Introduction

Globally, the prevalence and incidence of coronary artery disease (CAD) are on the rise, accounting for a third of all deaths1,2. Conversely, myocardial infarctions (MIs) represent the most severe clinical manifestation of CAD and are among the most dangerous coronary events3,4. According to 2023 statistics, CAD affected 620 million people worldwide, with 60 million new cases developing each year. A Harvard University report stated that over 14 million deaths from Cardiovascular disease (CVD) were reported in 20195, while the World Heart Federation revealed 20.5 million deaths in 20212. In the United States of America (USA), cardiovascular-associated death prevalence was 17.4%6, and 5% of individuals aged 20 and older have CAD7. The literature shows that over a million individuals die in the US from MI each year, and the condition affects up to 3 million people globally8. In 2021, about 2 in 10 deaths from CAD occur in adults under 657,9. In Saudi Arabia, data revealed a CAD prevalence of 56.3%10. The highest rates of cardiovascular disease mortality were seen in the Russian Federation, the European Union, and Indonesia5.The lowest death rates were found in Korea, Japan, and France5.

Coronary artery disease (CAD) or ischemic heart disease is characterized by an inadequate supply of blood and oxygen to the myocardium, leading to the obstruction of the coronary arteries and resulting in a demand-supply mismatch of oxygen11. Furthermore, CAD involves the formation of plaques in the lumen of coronary arteries that impede blood flow11,12. The main pathology of myocardial infarctions (MIs) involves the disruption of diastolic and systolic function, causing irreparable damage to the cardio myocyte by cutting off the oxygen supply8,13. Additionally, MIs also increase the patient’s risk of arrhythmias and other dangerous side effects. To effectively treat acute myocardial infarctions (AMI), reperfusion therapy must quickly restore blood flow to the heart cells8,13. In the US, individuals experience MIs every 40 s9. A previous study by Mishra et al. in 2022 reported a 15% incidence of myocardial infarction14. In Saudi Arabia, a study reported that 25.1% of the population had experienced MI10. Globally, the prevalence of MI among individuals is 3.8%, while for individuals aged over 60 years, the prevalence of MIs is 9.5%4.

The most frequently found non-modifiable risk factors for MI were age, sex, and family history15. In contrast, modifiable risk factors included smoking, dyslipidemia, diabetes mellitus, hypertension, obesity, sedentary lifestyle, poor oral hygiene, peripheral vascular disease, and elevated homocysteine levels15,16. Trauma, vascular disease, cocaine use, coronary artery defects, emboli, and excessive cardiac strain (hyperthyroidism, anemia) were among the other most frequent causes of MI15. Literature from Saudi Arabia has indicated a strong and favorable link between coronary artery disease and smoking, diabetes mellitus, hypertension, dyslipidemia, familial history of CAD, and overweight/obesity17,18. Despite these considerations, a recent study found that hypertriglyceridemia, older age, and male gender are significant risk factors for MI19.

The most common indications and symptoms of CAD and MIs include weakness, dizziness, nausea, and/or cold sweats; pain, pressure, or squeezing in the chest; sudden pain or discomfort in the arm or shoulder; and sudden dyspnea4,20. Previous literature suggested that 5.8% of American adults were unaware of MI symptoms21. Recent findings in Saudi Arabia indicate a lack of awareness of heart attack warning signs and symptoms22. In Tanzania, 84% of adults lack knowledge of MI symptoms23. Among Somalians, 53.35% lack knowledge about myocardial infarction24. Furthermore, the Saudi government, under the Saudi Vision 2030, aims to increase life expectancy from 75 to 80 years by addressing noncommunicable diseases, including cardiovascular disease (CVD)25,26. National efforts to reduce CAD incidence involve targeting risk factors like obesity, dyslipidemia, and hypertension through various strategies, such as primary prevention initiatives, public health campaigns, and promoting personal hygiene25,26. The government also suggests implementing national registries and digital solutions to support population-specific research, improve CVD surveillance, and reduce the burden of CVD in Saudi Arabia. Saudi Arabian citizens are encouraged to adopt healthy lifestyles25,26. The World Bank Group and the Saudi Public Health Authority have jointly produced a comprehensive report outlining steps to mitigate the negative effects of CVD on health and the economy, with the goal of increasing life expectancy25,26.

In Saudi Arabian society, studies assessing MI knowledge, attitudes, and beliefs were limited8,27,28. Additionally, it is crucial to minimize any delays in receiving an early diagnosis and treatment for MIs and CADs, as death and morbidity are often linked to reduced time between symptom onset and reperfusion13. Adequate knowledge of the disease is essential to save lives11. Therefore, patients must recognize the signs of CAD and MI as soon as possible and respond appropriately and promptly13,14,15. Moreover, a limited number of studies have evaluated the public’s understanding and awareness of CVD in Saudi Arabia, revealing a lack of knowledge and awareness of cardiovascular events16. This study aims to assess knowledge of symptoms and risk factors of MIs, as well as attitudes and beliefs regarding MIs and confidence in recognizing the symptoms of CADs in Riyadh, Saudi Arabia.

Methods

Study design, setting and population

Data collection was conducted using a cross-sectional study design. An electronic survey was created using Google Forms and distributed to the adult community residing in Riyadh, Saudi Arabia over a span of 6 months, from November 2023 to April 2024, with social media utilized as the data collection platform. Individuals both Saudis and non-Saudis residing in Riyadh, aged 18 and above, of any gender, who are able to comprehend Arabic and English and are willing to give informed consent, were eligible to participate in the study. Those who did not meet the inclusion criteria, lived outside of Riyadh were excluded from the study. The data was gathered through a self-administered online questionnaire.

Ethical approval and informed consent

This study was conducted in accordance with appropriate guidelines prescribed by the Declaration of Helsinki. The study questionnaires were approved by the King Saud University Ethical Approval Committee, which belongs to Human Research in Riyadh, Saudi Arabia. Additionally, respondents provided informed consent before completing the questionnaires.

Sample size estimation and sampling

The sample size for this study was determined using the Raosoft Sample Size Calculator (Seattle, WA, USA) based on the total population of Riyadh (7,821,000). With a predefined margin of error of 5% and a confidence level of 95%, the required sample size was calculated to be 385. In order to avoid sampling bias and enhance the validity of the study, we approached a total of 500 individuals. The data was collected using convenience sampling. Furthermore, recruiting more sample was achieved by distributing the questionnaires using snowball technique until the required sample size was obtained.

Questionnaire design and validation

The study questionnaires were prepared based on the literature to investigate knowledge and awareness of heart attacks24,29,30,31. It consisted of both closed and open-ended questions. The first section requested demographic information such as age, gender, educational level, monthly income, employment, and marital status. The second section used 21 questions to gather information about knowledge of heart attack symptoms. The third section asked respondents about their knowledge of risk factors for heart attacks, with 11 items measured on a three-point scale (Yes, No, I don’t know). The fourth section focused on attitudes and beliefs towards heart attacks, with 7 items assessed on a five-point Likert scale ranging from strongly agree to strongly disagree. The last section collected information on how confident respondents were in recognizing heart attack symptoms and providing help, with 4 items measured on a four-point scale (Fairly/Somewhat/Little/Not at all confident).

After the initial draft of the questionnaires, it was sent for a translation procedure using forward and backward translation with a native speaker. Three experts in the field were asked to evaluate the questionnaires in terms of structure, appropriateness, and content. After receiving expert opinions and validation, a pilot study was conducted with 30 randomly selected individuals to ensure linguistic and conceptual understanding of the questionnaires. The outcomes of the pilot study were not included in the final analysis. The reliability of the questionnaires was determined using Cronbach’s alpha, as shown in Fig. 1. The questionnaire was finalized in Arabic as self-administered, web-based questionnaires. The study used a simple random sampling method, and data was collected through social media platforms (WhatsApp, Facebook, and Twitter). Each questionnaire was completed anonymously, and all participants were guaranteed the confidentiality of the information they submitted.

The knowledge score was computed by assigning a score of one for the correct answer and a score of zero for the wrong answer. Similarly, the mean attitude score was computed by assigning as score of 5 for strongly agree and as core of 1 for the strongly disagree. The total knowledge score was obtained by computing the knowledge item. Later the knowledge score was further classified in to good knowledge for those who scored > 50% of the total knowledge score and poor knowledge for those who scored < 50% of the total knowledge score32,33.Similar concept was applied for classifying the attitudes levels.

Fig. 1
figure 1

Reliability of study tool.

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Data analysis

For each variable, descriptive statistics such as counts and percentages were generated. The statistical calculations were performed using the Statistical Package for Social Sciences version 26.0 (SPSS Inc., Chicago, IL, USA). Mean ages were computed. The association between demographic variables and heart attack knowledge questionnaires was assessed using the Chi-square test or Fisher’s exact test, as appropriate. A p-value of less than 0.05 was judged statistically significant.

Results

Description of the sample (n = 428)

A total of 428 individuals completed the survey. Table 1 displays the socio-demographic characteristics of the participants. Approximately 65.5% were male, while more than one third (34.6%) were female. A significant portion, 27.3%, fell between the ages of 26 and 30, with 17.3% aged 36–40. Additionally, 59.1% held a Master’s degree, while 10.5% had a secondary school education. In terms of marital status, the majority, 76.2%, were married, and 75.2% were employed. The monthly income for 41.1% of participants ranged from 5000 to 10,000 SAR. Table 1 also indicates that 48.4% had a family history of heart attack, and 60.3% had health insurance.

Table 1 Socio-demographic characteristics of the participants (n = 428).
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Knowledge of individuals about the symptoms of myocardial infarction

Regarding the symptoms of a heart attack, the most commonly reported were chest pain or pressure (85.9%), followed by weakness or fatigue (85.8%), palpitations or rapid heart rate, chest discomfort (83.4%), dizziness, lightheadedness (82.7%), and sweating (82.4%). The complete details of the study participants regarding the symptoms of a heart attack are depicted in Fig. 2.

Fig. 2
figure 2

Most commonly recognized symptoms of myocardial infarction.

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Knowledge of participants about the risk factors of MIs

Among participants, 91.6% were aware that smoking and obesity might increase the risk of MI, while 85.3% believed that a family history of coronary heart disease may affect the risk of experiencing a heart attack. Additionally, 71% of them identified high cholesterol and hypertension as other risk factors for MIs. In contrast, only 86.2% of participants were aware that diabetes mellitus is a risk factor for MIs. For MIs prevention, 19.4% reported that taking one tablet of Aspirin could be beneficial if they experience a heart attack. Furthermore, 82.3% reported that hospitals have treatments that can reduce damage from heart attacks (Table 2).

Table 2 Knowledge of participants about the risk factors of MIs.
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Attitudes and beliefs of the participants toward myocardial infraction

The findings revealed that the majority (92.3%) would seek medical care if they experienced chest pain within 15 min. However, 69.8% of them said they would be embarrassed to go to the hospital if they weren’t experiencing a heart attack. In contrast, 46.5% of participants said they would not visit the hospital unless they were certain. Additionally, 46.2% of respondents said they would rather have someone drive them to the hospital than have an ambulance come to them if they had symptoms of a heart attack. Almost half of the respondents expressed neutrality about the statement that if they suspected they experienced a heart attack, the cost of medical care would not influence their decision to visit the hospital. A total of 86.5% of participants strongly agreed that if they suspected they were having a heart attack; they would head to the hospital immediately (Table 3). The mean attitude score among the participants was 23.12 ± 3.11(median 22; Range 0–28).

Table 3 Attitudes and beliefs of the participants toward MIs.
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Confidence of the participants in recognizing the symptoms of a heart attack and providing help for the patients

In this study, 60.3% of participants reported having little confidence in identifying signs and symptoms of heart attacks in others. 54.4% were confident in themselves. Further, 46% of participants were pretty confident they could get help if they thought they were having a heart attack, while 41.8% thought they could get help on their own (Fig. 3).

Fig. 3
figure 3

Confidence of the participants in recognizing the symptoms of a heart attack and providing help for the patients.

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Table 4 illustrates the relationship between demographic characteristics and knowledge of myocardial infarction. The associations between respondents’ knowledge of MI with factors such as gender, age, education, and marital status were determined using the Chi-square/Fisher exact test at the significance level of < 0.05. Results showed that gender (p = 0.001), age (p = 0.004), education (p = 0.001), and marital status (p = 0.004) had a significant association with levels of knowledge of MI.

Table 4 Association between Knowledge of myocardial infarction concerning respondent’s demographic characters.
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Regarding the relationship between the level of knowledge of myocardial infarction and respondents’ monthly salary, the findings revealed a significant association. For example, poor knowledge was higher among individuals with a monthly salary between 5,000 and 10,000 Saudi riyals. Similarly, good knowledge of myocardial infarction was higher among individuals with a salary of 16,000–20,000 Saudi riyals per month, indicating a statistically significant association (p = 0.001) (Fig. 4). Additionally, family history of heart attack was significantly associated with knowledge of MIs (Fig. 5).

Fig. 4
figure 4

Respondents income and knowledge levels.

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Fig. 5
figure 5

Respondents’ Family history of heart attack and knowledge levels.

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Discussion

In this study, we assessed the understanding, attitudes, and beliefs of Saudi individuals regarding myocardial infarctions (MIs). MIs. Additionally, we evaluated the confidence of Saudis in recognizing heart attack symptoms and provided potential solutions to enhance their knowledge about CAD and MIs in order to reduce associated morbidity and mortality from these cardiovascular diseases. The findings of the study indicated that jaw pain, arm paralysis, chest pain or pressure (85.9%), weakness/fatigue (85.8%), palpitations or rapid heart rate, chest discomfort (83.4%), dizziness, lightheadedness (82.7%), and sweating (82.4%) were the most common initial signs of CAD. These results align with previous studies conducted in other countries20,24,29,30. For example, Shahmohamadi et al. revealed that 71.3% of Iranians considered chest pain or discomfort in the chest, followed by pain or discomfort in the arm or shoulder 62.7% as the main symptoms of MI20. Similarly, another study reported that 90% of Saudi adults knew that chest pain is a symptom of a heart attack30. In a study in Somalia, 53.3% of residents lacked knowledge of MI. It was revealed that only 50% of Somalis were aware that MI typically manifests as chest pain while 41.9% of Somalis were aware that MI might occasionally manifest without chest pain24. On the other hand, the literature revealed limited knowledge of MI among Malaysians. It was found that only 26.3% of Malaysians were aware of heart attack symptoms like pain and/or discomfort in the jaw, neck, or back, while 71.65% showed awareness only of chest pain or discomfort as symptoms29.

Many previous studies from developed countries have shown that the first sign of a myocardial infarction is chest pain27,28,34. In contrast, the current findings reveal that the first sign is jaw pain and arm paralysis, followed by chest pain. These findings are similar to an earlier study published in Nepal, where the author concluded that Nepalis reported chest pain as the second most common sign for MIs, suggesting that participants’ knowledge about MIs should be improved. It is well known that adequate knowledge, attitudes, and practices of individuals towards specific diseases can save patients from morbidity and mortality. If a patient has adequate knowledge, they may rush to the hospital immediately to seek treatment, which can save the patient from early death.

In this study, Saudi adults demonstrated good knowledge in recognizing risk factors for MI. Most of them were aware and agreed that smoking and obesity increase the risk of MIs. Additionally, 85.3% believed that a family history of coronary heart disease may affect the risk of experiencing MIs, followed by high cholesterol and hypertension (71%) and diabetes (86.2%) as risk factors. Previous studies have reported different findings. For example, Basham et al. found that 75% of Saudi adults recognized hypertension, cigarette smoking, and high cholesterol as risk factors for MI30. Similarly, a study in Iran by Shahmohamadi et al. revealed that anxiety, obesity, an unhealthy diet, high LDL levels, and Diabetes Mellitus were major risk factors identified. In Korea, 42.4% of the general public was aware of MI symptoms and recognized that chest pain and shortness of breath were the most common symptoms of MI. There was a low level of awareness of gastrointestinal symptoms and pain in the arm, shoulder, jaw, neck, and back35. Likewise, another study among patients and the public revealed that patients had higher knowledge of MI symptoms and risk factors than the general public36. These findings confirm that individuals and patients differ in their knowledge, possibly due to patients undergoing educational programs or counseling with healthcare providers, unlike the general public. Furthermore, patients may have different risk factors based on their disease condition and the presence of other comorbid diseases. Although literature suggests that genetics and hereditary factors play a role in MIs, which can be modifiable or controlled.

However, the attitudes of the respondents in this study vary regarding each attitude item. For example, the findings show a positive attitude and reveal that the majority would seek medical care if they experience chest pain after 15 min. Conversely, poor attitudes were reported by 46.5% of participants, stating they would not visit the hospital unless they were certain. Furthermore, approximately 70% of them mentioned they would be embarrassed to go to the hospital if they weren’t experiencing a heart attack. These results indicate a need for more education and awareness regarding the importance of recognizing the symptoms of the disease and adopting a positive outlook on it. Myocardial infractions are medical emergencies in which patients experience difficulty breathing, leading to the death of heart muscle and the potential for permanent damage to the heart. If it’s not a heart attack, people should avoid wasting time out of concern for humiliation. Individuals and patients who suffer from chest pain should consult a doctor as soon as possible, even if there is another reason for their chest pain.

In this study, half of the participants were confident in their ability to recognize their own MI symptoms, while the majority reported feeling less confident in their ability to recognize the signs and symptoms of heart attacks in others. Of the participants, 46% were fairly confident in their ability to get help if they suspected they were having a heart attack, while 41.8% believed they could get help on their own. These results are consistent with a previous survey conducted in England, which found that 51% of respondents were unconfident in their ability to recognize the symptoms of a heart attack that are frequently reported, and that almost half of individuals in the country are not confident in their ability to recognize heart attack symptoms37. Three-quarters of those surveyed (36%) said they wouldn’t call an ambulance for help if they or someone they knew were suffering from chest pain37. These findings suggest that campaigns for health awareness, especially for those who suffer from various cardiac diseases and risk of myocardial infractions, should be guided by these findings.

Limitations and recommendations

This study has some limitations, including the cross-sectional nature of the study design, which prohibits the ability to draw causal conclusions about the findings. The fact that the majority of the study population consisted of university students who are Saudi nationals limits the generalizability of the findings. Second, the study’s findings might not accurately represent the knowledge of all Saudi adults because they were derived from a single region in Saudi Arabia. Additionally, the majority of study participants were younger than 45 years old, which could be another limitation. Furthermore, social desirability bias might have been present because the online questionnaire used to collect the data was self-administered. To properly demonstrate the findings, a future study with a greater number of participants, including Saudi people residing in all other regions, is required. Notwithstanding these drawbacks, the results can serve as a basis for future research. Additionally, the information presented here can be utilized to create educational initiatives that increase the public’s understanding of the risk factors for MIs, thereby reducing the morbidity and mortality associated with MIs.

The study’s conclusions clearly demonstrate the importance of understanding MIs, which influences individual health and lowers the fatality rate related to MIs. The suggestions made for raising health literacy regarding MIs through education and awareness campaigns are sound and may influence the creation of healthcare policies. Furthermore, there is a need for the promotion of healthy lifestyles to mitigate the incidence of MIs and associated adverse outcomes. In addition, promoting physical activity, encouraging healthy habits for patients and communities by providing routine check-ups and free counseling on increasing healthy activities, improving fitness, and reducing sedentary behaviors are needed.

Conclusion

The results revealed that half of the population studied in Riyadh, Saudi Arabia had good knowledge and could identify symptoms such as jaw pain, arm paralysis, and chest pain/pressure. Additionally, the majority agreed that smoking and obesity were risk factors. Their attitudes were positive; with most stating they would seek medical care within 15 min if they experienced chest pain. However, despite having sufficient knowledge about the clinical perspective of myocardial infarction (MI), many expressed less confidence in recognizing heart attack symptoms and providing assistance to patients. This highlights the need for health education on the disease, recommendations, and guidance on how to effectively save lives by recognizing symptoms and offering timely help.