During onset of an acute myocardial infarction (AMI), less than 20 % of patients reach the hospital within an optimal time window. About 75 % of pre-hospital delay time is caused by deficits in the patients' subjective decision making. To date, little is known about the course of threat appraisal during AMI. We aim to show here that health psychology related concepts offer an attractive conceptual frame to understand paradoxical reactions of AMI patients during this life threatening phase of their life. Only if patients overcome a complex network of barriers in perception and interpretation of symptoms, AMI symptoms will become effective as cues-to-action. Perception of symptoms may be compromised by a wide range of nociceptive stimuli originating from the heart. Symptom vagueness and a mismatch between expected and perceived symptoms may limit interpretation of the threat, yet active misattributing coping strategies may be even more present. Negative outcome expectancies and an impaired perceived self-efficacy, predominately in subjects with co-morbid negative affectivity are likely to contribute to delay.