Closing the Knowledge Gap Before the Golden Hour: Strengthening Heart Attack Literacy in Pakistan

Cardiovascular disease (CVD) remains the leading cause of mortality worldwide, accounting for nearly 20 million deaths annually, with low- and middle-income countries bearing a disproportionate burden [1]. Pakistan faces a rapidly escalating cardiovascular crisis, driven by urbanization, sedentary lifestyles, tobacco use, metabolic disorders, and limited preventive literacy [2,3]. Despite improvements in tertiary cardiac care infrastructure, the effectiveness of acute myocardial infarction management ultimately depends on early recognition and timely presentation. In this context, public awareness becomes the first—and often weakest—link in the survival chain. The study by Ali et al. [4] provides valuable insight into heart attack knowledge among young and middle-aged adults in Quetta, Pakistan. Building upon prior work validating a regionally adapted awareness questionnaire [5], the authors report a moderate overall knowledge score, revealing both encouraging awareness and concerning gaps. While chest pain was recognized by the majority of participants, knowledge of atypical symptoms—such as nausea and arm numbness—was notably limited. Similar deficiencies in symptom recognition have been reported previously in Pakistani populations [6,7]. Such gaps are clinically significant, as delayed symptom recognition remains a primary contributor to prolonged pre-hospital delay and missed therapeutic windows. A particularly notable finding was the higher knowledge score among females compared to males. This is especially relevant in light of emerging data demonstrating a significant and often underrecognized cardiovascular burden among women in Pakistan [8]. While women may exhibit increasing health literacy in certain settings, gender-based disparities in access to care and outcomes persist. These findings underscore the need for gender-sensitive public health messaging and targeted educational strategies. Encouragingly, major risk factors such as hypertension and diabetes were widely recognized. However, smoking awareness lagged despite tobacco being a major modifiable contributor to premature myocardial infarction in Pakistan [2,3]. Furthermore, the persistence of misconceptions—including belief in home remedies—reflects gaps between knowledge and appropriate emergency action. Prior research in metropolitan South Asian populations similarly demonstrates that awareness does not consistently translate into correct health-seeking behavior [9]. The broader implications of these findings extend beyond knowledge scores. Even where hospitals achieve optimal door-to-device or door-to-balloon times, delayed patient arrival undermines system efficiency. National efforts to standardize cardiovascular care in primary health settings must therefore integrate structured community-level awareness strategies [10]. Improving cardiovascular literacy is not merely an educational objective; it is a mortality-reduction strategy. Methodologically, while the study offers valuable regional insight, its geographic focus limits generalizability. Pakistan exhibits substantial urban–rural, socioeconomic, and educational heterogeneity. Future multi-provincial surveys could explore these gradients more comprehensively, while longitudinal intervention studies would provide stronger evidence for sustainable policy implementation. From a policy standpoint, these findings support the need for scalable awareness initiatives. Integration of cardiovascular literacy into school curricula, primary care counseling, and digital health campaigns could enhance early symptom recognition. Community health workers and family physicians should be mobilized as frontline educators. Public messaging must emphasize not only symptom identification but also immediate activation of emergency medical services during the “golden hour.” In conclusion, strengthening heart attack literacy represents a critical and modifiable lever in reducing Pakistan’s cardiovascular mortality burden. As interventional cardiology services expand nationally, equal investment must be directed toward empowering communities with the knowledge necessary to seek timely care. Closing the awareness gap before hospital arrival may ultimately yield the greatest survival benefit. References World Health Organization. Cardiovascular diseases (CVDs). 2021. Available at: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) Siddiqi AK, Samad Z, Khan MS. Quantifying cardiovascular disease burden attributable to risk factors in Pakistan: a call for data-driven action. Proc (Bayl Univ Med Cent). 2025;38(5):615-6. DOI: 10.1080/08998280.2025.2531721 Mansoor T, Abdul Jabbar AB, Virani S, Minhas AMK. Burden of cardiovascular disease attributable to risk factors in Pakistan: insight from Global Burden of Disease Study 2019. Proc (Bayl Univ Med Cent). 2025;38(5):600-14. DOI: 10.1080/08998280.2025.2522617 Ali K, Haq N, Din JU, Nasim A, Fatima M. Assessment of Knowledge about Heart Attack among Young and Middle-Aged Adults in Quetta. Pak Heart J. 2025;58(3):378-85. DOI: 10.47144/phj.v58i3.2760 Ali K, Haq NU, Fatima M, Uddin SM, Saood M, Nasim A. Development of Questionnaire for the Assessment of Awareness about Heart Attack among Adults in Quetta Pakistan. J Adv Med Pharm Sci. 2022;24:1-10. https://hal.science/hal-05195228/ Rasool SM, Asad Z, Bhatti AA, Kulsoom A, Chaudhary NA, Rasool AS, et al. Assessment of Knowledge of Symptoms of Ischemic Heart Disease in Population Visiting a Tertiary Care Hospital in Pakistan. Cureus. 2019;11(8):e5482. DOI: 10.7759/cureus.5482 Jafary FH, Aslam F, Mahmud H, Waheed A, Shakir M, Afzal A, et al. Cardiovascular health knowledge and behavior in patient attendants at four tertiary care hospitals in Pakistan--a cause for concern. BMC Public Health. 2005;5:124. DOI: 10.1186/1471-2458-5-124 Bhatti S, Rehman S, Fayyaz S, Gurmani S, Karim M, Saghir T, et al. Burden of cardiovascular disease in women: data from Pakistan’s largest cardiac hospital network. npj Women's Health. 2025;3(1):38. DOI: 10.1038/s44294-025-00084-w Rafiq A, Mahraj P, Kamran AS, Bai D, Makhija R, Khemani S. Cardiovascular Disease Literacy and Risk Factor Awareness in a Metropolitan South Asian Population: Findings from a Cross-Sectional Study in Karachi. J Health Rehab Res. 2025:1-6. Pervez A, Mahmud O, Baloch F, Rizvi NA, Bukhari S, Ahmed B, et al. Standardizing the management of cardiovascular diseases in the primary health care setting of Pakistan. BMC Prim Care. 2025;27(1):25. DOI: 10.1186/s12875-025-03143-y