (SD = 14.17 years), and 57.1% ruled out for ACS. Between two and four distinct trajectory classes were identified for each symptom. The seven different types of trajectories identified across the eight symptoms were labeled "tapering off," "mild/persistent," "moderate/persistent," "moderate/worsening," "moderate/improving," "late onset, "and "severe/improving." Trajectories differed on age, gender, and diagnosis. DISCUSSION: Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.

The association of pain with protein inflammatory biomarkers: a review of the literature.

BACKGROUND: Pain is a key diagnostic criterion in many medical conditions. In the absence of self-reported pain, measurement of a proxy for pain, such as an inflammatory biomarker, could aid in diagnosis and disease management. OBJECTIVES: The aim was to determine if there is an association between inflammatory biomarkers and self-reported pain in individuals with medical conditions associated with the symptom of pain and to clarify whether inflammatory biomarkers might aid in the diagnostic process. METHODS: An integrative literature review was conducted. PubMed, CINAHL, and Cochrane databases were searched for articles published between January 2000 and September 2012. Inclusion criteria were original research testing a relationship between inflammatory biomarkers and pain, pain measurement, laboratory measure of inflammatory biomarkers, and a prospective single-group experimental design or comparative nonrandomized or randomized design. Excluded were studies describing an association between inflammatory biomarkers and treatment, risk, and generation; pathophysiology; or genetic polymorphisms/transcripts. Ten studies meeting inclusion criteria were reviewed. RESULTS: In most of the studies, baseline elevations in both proinflammatory and anti-inflammatory cytokines were reported in painful conditions compared with healthy controls. In half of the studies, higher levels of proinflammatory markers (C-reactive protein, tumor necrosis factor-alpha, interleukin-2 [IL-2], IL-6, IL-8, IL-10, and CD40 ligand) were associated with greater pain. Proinflammatory cytokines decreased after treatment for pain in only two studies. DISCUSSION: The association between inflammatory markers varied in the direction and magnitude of expression, which may be explained by differences in designs and assays, disease condition and duration, variations in symptom severity, and timing of measurement. Elevation in anti-inflammatory cytokines in the presence of pain represents a homeostatic immune response. Further study is required to determine the value of cytokines as biomarkers of pain.

Lives forever changed: family bereavement experiences after sudden cardiac death.

AIM: To describe the bereavement experiences of families who survived the sudden cardiac death of a family member and identify meanings of loss. BACKGROUND: Approximately 325,000 people experience sudden cardiac death (SCD) annually. It is important to examine family experiences after SCD because of the life altering impact of death on surviving family members. METHODS: A descriptive design, using the qualitative method of narrative analysis, was used to analyze family stories of bereavement. RESULTS: Five themes were identified across seven families: sudden cardiac death … boom; saying goodbye; grief unleashes volatile emotional reactions; life goes on … but never back to normal; and meanings in loss. CONCLUSIONS: This study adds to an understanding of family bereavement and findings suggest that providing information about the cause of death and allowing family members to tell their stories are potentially important interventions for clinicians who interact with bereaved families.

Implementing clinical research in the high acuity setting of the emergency department.

INTRODUCTION: Clinical research in the emergency department provides supporting evidence needed for the development of practice guidelines, such as door-to-needle and door-to-balloon times for treatment of acute coronary syndromes, and is vital to improvements in patient outcomes. The purpose of this article is to describe barriers and lessons learned in launching a multisite clinical research study of symptoms of acute coronary syndromes in the emergency department. METHODS: Participants included ED and research staff in 4 busy emergency departments in 3 states. At each step of the study launch, the principal investigator at the clinical site identified barriers that either were anticipated or experienced and discussed them with the site staff and study principal investigator to validate the issue as a barrier. Orientation sessions and ongoing communication between clinicians, research staff, and the research study team provided opportunity for adjustment of study protocols. RESULTS: Barriers were lack of staff engagement in research, difficulty identifying eligible patients, perception of interference in clinical care, variability in research staff education and training, patient refusals, nurses' perceptions of lack of time, undifferentiated patients, and time-sensitive quality improvement indicators necessitating acceleration in care. DISCUSSION: Important strategies to overcome barriers were developed, including identification and support of unit champions in emergency nursing and medicine; minor protocol modifications to improve enrollment goals; development of specific written expectations, roles, research protocols, and algorithms; and sharing successes among sites.

Unusual Fatigue and Failure to Utilize EMS Are Associated With Prolonged Prehospital Delay for Suspected Acute Coronary Syndrome.

BACKGROUND: Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS), but efficacy is time dependent. The aim of this study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS, stratified by final diagnosis (ACS vs. no ACS). METHODS: A heterogeneous sample of emergency department (ED) patients with symptoms suggestive of ACS was enrolled at 5 US sites. Accelerated failure time models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis. RESULTS: Enrolled were 609 (62.5%) men and 366 (37.5%) women, predominantly white (69.1%), with a mean age of 60.32 (±14.07) years. Median delay time was 6.68 (confidence interval 1.91, 24.94) hours; only 26.2% had a prehospital delay of 2 hours or less. Patients presenting with unusual fatigue [time ratio (TR) = 1.71, P = 0.002; TR = 1.54, P = 0.003, respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR = 1.93, P < 0.001; TR = 1.71, P < 0.001, respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR = 0.65, P = 0.013 and TR = 0.67, P = 0.022, respectively). Predictors of shorter delay for patients ruled out for ACS were chest pain and sweating (TR = 0.071, P = 0.025 and TR = 0.073, P = 0.032, respectively). CONCLUSION: Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is important for patients with possible ACS symptoms. Calling 911 can be positively framed to at-risk patients and the community as having advanced care come to them because EMS capabilities include 12-lead ECG acquisition and possibly high-sensitivity troponin assays.

Trajectories of Depression and Anxiety in Latina Breast Cancer Survivors.

OBJECTIVES: To identify subgroups of Latina breast cancer survivors with unique trajectories of depression and anxiety and examine predictors associated with these subgroups. SAMPLE & SETTING: Secondary analysis of Latina breast cancer survivors (N = 293) from three psychosocial intervention studies. METHODS & VARIABLES: Depression and anxiety were assessed at intake and at weeks 8 and 16. Group-based growth mixture modeling was used to identify subgroups who followed distinct trajectories of depression and anxiety. Multinomial logistic regression models were used to identify predictors of trajectory-based subgroup membership. RESULTS: Three trajectories emerged for depression. IMPLICATIONS FOR NURSING: Latina women treated for breast cancer are at an elevated risk for depression and anxiety and follow distinct trajectories of these symptoms. Psychosocial interventions are needed to manage these symptoms, particularly for subgroups in which depression and anxiety persist or worsen.

Protein Cytokines, Cytokine Gene Polymorphisms, and Potential Acute Coronary Syndrome Symptoms.

The purpose of this study was to determine whether relationships exist among protein cytokines, cytokine gene polymorphisms, and symptoms of potential acute coronary syndrome (ACS). Participants included 438 patients presenting to the emergency department (ED) whose symptoms triggered a cardiac evaluation (206 ruled in and 232 ruled out for ACS). Presence or absence of 13 symptoms was recorded upon arrival. Levels of tumor necrosis factor α (TNF-α), interleukin (IL)-6, and IL-18 were measured for all patients. A pilot analysis of 85 patients (ACS = 49; non-ACS = 36) genotyped eight single-nucleotide polymorphisms (SNPs; four TNF and four IL6 SNPs). Logistic regression models were tested to determine whether cytokines or SNPs predicted symptoms. Increased levels of TNF-α and IL-6 were associated with a decreased likelihood of chest discomfort for all patients. Increased levels of IL-6 were associated with a lower likelihood of chest discomfort and chest pressure for ACS patients, and an increased likelihood of shoulder and upper back pain for non-ACS patients. Elevated IL-18 was associated with an increased likelihood of sweating in patients with ACS. Of the four TNF SNPs, three were associated with shortness of breath, lightheadedness, unusual fatigue, and arm pain. In all, protein cytokines and TNF polymorphisms were associated with 11 of 13 symptoms assessed. Future studies are needed to determine the predictive ability of cytokines and related SNPs for a diagnosis of ACS or to determine whether biomarkers can identify patients with specific symptom clusters.

Rural women walking for health.

The purpose of this qualitative study is to describe rural women's barriers and motivators for participation in a walking program. Twenty rural women, ages 22 to 65, participated in a 12-week walking program. Data from field notes and focus groups were analyzed using qualitative content analysis. Data were inductively coded, codes were categorized into themes, and themes were classified as barriers or motivators to adopting a walking program. Three main barriers are identified: balancing family and self, chronic illness gets in the way of routine, and illness or injury breaks routine. Seven motivators are identified: being part of a group, group camaraderie, learning, pacesetter, seeing progress, energizing, and I am a walker. Women report that family responsibilities are a powerful and pervasive barrier. Motivators center on the importance of group interaction. This qualitative study increases our understanding of rural women's barriers and motivators to embarking on and sustaining a regular walking routine.

Acute Myocardial Infarction Experience Among Mexican American Women.

INTRODUCTION: Health disparities in cardiovascular disease risk factors affect a burgeoning segment of the U.S. population-Mexican American (MA) women. MAs experience disparities in the prevalence of heart disease risk factors. However, there are no studies describing acute myocardial infarction (AMI) symptoms unique to this Hispanic subgroup. The aim of the study was to describe MA women's AMI symptom experience. METHODS: A qualitative descriptive design guided the study. Data were collected in semistructured interviews with eight MA women who reported having an AMI within the past 18 months. Data were analyzed using qualitative content analysis. RESULTS: The overall theme was "The nature of my AMI experience." This theme, composed of four categories, described their prodromal and AMI symptom experience: my perception of AMI, having a heart attack, AMI symptoms, and actions taken. No participants recognized prodromal or symptoms of AMI. Asphyxiatia (asphyxiating) and menos fuerza (less strength) were commonly described symptoms. CONCLUSION: Participants attributed both prodromal and AMI symptoms to noncardiac causes, self-managed symptoms, and delay in seeking health care. Findings suggest that community engagement through culturally tailored family-focused heart health education for MA women and their family members may improve recognition of prodromal symptoms.

Heart-to-Heart: promoting walking in rural women through motivational interviewing and group support.

BACKGROUND: Walking can significantly increase cardiorespiratory fitness and thereby reduce the incidence of heart disease in women. However, there is a paucity of research aimed at increasing walking in rural women, a high-risk group for heart disease and one for which exercise strategies may pose particular challenges. PURPOSE: This study tested Heart-to-Heart (HTH), a 12-week walking program, designed to increase fitness through walking in rural women. Heart-to-Heart integrated individual-oriented strategies, including motivational interviewing, and group-based strategies, including team building. METHODS: Forty-six rural women were randomized to either HTH or a comparison group. The primary outcome of cardiorespiratory fitness and secondary outcomes of self-efficacy and social support were measured preintervention and post-intervention. Group differences were analyzed with repeated-measures analysis of variance. RESULTS: Women in HTH group had a greater improvement in cardiorespiratory fitness (P =.057) and in social support (P =.004) compared with women in the comparison group. Neither group of women experienced a change in exercise self-efficacy (P =.814). CONCLUSIONS: HTH was effective in improving cardiorespiratory fitness in a sample of rural women. Further research is needed to refine HTH and determine the optimal approach in rural women to increase their walking.

Impact of comorbidities by age on symptom presentation for suspected acute coronary syndromes in the emergency department.

BACKGROUND: It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions. AIMS: Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis. METHODS: A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis. RESULTS: The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS. CONCLUSIONS: Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.

State of the heart: building science to improve women's cardiovascular health.

Cardiovascular disease is the No. 1 killer of women in the United States, and marked disparities in cardiovascular health exist between women and men and among groups of women. Coronary heart disease is underdiagnosed, undertreated, and under-researched in women. Women with suspected heart disease are less likely than men to receive indicated diagnostic tests and procedures; sex-based biases in treatment of myocardial infarction persist; and women continue to be underrepresented in cardiovascular research. An accumulating body of literature points to 3 major explanations: sex-based physiology, provider bias, and psychosocial influences. Women's acute and prodromal signs and symptoms of myocardial infarction have been described, yet women have difficulty recognizing and acting on these indications. Primary and secondary prevention of heart disease in women is imperative; although the science is lacking in several areas, existing evidence on diet, hormone therapy, aspirin, physical activity and obesity, and diabetes can serve as the basis for interventions. Potentially, large impacts could be made on women's morbidity and mortality if current scientific knowledge were implemented. The state of the science of women and heart disease is reviewed, with a focus on those areas with the greatest potential to address the needs of women's cardiovascular status. Key gaps in the science and remaining questions are presented as a research agenda for the coming decade.

Learning through connections with others: women's cardiac symptoms.

Conducting group sessions in which women can share experiences, develop connections, and learn from each other may potentially be a powerful health educational tool. In a focus group conducted for evaluative feedback, the authors found that women began spontaneously sharing their experiences and feelings, receiving validation, and learning from each other almost from the start of the group session. The participants who were dissimilar in age, ethnicity/race, and socioeconomic status developed a strong connection based on the common experience of having had a heart attack. Although the participants had received patient education after their heart attack, they learned new information about cardiac symptoms and how to respond to them in the group session. This case example is a compelling reminder that women learn through connections. Therefore, a group approach to health education that acknowledges the salience of personal experiences, the experiences of others, the development of connections, and the exchange of information may provide a meaningful learning environment. Further research needs to be conducted to determine if conducting group appointments for women that fosters the development of connections and the exchange of information enriches the learning environment and enhances patient education.