Sex Differences in Acute Coronary Syndrome Symptom Presentation in Young Patients.

Khan NA, Daskalopoulou SS, Karp I et al; for the GENESIS PRAXY Team
JAMA Intern Med. 2013 Sep 16. doi: 10.1001/jamainternmed.2013.10149.

Background

Chest pain is the critical distinguishing symptom that initiates diagnostic testing for acute coronary syndrome (ACS) and urgent lifesaving therapy. However, up to 35% of patients with ACS do not report chest pain [1], which may lead to misdiagnosis and higher risk of death [2].
In elderly cohorts, absence of chest pain seems to be common in both men and women. Women may however have milder or more often absent chest pain than men. It is possible that a higher prevalence of comorbid conditions such as diabetes may explain some of the sex-based differences in ACS presentation in elderly women [3].
It is unknown whether similar sex-differences and predictors of non-chest pain presentation exist in young ACS populations. Women under 55 years old are more likely than men to have ACS misdiagnosed in the emergency department [4,5], and they run a higher risk of death once admitted with ACS [1,6].
This study evaluated sex differences in symptom presentation in 1015 patients of 55 years or younger, using standardized data collection in patients hospitalized for ACS. The data were adjusted for potentially confounding baseline factors such as anxiety, depression, gender identity, comorbid conditions and extent of coronary disease.

Main results

• 96.6% of men and 97.0% of women presented with at least one symptom: chest pain, shortness of breath, or one of the non-chest pain MAPMISS symptoms. Chest pain was the most common symptom for men and women regardless of ACS type. Women reported more symptoms than men.
• Women more often presented without chest pain than men (19.0% vs. 13.7%, P=0.03).
  In the absence of chest pain, patients generally reported fewer symptoms than when patients experienced chest pain, both in women (3.5 vs. 5.8, P<0.001) and men (2.2 vs. 4.7, P<0.001).
• 84.5% of women and 78.4% of men who did not report chest pain, had at least 1 non-chest pain symptom. No clinically predictive pattern of presenting symptoms could be identified for those with and without chest pain.
• In multivariate analysis, only female sex (OR: 1.95, 95%CI: 1.23-3.11) and tachycardia (OR: 2.07, 95%CI: 1.20-3.56) were independently associated with ACS presentation without chest pain.
• The most common non-chest pain symptoms reported in those without chest pain were not associated with markers of ACS severity, except for cold sweats and weakness, which were associated with increased odd of STEMI as compared to NSTEMI or unstable angina (OR: 2.05, 95%CI: 1.50-2.79) vs OR: 1.55, 95%CI: 1.12-2.13).

Conclusion

This study shows that chest pain is the predominant symptom of ACS in both younger (<55 years ) men and women, regardless of ACS type. Women have a higher chance of presenting without chest pain than men. If patients present without chest pain, they generally have at least 1 other non-chest pain symptom, thus standardized collection of all ACS-related symptoms is needed.

References

1. Canto JG, RogersWJ, Goldberg RJ, et al; NRMI Investigators. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813-822.
2. Brieger D, Eagle KA, Goodman SG, et al; GRACE Investigators. Acute coronary syndromes without
chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2): 461-469.
3. Canto JG, Goldberg RJ, Hand MM, et al. Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch Intern Med. 2007;167(22):2405-2413.
4. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170.
5. Kaul P, ChangWC, Westerhout CM, et al.. Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes. CMAJ. 2007;177(10):1193-1199.
6. Vaccarino V, Parsons L, Peterson ED et al. Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006. Arch Intern Med. 2009;169(19):1767-1774.

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