The methodology used to conduct the study is hermeneutic phenomenology according to Cohen (49), which combines descriptive (Husserlian) phenomenology with interpretative (Gadamerian) phenomenology. This approach was chosen because it allows for an in-depth understanding of the experiences lived by the participants and the meanings, they attribute to these experiences (50). Cohen's phenomenological approach integrates Heidegger's thought, which is focused on the description of experiences, with that of Gadamer who emphasizes hermeneutics as the study of texts and communications, including verbal expressions and symbolic activities. This method aims to explore the nature of consciousness, focusing on the meaning of individual experiences (49). Phenomenology proves particularly effective in the analysis of complex, ambiguous and emotionally meaningful themes (51). This methodology was selected for its ability to offer a detailed and deep understanding of the experiences lived by the participants and the meanings they attribute to these experiences (51). Some authors have already successfully used this method in previous studies, for example, to explore and understand the experiences lived by women with endometriosis (52). In fact, this methodology is considered the only one that provides an authentic assessment of the experiential experience (53, 54). In order to truly explore early perception, the timing of the interviews is fundamental. Scientific literature shows that the first days of hospitalization are the ideal period to understand pre-hospitalization attitudes (55), since longer times can distort the data (43). In fact, some studies recommend analyzing pre-hospital behaviors in the early phase to obtain more accurate information (12, 36, 55). The quality of the study is guaranteed by adhering to the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure the quality of the study (56).

Participants were enrolled within 5 days of undergoing PCI, which followed in emergency the AMI event. This timing was chosen to balance the immediacy of emotions with the ability for critical reflection, ensuring that participants were sufficiently distanced from the acute event to reflect on their experiences, yet still close enough to provide detailed and accurate recollections. Previous studies, such as Morse (57), have highlighted that the timing of interviews can significantly impact the quality of data collected: interviews conducted too early may result in accounts heavily influenced by the immediate emotional experience, while those conducted too late may be subject to memory lapses or reinterpretations. The study was conducted in two healthcare facilities in the Campania region. A total of 22 women were enrolled through convenience sampling, selected based on their hospitalization for AMI in these facilities. All participants were admitted under emergency conditions and had undergone PCI in the preceding days. Data collection took place from October 2023 to April 2024. To be included in the study, participants had to meet the following criteria: (a) age between 18 and 85 years; (b) a confirmed diagnosis of ischemic heart disease by a cardiologist; (c) undergoing PCI; (d) physically stable and able to participate in interviews; (e) consent to be video and audio recorded during the interviews; (f) fluency in the Italian language; (g) absence of cognitive deficits.

Cohen's method allows a deeper knowledge of the meaning that people give to their lived experience, and rigorous analysis is enhanced by bracketing. This initial step required interviewers to identify and suspend their personal experiences and insights that could potentially influence data analysis. Through this preliminary reflection, researchers aimed to prevent their biases from affecting the analysis (50). Cohen's method facilitates a deeper understanding of the meaning that individuals attribute to their lived experiences, and the rigor of the analysis is further enhanced by the disciplined application of bracketing, ensuring that the interpretation remains true to the participants' perspectives. This crucial step was followed by the interviewing phase, during which open-ended questions were employed to allow participants to freely share their experiences. The interviews were conducted in the participants' native language (Italian) by one trained researcher (V.G.). To become familiar with the methodology, two preliminary interviews were conducted, which were not included in the data analysis. Participants were asked, “Can you describe your experience of recognizing symptoms and deciding to seek medical care during your heart attack?” This approach prioritized participants' perspectives. During the interviews, the researchers employed a “welcome attitude”, characterized by an open and receptive approach towards the study participants (58, 59). Field notes were collected throughout the interviews. The interviews continued until no new relevant information emerged to further the study's purposes, indicating data saturation (60). In accordance with Strauss and Corbin's guidelines, data saturation was considered achieved when the new data collected exhibited a significant amount of repetition. Data saturation, indicated by the redundancy of emerging themes, was reached by the 22nd interview (60). All interviews, lasting between 20 and 40 min, were audio-recorded and conducted in a setting chosen by the participants. Each interview concluded when participants indicated that they had no further comments to add. After conducting the interviews, the next step involved transcribing the audio recordings verbatim, supplemented by the field notes. This transcription process was essential to accurately capture the full content of the interviews, including subtle nonverbal cues noted during the discussions (60). The transcripts were then thoroughly reviewed by each researcher, this first phase, known as immersion in the data. This phase aimed to allow researchers to deeply engage with the data, leading to the initial extraction of themes. Data analysis was conducted using a manual coding process consistent with Cohen's phenomenological methodology. This method involved iterative and in-depth readings of the transcriptions, employing line-by-line coding to identify meaningful units of data. Themes were developed progressively through an iterative process of coding, categorizing, and refining. To ensure rigor and transparency, detailed coding matrices were meticulously maintained throughout the analysis, providing a structured framework for organizing and interpreting the data. The analysis of these data was then conducted by two researchers who conducted the interviews (V.G. and A.G.), who had no prior contact with the participants, and two other members of the research team (T.R. and S.S.). Interviews were transcribed verbatim and supplemented with contact summaries. Following Cohen et al. (49), each researcher first read all the interviews to get a general sense of the content, then re-read each transcription line by line, assigning general themes to various text passages. Following transcription, the data underwent a phase of data transformation and reduction. This step involved carefully selecting relevant portions of the data and organizing them in a way that retained the essence of the participants' narratives while preparing the data for further analysis. This careful curation was essential to maintain the integrity of the data while making it manageable for the next phase of analysis. The reduced and transformed data were subjected to line-by-line coding, necessary for thematic analysis. The researchers compared the extracted themes, and no discrepancies were found between their results. Participants were informed of the identified themes in a follow-up meeting to confirm the extracted themes. All participants confirmed the themes and did not add any further insights into their experiences. This process, known as member checking, is fundamental in the phenomenology of Cohen et al. (49). As described by Cohen et al. (49) and Lincoln & Guba (61), themes should be verified with participants to ensure they accurately capture the meaning that the participants intended to convey. This process ensured the scientific rigor of the present study.

Adherence to Lincoln and Guba's criteria further confirmed the scientific rigor of this study. convenience sampling until saturation data ensured credibility, corresponding to internal validity and ensuring the study examined its intended focus (61–63). To further reliability of the study findings, we employed the technique of triangulation by involving multiple researchers in the data analysis process (61). This approach facilitated the generation of diverse observations and conclusions, not only reinforcing the validity of the results while enriching the analysis through varied perspectives and comprehensive understanding of the phenomenon under investigation. The criterion of confirmability was addressed by engaging participants in verifying the extracted themes, thereby ensuring that the findings accurately reflect their experiences and perceptions. Additionally, we utilized critical reflection techniques, which enabled researchers to “bracket” their own preconceptions, biases, and assumptions related to the studied phenomenon, thus minimizing potential interpretative biases and enhancing the objectivity of the analysis. Lastly, the criterion of transferability was fulfilled by providing detailed descriptions of the participants' experiences alongside their sociodemographic characteristics. This thorough contextualization allows for the assessment of the applicability and generalizability of the study results to similar settings and populations, thereby extending the relevance and impact of the research findings. Data analysis and result verification, as well as interview conduction, were performed in Italian. Translation and back-translation processes followed the World Health Organization (64) methodology for validating tools across different cultures and languages, focusing on conceptual content rather than literal equivalence. This ensured the data's meaning was preserved.

The participants provided detailed and vivid descriptions of their experiences from the onset of symptoms to hospitalization. During the interviews, they described the behavioral strategies they employed to manage the perceived symptoms, revealing a wide range of responses that reflect a lack of awareness or understanding of the severity of their condition. NMF14 declares “I also felt them in the days before, about eight days ago. The pain wasn't so bad, though, compared to the pain that presented itself on Tuesday. Now my arms were also bothering me, but I thought it was something like that, due to the cigarette, that could cause me these complaints”.

The participants shared their knowledge and expectations regarding the manifestation of myocardial infarction (MI) symptoms, as well as their personal perceptions of the associated risks. These narratives reveal a nuanced understanding of how awareness and risk perception can significantly impact behavior, particularly in the context of seeking timely medical assistance. LOF12 says “I didn't understand what was happening to me; in fact, I didn't think about myocardial infarction of the heart. I just thought I was feeling sick, but I couldn't understand what it was about”.

All participants shared their experiences and the processes that led to their decision to seek hospital care, as well as their interactions with the National Health Service (NHS). The interviews revealed that while some women were determined to go to the hospital due to the unbearable pain they were experiencing (“I couldn't wait any longer”, GTF07), others were persuaded by family members (“I didn't want to go, but F****** pulled me” and said, “Mom, stop it, you have to go!”, RIP18). These testimonies highlight the challenges faced by both patients and healthcare providers in recognizing and managing an AMI. Key issues included delayed or incorrect diagnoses, a lack of understanding of risk by emergency services, and variability in treatment received. These experiences underscore the critical importance of timely medical response and immediate support from loved ones.

All participants reported seeking advice and comparing their experiences with those of others to guide their decisions regarding the need for medical assistance. The women's choices about seeking care and managing symptoms were often influenced by their interactions and the opinions of others. LOF12 reports “I waited for my daughter for about one hour, waiting It was 4pm when the pain started, and my daughter came at 5.30 pm. I didn't want to go to hospital, she insisted”.

The interviews revealed two distinct types of reflections on the decision-making process regarding seeking medical care after experiencing an AMI. JQF10 say “When something happens, a person reflects and thinks that if he had known earlier, he would have acted differently to avoid the irreparable. I should have acted immediately because I was really sick, but unfortunately, I did not realise that it was a myocardial infarction of the heart”.

The women interviewed reported that they did not recognise the symptoms as belonging to a heart problem, sometimes ignoring it or associating it with another cause. Women's lack of recognition of AMI symptoms is also reported in the literature, which not only delays access to treatment, but also leads to worse outcomes (65).

Women AMI clearly described the behavioral strategies they employed to manage the perceived symptoms. The study shows that some women tend to underestimate AMI symptoms, resorting to over-the-counter medications such as anti-inflammatories and analgesics, and dismissing the possibility of a heart attack due to a lack of knowledge about the symptoms. This practice can be risky and exacerbate the condition (66). The literature supports that many women prefer self-treatment to avoid disturbing others and to maintain control over their symptoms, leading to delayed medical assistance for 92% of women, as reported in Higginson's study (46). In developing countries, easy access to over the counter and prescription medications contributes to self-medication among women, who tend to manage various short-term ailments autonomously (67, 68). In contrast, women when faced with unclear symptoms, tend to adopt generic coping responses such as moving around, resting, or drinking something, as also demonstrated in studies by Meiscke (69) and Dempsey et al. (70).

The women often reported feelings of resignation and interpreted the symptoms as signs of an inevitable fatal outcome, which reduced their motivation to seek medical help. This sense of helplessness may also be influenced by personal religious beliefs (71). Women, also, tended to downplay their symptoms, sometimes reducing their severity or stating that they were not concerned about the possibility of death; an attitude of minimising symptoms also discussed in the study by Rosendelf et al. (25), while continuing to carry out household work and activities of daily living.

Coping strategies identified in the study include ignoring symptoms, hiding them from others, and not recognizing them as signs of a heart attack. These behaviors share the denial mechanism, a common self-defense strategy that leads to rejecting ideas associated with unpleasant experiences (72). Denial is frequent among patients with signs of AMI (73, 74) and can cause significant pre-hospital delays (75–77), as demonstrated by O'Carroll et al. (78), where AMI patients who waited more than 4 h before seeking medical assistance had significantly higher denial scores. Moreover, the denial defense mechanism can persist over time, preventing patients from having a clear view of their condition, avoiding medical recommendations, and inadequately managing disease-related problems (79). Women with mild or intermittent symptoms often ignore the initial signs, hoping that they will resolve themselves (69) or consider them to be minor problems (79) or to avoid being a burden on others, and to avoid causing concern and disturbance to doctors and family members (46, 80, 81) and to avoid these they may minimize, delaying help-seeking even in the presence of intense pain, especially at night or on weekends (25).

During the onset of symptoms, some enrolled women choose to rest, hoping that the symptoms will improve, while others continue to manage their daily responsibilities, demonstrating strong dedication to their family and professional duties, behaviour also reported by other studies (36, 81). Turris demonstrates that women's adherence to daily commitments is deeply connected to their sense of personal identity (81), while Davis et al. add that during an acute event, women try to ensure that nothing is left unfinished, attitude also carried out by female workers, who try to obtain leave or find a replacement before going to the emergency room to ensure that their responsibilities are managed by capable people (36).

The second theme concerns the analysis of “knowledge and c risk perception of AMI”. The lack of knowledge about AMI symptoms is a global issue: while chest pain is recognized as a primary symptom (82, 83), other less known symptoms are not recognized (84). The poor awareness of atypical AMI symptoms indeed contributes to delays in seeking help and to negative health outcomes (26, 68, 82, 85–87).

Many study participants reported not having sufficient information about AMI symptoms, and even among those who had some knowledge, it was often limited and/or superficial. As reported by Gkika et al. (88), knowledge of symptoms is mostly obtained through experiences of family members or friends rather than through reliable medical sources. It is important to note that although AMI patients tend to have inadequate knowledge compared to patients with other heart problems, their level of awareness is still higher than the average (88). In fact, an Italian survey conducted by Maffei et al. (89) showed that 69.8% of Italian women are aware of cardiovascular diseases as the leading cause of death. These data are significantly higher than the awareness percentages of women in the United States (56%) according to Mosca (90), and women in Australia (32%) according to Hoare et al. (91). However, mere knowledge of symptoms is not sufficient to correctly attribute AMI symptoms (92), as emotional factors also play a significant role during an acute event (93, 94). The study by Albarqouni et al. showed that STEMI patients with a history of AMI or stent placement had significantly lower knowledge levels compared to those without such experiences (95). Moreover, Strömbäck et al. (96) found that the presence of atypical symptoms during a second AMI does not predict a longer delay in seeking assistance. This observation may be due to the fact that the history of AMI is associated with an increase in symptom congruence (96). However, the study by MacInnes suggests opposite behavior, where women with a previous history of AMI seemed more likely to seek immediate medical assistance (27). Some participants had difficulty recognizing AMI symptoms because they did not match their expectations due to the influence of descriptions of heart attack symptoms, such as severe chest pain, reported by family members. Indeed, the literature points to the importance of the correspondence between symptoms and expectations in the recognition of AMI (97–101), as stated by Fox-Wasylyshyn et al., who report that “the extent to which personal experience with symptoms of AMI aligns with expectations of an AMI” is crucial (98).

The study participants, particularly those with known risk factors and typical AMI symptoms, underestimated their cardiovascular risk; this lack of awareness is particularly evident among those with previous heart attacks or a family history of heart disease. Maffei et al. in fact report how this misunderstanding is particularly evident among younger women, who may not pay sufficient attention to cardiovascular health due to a lack of experience and knowledge (89). Dempsey et al. have also demonstrated that many women are skeptical about their cardiovascular risk due to erroneous beliefs and the desire to maintain control over their experience, associating such pathologies only with the male gender (70). Some women are also affected by an “illusion of invulnerability” (102), believing they are protected due to a healthy lifestyle and/or the absence of a family history of heart disease (102–104).

The enrolled women compare their own symptoms with those of family members or friends with a previous AMI, considering their symptoms severe only when they were similar to those already known (73). Petrie and Weinman, indeed support that the personal experience of heart disease through a family member tends to foster the perception of a serious illness and can contribute to reducing treatment delays (105). However, the data suggests that this influence may be more closely related to the degree of similarity or difference in symptoms rather than the experience itself (105). Medical and nursing staff play a crucial role in educating women with AMI about knowledge regarding the onset, characteristics, and progression of AMI, risk factors, and preventive measures (88). Nurses should be able to correct patients' misconceptions about their condition and educate them about symptoms and risk behaviors (106).

The women involved in the study, past experiences also influence the perception of symptoms and the decision to seek help: women with previous heart attacks often minimize new symptoms, attributing them to alternative causes such as allergies or indigestion, as reported in numerous studies (25, 27, 106, 106).

The third theme examines women's “decisions and seeking medical assistance”, to explore the challenges they face in the decision-making process. Difficulties include the influence of family and social roles, which can both support and hinder the decision to seek help, an inadequate self-care, influenced by previous negative experiences with health services and anxiety and fear arising from past experiences. Further challenges arise from reluctance to seek care due to the frequency of symptoms and lack of knowledge about health professionals. These factors combined can complicate interaction with care providers, negatively affecting the timeliness and effectiveness of seeking medical care.

The enrolled women delayed seeking medical assistance until the symptoms became unbearable, as reported in two studies (73, 107). Despite the autonomous decision of the enrolled women to seek assistance, however, instead of going directly to the Emergency Room, many women chose to contact their general practitioner or a private cardiologist, prolonging the time to intervention, behaviors reported also in studies by Gallagher et al. (43), Johansson et al. (107), Coventry et al. (108), and McKee et al. (109).

The interviews reveal that in many cases, family members convinced or forced the women to seek medical assistance, indicating a lack of self-efficacy or awareness (73). Family responsibilities significantly influenced the decision to seek medical assistance: women, in fact, procrastinate or avoid seeking help for fear of leaving disabled or elderly family members without adequate care (34, 35). The cause may be found in cultural and social norms, which often attribute the primary role of family care to women, leading them to neglect their own health (81, 110, 111).

Women neglect their own health due to family commitments and the emotional burden associated with caring for sick or elderly family members, resulting in delays in check-ups and the management of medical conditions (34, 112). This role as a caregiver may make them less inclined to seek urgent medical assistance, as indicated by Turris et al. (111), reducing attention to their own health concerns (29, 113).

The women interviewed frequently reported that the healthcare system offers insufficient responses, both in emergency situations and during visits with general practitioners. This often leads them to consult their family doctor before going to the emergency room, as was also highlighted by a Swedish study (102).

The women interviewed often reported a lack of trust in healthcare professionals, as they tended to play down symptoms, attribute them to non-cardiac causes or send patient's home. This mistrust, also reported in the literature, is further accentuated when a clear diagnosis cannot be obtained, mainly due to difficulties in describing symptoms, making the diagnostic process complex and ambiguous (114). For example, in the study by Gallagher et al. (43), GPs experienced the same difficulties as patients in recognizing a cardiac cause in female symptoms, despite the fact that these could signal potentially serious events.

The interviews also reveal that anxiety and fear related to medical care are significant barriers. Many women avoid treatments due to past negative experiences or generalized anxiety about healthcare facilities (114), compounded by negative attitudes from healthcare providers and access issues (114).The enrolled women, also report that past negative experiences, both personal and family-related, and distrust in the healthcare system, fueled by inadequate treatments or previous medical errors, lead them to avoid assistance even in the presence of severe symptoms. Hadid et al. (115) found in 32 AMI patients a lack of trust in hospitals or medical personnel due to previous negative experiences with close relatives, and they fear dying due to medical negligence or incompetence.

The women participating in the study reported that they procrastinated seeking medical help for fear of appearing to seek help too often (“I often don't feel well and if I had to call for help every time it would be too much”). The women participating in the study reported that they procrastinated seeking medical help for fear of appearing and being judged as those who ask for help too often, due to the frequency with which they manifest symptoms, a concern also reported in the study by Hadid et al. (115),. This behaviour suggests a kind of self-censorship due to a fear of social judgement and a concern that they do not want to “disturb” the healthcare system, even when their symptoms are serious.

Interviews reveal a difficulty in recognizing cardiac symptoms and ineffectiveness of responses from healthcare personnel, as reported in numerous studies (116, 117), where severe symptoms are misinterpreted as less severe symptoms (bronchitis or stress), leading to inadequate treatment (118). Rosenfeld et al. report the case of a woman with chest pain who was diagnosed with a gastrointestinal problem (74). Sjostrom-Strand & Fridlund instead, describe the case of a 39-year-old patient who was reassured by the doctor that she was too young to have a heart attack, showing how age-based biases can lead to misdiagnoses and treatment delays (35). Furthermore, among the women interviewed, many had been diagnosed with bronchitis and/or stomach ache, similar to those reported in the study by Berg Gundersen et al. (119). This attitude of minimising gravity is consistent with Healy's (16) “Yentl syndrome”, in which women's heart problems are not recognised by health professionals until they reach maximum severity.

The fourth theme analyzes how the “influence of others on decision-making”. The influence of others, in fact, can act as a catalyst or a brake in the decision to seek timely medical attention.

The interviews showed that if the symptoms experienced by the women do not correspond to those already known or experienced, for example, by family members, the women are less likely to recognise them as signs of AMI. In fact, according to the study by Davis et al. when women fail to interpret their symptoms correctly, they often consult other people; some do so immediately, others later in the course of the symptoms (36). This comparison serves to obtain advice and confirmation of their suspicions, even among women who have already had a heart attack, due to the atypical nature of the symptoms, which do not correspond to those commonly known (36).

Women interviewed, report that family play a significant role both as secondary decision-makers and as emotional support: their presence can incentivise seeking care, suggesting that the decision to seek care is often influenced by social pressure and perceived support (120). Sharing symptoms with loved ones may help patients overcome fear or denial of the illness, reducing the delay in accessing pre-hospital care (29, 93, 97, 102, 107, 121–126). Alonzo's study (127) found that, among more than 1,000 patients with AMI, 93% consulted family members or friends before seeking professional help, with both positive and negative effects, sometimes waiting for family members to return home to discuss symptoms (111, 128, 129). This behaviour could be explained to the lack of autonomy of some women, who depend on men to make decisions, asking men's permission before spending money on medical care (129, 130).

Many women report a sense of relief when the decision to go to hospital is made by a family member, and they often prefer to wait until the most convenient time for their partner, especially if their symptoms are stable, rather than calling the emergency room immediately (36). However, the delay time tends to increase if the patient consults a spouse or another family member, compared to when a third-party present during the acute event immediately makes the decision to seek medical assistance (125). In addition, the presence of a third party, during the onset of the acute event, has been shown to be influential in the decision to seek medical help (126, 131–133).

In order to confirm their initial perception of the symptoms, many women interviewed chose to share them with friends or family members, seeking a comparison to validate their feelings. This sharing process is a crucial step in strengthening their awareness of the severity of the situation. When women discuss their symptoms with family members and receive confirmation that these could be related to a heart attack, their decision to seek medical attention becomes more solid and urgent (36), which allows them to overcome doubt or denial and act more confidently and quickly.

Conversely, some women reported that their concerns were minimized by family and friends, who attributed the symptoms to less serious causes such as stress or fatigue, often accompanied by non-medical suggestions such as taking chamomile or eating biscuits, leading to an underestimation of the problem. Therefore, if sometimes family and friends can validate symptoms and encourage help-seeking (134, 135), at other times they may minimize symptoms to reassure, hindering care (112, 136).

The fifth theme includes “reflection on the post-AMI decision-making” process regarding seeking medical assistance in the presence of symptoms. Many women, after experiencing an AMI, rethink the decisions they made during that critical event, with two main feelings: validation of initial choices and regret for delaying action. Validation of initial decisions occurs when patients feel they acted in the best possible way, considering the information and emotions available to them at the time. This reflection process leads them to justify their choices, especially if the severity of the symptoms was not obvious or if family support was relied upon to make the decision. On the other hand, however, many express regret for having delayed in seeking medical help. This regret stems from the knowledge that earlier action could have reduced the risks and improved the outcome of their condition. This process of reflection, between validation and regret, provides a valuable opportunity to raise awareness and improve the response to cardiac emergencies in women.

The interviews show that some women, despite having experienced heart attack symptoms, would have chosen not to seek immediate medical assistance due to fear or distrust in the healthcare system. As demonstrated in Hadid's et al., study (115). Participants fear that negligence or poor medical decisions, such as those that have already affected some of their family members, could put their lives at risk. The interviews also reveal that choosing private facilities can ensure faster and higher quality care: in fact, some women believe that paying for a medical service corresponds to better quality care, in line with the study by Owusu Kwateng et al. (137).

Others, however, reflecting on these experiences, expressed regret for not acting promptly. Statements like “I would go right away” and “I would have called 118 sooner” highlight the recognition of the importance of a quick response in the event of a cardiac emergency. After overcoming the critical phase, women develop greater awareness of the risks and urgency of heart attack symptoms of AMI, positively influencing their future healthcare decisions (14). Adopting a quicker response in the future may be influenced by this belated recognition of urgency (138).

The adoption of a qualitative approach to explore the meaning of AMI for women is likely to have led to the creation of a more detailed picture that goes beyond pre-existing models and theories. Consequently, this study represents an important opportunity to gain a deeper understanding of the lived experiences of women with AMI. The multiple themes and sub-themes that emerged from the interviews enriched this understanding and can serve as a basis for the design of targeted and specific educational programmes.