Challenging the rules: women's prodromal and acute symptoms of myocardial infarction

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction

OBJECTIVES

Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers.

METHODS

Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied.

RESULTS

Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see".

CONCLUSION

Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response.

PRACTICE IMPLICATIONS

Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

Myocardial Infarction Signs and Symptoms: Females vs. Males

Cardiovascular disease is the number one killer of females in the United States today, and myocardial infarction (MI) plays a role in many of these deaths. Females also present with more "atypical" symptoms than males and appear to have differences in pathophysiology underlying their MIs. Despite both differences in symptomology and pathophysiology being present in females versus males, a possible link between the two has not been studied extensively. In this systematic review, we analyzed studies examining differences in symptoms and pathophysiology of MI in females and males and evaluated possible links between the two. A search was performed for sex differences in MI in the databases PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Biomedical Reference Collection: Comprehensive, Jisc Library Hub Discover, and Web of Science. Seventy-four articles were ultimately included in this systematic review. Typical symptoms for both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) such as chest, arm, or jaw pain were more common in both sexes, but females presented on average with more atypical symptoms such as nausea, vomiting, and shortness of breath. Females with MI also presented with more prodromal symptoms such as fatigue in days leading up to MI, had longer delays in presentation to the hospital after symptom onset, and were older with more comorbidities than males. Males on the other hand were more likely to have a silent or unrecognized MI, which concurs with their overall higher rate of MI. As they age, females have a decrease in antioxidative metabolites and worsened cardiac autonomic function than male. In addition, at all ages, females have less atherosclerotic burden than mles, have higher rates of MI not related to plaque rupture or erosion, and have increased microvasculature resistance when they have an MI. It has been proposed that this physiological difference is etiologic for the male-female difference in symptoms, but this has not been studied directly and is a promising area of future research. It is also possible that differences in pain tolerance between males and females may play a role in differing symptom recognition, but this has only been studied one time where females with higher pain thresholds were more likely to have unrecognized MI. Again, this is a promising area for future study for the early detection of MI. Finally, differences in symptoms for patients with different atherosclerotic burden and for patients with MI due to a cause other than plaque rupture or erosion has not been studied and are both promising avenues to improve detection and patient care in the future.

Specific prodromal symptoms in patients with acute coronary syndrome

AIMS

Assessing the prodromal cardiac symptoms in patients with acute coronary syndrome (ACS) and compare them with healthy population.

BACKGROUND

Identifying specific prodromal cardiac symptoms can play an important role in screening people at risk.

DESIGN

A comparative study of prodromal symptoms.

METHODS

In this comparison study, an 80-item checklist of prodromal symptoms was designed and completed by 337 participants in three groups (Patient group I, Patient group II and Healthy group). All participants were studied over a period of six months (from May to October 2017). SPSS-15 software was used to analyse the data.

RESULTS

The symptoms of pain/discomfort in chest, pain/discomfort centred in the superior part of chest, pain/discomfort in the left breast and numbness or burning of both arms were the most important symptoms to predict ACS incidence in the two patient groups (odds ratio > 4 and p ≤ .05).

Validation of the Multidimensional Fatigue Inventory with Coronary Artery Disease Patients

BACKGROUND

Fatigue is a common distressing symptom in patients with coronary artery disease (CAD). The Multidimensional Fatigue Inventory (MFI) is used for measuring fatigue in various clinical settings. Nevertheless, its multidimensional structure has not been consistent across studies. Thus, we aimed to psychometrically evaluate the MFI in patients with CAD.

METHODS

In sum, 1162 CAD patients completed questionnaires assessing their subjective fatigue level (MFI-20), mental distress symptoms (HADS, STAI), and health-related quality of life (SF-36). Participants also completed exercise capacity (EC) testing.

RESULTS

Confirmatory factor analysis of the four-factor model, showed acceptable fit (CFI = 0.905; GFI = 0.895; NFI = 0.893, RMSEA = 0.077). After eliminating four items, confirmatory factor analysis testing showed improvement in the four-factor model of the MFI-16 (CFI = 0.910; GFI = 0.909; NFI = 0.898, RMSEA = 0.077). Internal consistency values were adequate for the total score and four MFI-16 subscales: General fatigue, physical fatigue, reduced activity, and mental fatigue with Cronbach's α range: 0.60-0.82. The inadequate value (Cronbach's α = 0.43) was received for the subscale of reduced motivation in both MFI-20 and MFI-16. Correlations between the MFI-16 and HADS, STAI, SF-36, and EC measures were statistically significant (all p's < 0.001).

CONCLUSIONS

The Lithuanian version of the modified MFI of 16 items showed good factorial structure and satisfactory psychometric characteristics, except for reduced motivation subscale.

Risk stratification of patients with chest pain or anginal equivalents in the emergency department

We studied whether previously developed cardiac risk scores-including history, ECG, age, risk factors, and troponin (HEART); Thrombolysis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); and Emergency Department Assessment of Chest Pain (EDACS)-could be applied to predict major adverse cardiac events (MACE) in patients with possible coronary artery disease, including anginal equivalents. Patients with chest pain or anginal equivalents who underwent coronary computed tomographic angiography were included. The primary outcome was 30-day MACE. We compared the cardiac risk scores by the area under the receiver-operating characteristic curves (AUC). The primary outcome occurred in 200 patients (16.0%) of the 1247 patients included. For the prediction of MACE, the AUC of the HEART score (0.765) was superior to those of the TIMI (0.726), GRACE (0.612), and EDACS (0.631) scores. Among patients identified by each score as being at low risk, the MACE rate was the lowest for the HEART score (5.7%), followed by the TIMI (8.8%), EDACS (11.2%), and GRACE (12.2%) scores. At a sensitivity level of a < 2% rate of misses, the negative predictive value of the HEART score (1.0) outperformed those of the GRACE (0.932) and EDACS (0.964). The HEART score appeared to be more predictive of MACEs than the TIMI, GRACE, and EDACS in patients with chest pain or anginal equivalents. However, previously suggested cutoff could not safely identify low-risk patients for early discharge because of the unacceptably high rate of missed MACEs.

Prodromal Myocardial Infarction Fatigue: A Concept Analysis

Patients' care-seeking behaviors are often based on the symptoms they experience. Prodromal myocardial infarction symptoms are those symptoms that occur prior to a myocardial infarction, and fatigue is common. However, the concept of prodromal myocardial infarction fatigue has not been explored from a multidimensional perspective using a concept analysis approach. The purpose of this concept analysis was to analyze this concept, using Walker and Avant's (2011) concept analysis methodology. A comprehensive literature search revealed 41 records for analysis. The structure and function of this concept was examined, and an operational definition of prodromal myocardial infarction fatigue was developed.

Treatment-Seeking Delay Among Hispanic and Non-Hispanic Women with Acute Myocardial Infarction

Purpose: Women and minorities with acute myocardial infarction (AMI) often fail to recognize prodromal symptoms leading to delays in care. The objective of this study was to conduct a mixed method assessment of the impact of ethnicity on symptom description, recognition, and treatment-seeking behavior in Hispanic and non-Hispanic women before hospitalization for AMI.

Methods: We explored differences in symptomatology, treatment-seeking behavior, and delay patterns among a convenience sample of 43 women diagnosed with AMI (17 Hispanic women, 26 non-Hispanic women) in seven rural and urban Colorado hospitals. We performed in-depth interviews to establish patterns (typologies) of treatment-seeking behaviors. Chart abstraction provided delay times as a function of ethnicity.

Results: Most (28/43) women reported prodromal symptoms in the weeks before their index AMI. Overall, fewer Hispanic women presented within 24 h of symptom onset (3/18, 17% vs. 15/18, 83%, p<0.01). A typology of treatment-seeking behavior emerged: women who (1) recognized symptoms and promptly sought care; (2) did not recognize symptoms, yet promptly sought care; (3) recognized symptoms and promptly sought care, but providers misconstrued symptoms as noncardiac; and (4) misinterpreted symptoms due to an underlying chronic disease.

Conclusion: Women and primary care providers often underappreciate prodromal AMI symptoms. Hispanic women are more likely to misinterpret ischemic symptoms and delay care, suggesting a need for tailored patient and provider education.

Symptom description in patients with chest pain-A qualitative analysis of emergency medical calls involving high-risk conditions

AIMS AND OBJECTIVES

To explore the symptoms descriptions and situational information provided by patients during ongoing chest pain events caused by a high-risk condition.

BACKGROUND

Chest pain is a common symptom in patients contacting emergency dispatch centres. Only 15% of these patients are later classified as suffering from a high-risk condition. Prehospital personnel are largely dependent on symptom characteristics when trying to identify these patients.

DESIGN

Qualitative descriptive.

METHODS

Manifest content analysis of 56 emergency medical calls involving patients with chest pain was carried out. A stratified purposive sampling was used to obtain calls concerning patients with high-risk conditions. These calls were then listened to and transcribed. Thereafter, meaning units were identified and coded and finally categorised. Consolidated criteria for reporting qualitative studies guidelines have been applied.

RESULTS

A wide range of situational information and symptoms descriptions was found. Pain and affected breathing were dominating aspects, but other situational information and several other symptoms were also reported. The situational information and these symptoms were classified into seven categories: Pain narrative, Affected breathing, Bodily reactions, Time, Bodily whereabouts, Fear and concern and Situation management. The seven categories consisted of 17 subcategories.

CONCLUSIONS

Patients with chest pain caused by a high-risk condition present a wide range of symptoms which are described in a variety of ways. They describe different kinds of chest pain accompanied by pain from other parts of the body. Breathing difficulties and bodily reactions such as muscle weakness are also reported. The variety of symptoms and the absence of a typical symptomatology make risk stratification on the basis of symptoms alone difficult.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the importance of an open mind when assessing patients with chest pain and the requirement of a decision support tool in order to improve risk stratification in these patients.

Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients)

BACKGROUND

Some studies report that women are less likely to present with chest pain for acute myocardial infarction (AMI). Information on symptom presentation, perception of symptoms, and care-seeking behaviors is limited for young patients with AMI.

METHODS

We interviewed 2009 women and 976 men aged 18 to 55 years hospitalized for AMI at 103 US hospitals participating in the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Structured patient interviews during the index AMI hospitalization were used to collect information on symptom presentation, perception of symptoms, and care-seeking behaviors. We compared patient characteristics and presentation information by sex. Multivariable hierarchical logistic regression was used to evaluate the association between sex and symptom presentation.

RESULTS

The majority of women (87.0%) and men (89.5%) presented with chest pain (defined as pain, pressure, tightness, or discomfort). Women were more likely to present with ≥3 associated symptoms than men (eg, epigastric symptoms, palpitations, and pain or discomfort in the jaw, neck, arms, or between the shoulder blades; 61.9% for women versus 54.8% for men, P<0.001). In adjusted analyses, women with an ST-segment-elevation AMI were more likely than men to present without chest pain (odds ratio, 1.51; 95% confidence interval, 1.03-2.22). In comparison with men, women were more likely to perceive symptoms as stress/anxiety (20.9% versus 11.8%, P<0.001) but less likely to attribute symptoms to muscle pain (15.4% versus 21.2%, P=0.029). Approximately 29.5% of women and 22.1% of men sought medical care for similar symptoms before their hospitalization (P<0.001); however, 53% of women reported that their provider did not think these symptoms were heart-related in comparison with 37% of men (P<0.001).

CONCLUSIONS

The presentation of AMI symptoms was similar for young women and men, with chest pain as the predominant symptom for both sexes. Women presented with a greater number of additional non-chest pain symptoms regardless of the presence of chest pain, and both women and their healthcare providers were less likely to attribute their prodromal symptoms to heart disease in comparison with men.

Sex differences in symptoms experienced, knowledge about symptoms, symptom attribution, and perceived urgency for treatment seeking among acute coronary syndrome patients in Karachi Pakistan

BACKGROUND

Patients' experience of acute coronary syndrome (ACS) symptoms is important in determining their prehospital delay.

OBJECTIVE

To explore gender differences in acute symptoms of ACS, knowledge about the symptoms, their attribution, and perception of urgency, among Pakistani ACS patients.

METHODS

Comparative, cross-sectional study design with 249 ACS patients.

RESULTS

The most commonly reported symptoms were ghabrahat (fidgetiness), chest pain, and chest heaviness. Most atypical symptoms were experienced more by women, such as nausea/vomiting (p < 0.001), backache (p < 0.001), palpitations (p = 0.004), and epigastric pain (p = 0.005). Chest pain and palpitations were the symptoms most commonly attributed to cardiac causes, whereas epigastric pain was most commonly attributed to non-cardiac causes by both men and women. Significantly more women than men perceived dyspnea (p = 0.026), nausea/vomiting (p = 0.027), sweating (p = 0.014), and palpitations (p = 0.01) as symptoms not at all urgent for treatment.

CONCLUSIONS

Gender disparity in symptom experience along with the women's perception of non-urgency for their symptoms, could lead to delayed care seeking.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

BACKGROUND

Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences.

OBJECTIVE

The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS.

METHODS

A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured.

RESULTS

The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00-2.42), shoulder pain (OR, 1.76; CI, 1.13-2.73), and upper back pain (OR, 2.92; CI, 1.81-4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women.

CONCLUSIONS

Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

An integrative review of fatigue experienced by women before and during myocardial infarction

AIMS AND OBJECTIVES

To explore the extant literature for key features of prodromal and acute myocardial infarction fatigue experienced by women, including estimates of severity, narrative descriptors, impacts on activities of daily living and frequency, and to describe what is known from the current evidence base.

BACKGROUND

Several studies, conducted across the globe, have investigated prodromal and acute myocardial infarction symptoms experienced by women and suggested that fatigue is prevalent, and they have also sporadically described specific characteristics of fatigue, such as narrative descriptors and severity. However, no review specific to this acute and prodromal fatigue could be located in the literature.

DESIGN

Integrative review, guided by Whittemore and Knafl's approach and the Theory of Unpleasant Symptoms.

METHODS

We used a comprehensive, systematic approach to searching, screening, selecting, evaluating and analysing the records. Data were collected in February 2017.

RESULTS

Twenty-one articles were included in the review, including nine quantitative, six qualitative and six mixed-methods studies, with the majority (14) published in the USA. The average age of participants across the studies was the early 60s. Distress, quality, intensity and timing of prodromal myocardial infarction fatigue were more completely described in the literature than acute myocardial infarction fatigue.

CONCLUSIONS

Fatigue is the most common prodromal myocardial infarction symptom experienced by women and is also a common acute symptom. Additional research exploring prodromal and acute myocardial infarction fatigue is necessary.

RELEVANCE TO CLINICAL PRACTICE

As healthcare professionals work with women across the healthcare spectrum, recognising fatigue as an important potential myocardial infarction symptom is essential. Not only can women be educated about this symptom and other possible myocardial infarction symptoms, but clinicians can consider fatigue as an important symptom in a constellation of factors when evaluating women's health and the potential for coronary disease and myocardial infarction.

Impact of Prodromal Symptoms on Future Adverse Cardiac-Related Events: A Systematic Review

BACKGROUND

Recognition of specific and nonspecific cardiac-related prodromal symptoms, indicative of myocardial ischemia, is critical for preemptive coronary heart disease (CHD) screening and effective diagnosis and treatment. In this systematic review, we examined whether prodromal symptoms were predictive of acute symptom presentations, cardiac events, or treatment interventions.

METHODS

Studies that measured the association of prodromal symptoms with acute coronary syndrome (ACS) symptom presentation, acute cardiac event, and/or intervention in men and/or women with confirmed CHD were included.

DATA SOURCES

Electronic searches in the Cochrane Library, MEDLINE, PubMed, PsyhINFO, Embase, CINAHL, and Scopus databases from 1990 to 2013 were conducted using medical subject heading terms including prodromal symptoms, ACS, acute myocardial infarction, unstable angina, and CHD. Key words such as shortness of breath, anxiety, atypical pain, sleep disturbance, fatigue, and nausea/vomiting were also used. Abstracts, relevant journals, key authors, and reference lists were reviewed.

RESULTS

Seven studies that included 6716 individuals with prodromal symptoms (65.7% women). Mean age was 68 ± 13 and 58.5 ± 9 years for women and men, respectively. Cardiac-related prodromal symptoms were predictive of patients' ACS-related symptoms and associated events from 3 to 24 months. Across studies, the prodromal symptoms consistently reported before cardiac event were chest discomfort/pain (n = 4, 57%), arm pain/discomfort (n = 6, 86%), jaw pain (n = 3, 43%), back/shoulder blade pain (n = 3, 43%), unusual fatigue (n = 7, 100%), shortness of breath (n = 6, 86%), sleep disturbance (n = 2, 29%), dizziness (n = 3, 43%), headache (n = 3, 43%), anxiety (n = 7, 100%), and gastrointestinal complaints (nausea, vomiting, indigestion; n = 5, 71%). Patients with prodromal arm, jaw, and back pain; fatigue; and shortness of breath had increased risk of experiencing similar symptoms during an ACS episode. Prodromal symptoms were predictive of adverse cardiac events and cardiac interventions. There is some preliminary evidence to suggest that prodromal symptoms of headache, sleep disturbance, and anxiety may predict ACS symptom presentation during an acute cardiac event.

CONCLUSION

Future research is warranted that would examine prospectively the predictive value of prodromal headache, sleep disturbance, and anxiety within this cardiovascular population on major adverse cardiac events. Preemptive screening for cardiac-related prodromal symptoms in men and women should be considered as a standard in clinical practice. This may potentiate early diagnosis, effective risk modification, timely pain management, and treatment intervention and decrease CHD-related morbidity and mortality.

Prevalence of acute and prodromal myocardial infarctions symptoms in adult women with confirmed diagnoses: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The purpose of this review is to systematically review literature to determine the period of prevalence of prodromal and acute symptoms experienced by adult women diagnosed with an acute myocardial infarction (AMI).More specifically, the objective of this descriptive review is to assess the prevalence and describe the distribution of prodromal and acute symptoms experienced by adult women during an AMI event, evident in documented literature between 1994 and the present date.The specific question for this review is: how common and how are prodromal and acute symptoms of an AMI distributed in adult women diagnosed with an AMI?

CENTER CONDUCTING THE REVIEW

University of Victoria and the Queen's Joanna Briggs Collaboration for Patient Safety: a Collaborating Centre of the Joanna Briggs Institute.

Can Anyone Hear Me? Does Anyone See Me? A Qualitative Meta-Analysis of Women's Experiences of Heart Disease

Female heart patients are underdiagnosed and undertreated. The purpose of this qualitative meta-data-analysis was to explain how societal expectations related to gender and the treatment environment influence women's experiences and can inform optimal care. The authors used grounded theory methodology and a social constructionist gender lens to analyze 43 studies (1993-2012) of women's experiences of heart disease. The analysis illustrates how social expectations within both medical and relational contexts led to women experiencing barriers to diagnosis and treatment and inadvertent minimization of their experience and knowledge. Women's descriptions of their experiences suggest three kinds of health care strategies that have the potential to increase women's engagement with heart disease treatment and rehabilitation: (a) support give and take in relational connections, (b) identify and acknowledge unique health-promoting behavior, and (c) focus on empowerment. These findings have interdisciplinary implications for practice with women with heart disease.

Symptom recognition and healthcare experiences of young women with acute myocardial infarction

BACKGROUND

Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ≤55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population.

METHODS AND RESULTS

We conducted a qualitative study using in-depth interviews with 30 women (aged 30-55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease.

CONCLUSIONS

Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women's elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

The experience of younger adults following myocardial infarction

The aim of this study was to elucidate the meaning of the experience of younger people (< 55 years) during their first year following a myocardial infarction. We analyzed 17 interviews using a phenomenological-hermeneutic method. The core theme and central phenomenon was the everyday fight to redress the balance in life, which encompassed an existential, physical, and emotional battle to regain a foothold in daily life. The aftermath of a life-threatening event involved a process of transition while at the same time creating a new meaning in life. Lack of energy and its impact on the complex interplay of midlife combined with unreasonable demands from employers and health care professionals seemed to color the experience of the informants. The knowledge gained in this study can constitute a valuable contribution to overall quality assurance in nursing care and the development of nursing interventions for the cardiac rehabilitation of younger patients.

Gendered symptom presentation in acute coronary syndrome: a cross sectional analysis

BACKGROUND

The international literature suggests that the symptom presentation of acute coronary syndrome may be different for men and women, yet no definitive conclusion about the existence of gendered presentation in ACS has been provided.

OBJECTIVE

This study examines whether gendered symptom presentation exists in a well-defined sample of men and women with ACS.

DESIGN AND SETTING

A cross-sectional analysis of baseline data pertaining to symptom experience and medical profiles were recorded for all ACS patients who participated in a multi-centered randomized control trial, in 5 hospitals, in Dublin, Ireland.

PARTICIPANTS

: Patients were deemed eligible if they were admitted through the Emergency Department (ED) with a diagnosis of ACS, if they were at least 21 years of age and able to read and converse in English. Patients were excluded if they had serious co-morbidities, cognitive, hearing or vision impairment.

METHODS

Patients were interviewed 2-4 days following their ACS event and data was gathered using the ACS response to symptom index.

RESULTS

The study included 1947 patients of whom 28% (n=545) were women. Chest pain was the most commonly experienced symptom in men and women, reported by 71% of patients. Using logistic regression and adjusting for clinical and demographic variables, women had greater odds of experiencing shortness of breath (50% vs 43%; odds ratio [OR]=1.32; 95% CI=1.08-1.62; p=.006) palpitations (5.5% vs 2.8%; OR=2.17; CI=1.31-3.62; p=.003) left arm pain (34% vs 30.5%; OR=1.27; CI=1.02-1.58; p=.03) back pain (7.5% vs 4.8%; OR=1.56; CI=1.03-2.37; p=.034) neck or jaw pain (21.5% vs 13.8%; OR=1.84; CI=1.41-2.40; p=.001) nausea (28% vs 24%; OR=1.30; CI=1.03-1.65; p=.024) a sense of dread (13.4% vs 10.5%; OR=1.47; CI=1.08-2.00; p=.014) and fatigue (29% vs 21.5%; OR=1.64; CI=1.29-2.07; p=.001) than their male counterparts.

CONCLUSIONS

Although chest pain is the most commonly experienced symptom by men and women, other ACS symptomology may differ significantly between genders.

Impact of prodromal symptoms on prehospital delay in patients with first-time acute myocardial infarction in Korea

BACKGROUND

Information is limited concerning how affected individuals respond to early warning signs before their acute coronary event and how the presence of prodromal symptoms impacts prehospital delay.

OBJECTIVES

This study's aim was to identify the characteristics and interpretation of prodromal symptoms in patients with a first-time acute myocardial infarction (AMI) and to determine whether the presence of prodromal symptoms was predictive of prehospital delay.

SUBJECTS AND METHODS

This was a descriptive study using semistructured interview. A total of 271 hospitalized patients diagnosed as having AMI were interviewed from November 2007 to December 2008 at a university hospital in Korea. Patients were queried regarding whether they noticed a most troubling prodromal symptom prior to their acute cardiac event and how they responded to the symptom.

RESULTS

Men (53.0%) and women (54.2%) experienced prodromal symptoms. Patients who reported prodromal symptoms were more likely to be older and to have no chest pain upon hospitalization than those with no prodromes. Many patients did not generally recognize the importance of their warning symptoms; only about 40% visited a clinic in response to any prodromal symptom. Logistic regression analyses revealed that the presence of prodromal symptoms was an independent predictor affecting prehospital delay of more than 3 hours and more than 12 hours.

CONCLUSIONS

Recognizing prodromal symptoms as needing attention could be a trigger for patients to seek medical help earlier. Educational strategies should focus on improving awareness of prodromal symptoms of AMI, particularly in those with a family history or at high risk for cardiovascular disease.

Gender differences in fatigue associated with acute myocardial infarction

INTRODUCTION

Fatigue is a symptom of acute myocardial infarction (AMI); however, few studies have characterized the fatigue associated with AMI in men and women.

METHODS

The convenience sample included 88 men and 28 women admitted with a diagnosis of AMI at 6 Midwestern facilities. Data were collected upon hospital admission and 30 days after discharge. A total of 37 men and 10 women responded to the 30-day questionnaires. The Profile of Mood States Fatigue (POMS-F) subscale was used to measure fatigue and the Depression-Dejection subscale to measure depressed mood.

RESULTS

At baseline, significant gender differences were found, with women more likely to have higher POMS-F scores (15.80, SD = 7.33) than men (11.19, SD = 7.04, P = .004). Significant gender differences were also found at 30 days (t = 2.40, df = 45, P = .02). POMS-F scores for women were higher at baseline, with decreased fatigue levels 30 days after discharge (t = 5.36, df = 9, P < or = .05). No differences were found in POMS-F scores for men (t = 1.26, df = 36, P = .213) between baseline and 30 days after discharge. Fatigue was associated with depressed mood and gender at baseline (R(2) = 0.48, P < .05) and 30 days after discharge (R(2) = 0.308, P < .05).

CONCLUSIONS

In this sample, fatigue at baseline and at 30 days after discharge was associated with gender and depressed mood. Women reported high levels of fatigue with AMI and lower fatigue after discharge. Men reported moderate to high fatigue levels, which did not change over time. Further research is needed to discern fatigue patterns before and after AMI.

Classifying subgroups of patients with symptoms of acute coronary syndromes: A cluster analysis

The purpose of the study was to identify subgroups of patients presenting with acute coronary syndromes based on symptom clusters. Two hundred fifty-six patients completed a symptom assessment in their hospital rooms. Latent class cluster analysis and analysis of variance were used to classify subgroups of patients according to selected clinical characteristics. Four subgroups were identified and labeled as Heavy Symptom Burden, Chest Pain Only, Sweating and Weak, and Short of Breath and Weak (model fit χ(2) [130,891, n = 256] = 867.5, p = 1.00). The largest group of patients experienced classic symptoms of chest pain and shortness of breath but not sweating. Younger patients were more likely to cluster in the Heavy Symptom Burden group (F = 5.08, p = .002). Interpretation of the clinical significance of these groupings requires further study.

Cluster analysis of women's prodromal and acute myocardial infarction symptoms by race and other characteristics

BACKGROUND AND OBJECTIVE

Although research has identified women's prodromal and acute myocardial infarction (MI) symptoms, diagnosing coronary heart disease in women remains challenging. Knowing how individual symptoms cluster by race and other characteristics would provide key diagnostic information. We performed a secondary analysis to: (a) generate naturally occurring symptom clusters based on prodromal and acute MI symptom scores separately, (b) examine the association between women's characteristics and symptom clusters, and (c) describe the percentage of women who reported experiencing the same symptoms in both prodromal and acute MI phases.

SUBJECT AND METHODS

The database contained retrospective self-reported data obtained by telephone survey from 1270 women (43% black, 42% white, 15% Hispanic) with a confirmed MI recruited from 15 geographically diverse sites. Data included frequency and severity of 33 prodromal symptoms, intensity of 37 acute MI symptoms, and comorbidities/risk factors. We used both bivariate and multivariate analyses to examine associations between cluster assignment and characteristics/risk factors. Because of the possibility of complex interactions, we explored nonlinear interactions with recursive partitioning.

RESULTS

Cluster analysis yielded 3 naturally occurring clusters for each of the prodromal and acute symptom sets. Each cluster contained women who reported increasing frequency and severity of symptoms. Six characteristics (age, race, body mass index, personal history of heart disease, diabetes, smoking status) were strongly associated with the clusters. Body mass index was the most important factor in classifying prodromal symptoms, whereas age was for acute symptoms.

CONCLUSIONS

Black women younger than 50 years were more likely to report frequent and intense prodromal symptoms, whereas older white women reported the least. Younger, obese, diabetic black women reported the most acute symptoms, whereas older nonobese, nondiabetic white women reported the fewest. Symptom clusters and characteristics of women in these clusters provide valuable diagnostic information. Further research with a control group is needed.

Psychometric properties of three instruments to measure fatigue with myocardial infarction

The purpose of this study was to evaluate the psychometric properties of three questionnaires to measure fatigue with myocardial infarction. The Fatigue Symptom Inventory Interference Scale, Profile of Moods States Fatigue subscale (POMS-F), and Short Form 36 (SF-36) Vitality Scale were completed during hospitalization (n = 116) and 30 days after hospital admission (n = 49). Moderate to strong correlations were found among each of these fatigue scales and between each fatigue scale and measures of other variables to include vigor, depressed mood, anxiety, and physical functioning. POMS-F scores decreased significantly at Time 2, but this decline in fatigue was not validated on the other fatigue scales. Patients' Time 1 scores reflected significantly more fatigue compared to published scores for healthy adults. The ability to discriminate between groups suggests that the instruments may be useful for identifying patients with cardiovascular risk factors who report clinically significant fatigue.

Early warning signs of an acute myocardial infarction and their influence on symptoms during the acute phase, with comparisons by gender

BACKGROUND

Identifying early warning signs of an acute myocardial infarction (AMI) may aid in the early diagnosis of coronary artery disease.

OBJECTIVES

This study was conducted to assess early warning signs (prodromal symptoms) of AMI, with comparisons made by gender. Another aim was to determine whether these early warning signs had any influence on the patients' acute symptoms of AMI.

METHODS

This was a multicenter, cross-sectional study of Norwegian patients (aged <or=75 years) hospitalized with their first AMI. A self-administered questionnaire was used to gather information on prodromal symptoms, defined as pain in the chest, pain in the shoulder or back, radiating pain or numbness in the arms, dyspnea, and fatigue. Symptoms were reported for the year before AMI and during the acute stage. Logistic regression analyses were used to examine the association between prodromal symptoms and acute symptoms and the effect of medical history (hypertension, diabetes, and hypercholesterolemia).

RESULTS

The self-administered questionnaire had a 72% response rate; the study included 149 women and 384 men diagnosed with first-time AMI. Symptoms occurring during the year before AMI included pain in the chest in 45% (240/533), shoulder or back pain in 51% (270/533), arm pain in 38% (205/533), dyspnea in 33% (176/533), and fatigue in 62% (330/533). There were no statistically significant gender differences. The risk of experiencing chest symptoms in the acute phase was >5 times higher in women who had experienced prodromal symptoms in the chest (adjusted odds ratio [OR] = 5.11; 95% CI, 1.38-18.88) and nearly 3 times higher in men (OR = 2.80; 95% CI, 1.17-6.70). The risk of experiencing shoulder or back pain was almost 5 times higher in men with prodromal shoulder or back pain (OR = 4.96; 95% CI, 3.01-8.19), but no statistically significant association was found in women. The risk of experiencing radiating arm pain or numbness in the acute phase was more than doubled in women with prodromal arm pain (OR = 2.68; 95% CI, 1.19-6.20) and more than tripled in men with prodromal arm pain (OR = 3.11; 95% CI, 1.90-5.07). The risk of experiencing dyspnea in the acute phase was more than doubled in women with prodromal dyspnea (OR = 2.67; 95% CI, 1.25-5.71) and >5 times higher in men with prodromal dyspnea (OR = 5.73; 95% CI, 3.42-9.62). Finally, the risk of fatigue was almost tripled in women (OR = 2.97; 95% CI, 1.28-6.85) and more than doubled in men (OR = 2.51; 95% CI, 1.54-4.11). Hypertensive women, but not men, were less likely to experience chest symptoms in the acute phase (OR = 0.29; 95% CI, 0.10-0.82).

CONCLUSIONS

Almost half of the study patients (45%) experienced prodromal chest symptoms the year before their first AMI. These prodromal symptoms predicted the symptoms that occurred during the acute stage of AMI, with some differences between the sexes.

Racial differences in women's prodromal and acute symptoms of myocardial infarction

BACKGROUND

Minority women, especially black and Hispanic women, have higher rates of coronary heart disease and resulting disability and death than do white women. A lack of knowledge of minority women's symptoms of coronary heart disease may contribute to these disparities.

OBJECTIVE

To compare black, Hispanic, and white women's prodromal and acute symptoms of myocardial infarction.

METHODS

In total, 545 black, 539 white, and 186 Hispanic women without cognitive impairment at 15 sites were retrospectively surveyed by telephone after myocardial infarction. With general linear models and controls for cardiovascular risk factors, symptom severity and frequency were compared among racial groups. Logistic regression models were used to examine individual prodromal or acute symptoms by race, with adjustments for cardiovascular risk factors.

RESULTS

Among the women, 96% reported prodromal symptoms. Unusual fatigue (73%) and sleep disturbance (50%) were the most frequent. Eighteen symptoms differed significantly by race (P<.01); blacks reported higher frequencies of 10 symptoms than did Hispanics or whites. Thirty-six percent reported prodromal chest discomfort; Hispanics reported more pain/discomfort symptoms than did black or white women. Minority women reported more acute symptoms (P < .01). The most frequent symptom, regardless of race, was shortness of breath (63%); 22 symptoms differed by race (P <.01). In total, 28% of Hispanic, 38% of black, and 42% of white women reported no chest pain/discomfort.

CONCLUSIONS

Prodromal and acute symptoms of myocardial infarction differed significantly according to race. Racial descriptions of women's prodromal and acute symptoms should assist providers in interpreting women's symptoms.

Sex differences in patients seeking medical attention for prodromal symptoms before an acute coronary event

BACKGROUND

Patients with acute coronary syndromes (ACS) may experience nonspecific prodromal symptoms before their cardiac event. We used population-level data to determine the rate at which such patients seek medical attention for these symptoms, whether sex differences are present, and if an association between prodromes and 1-year mortality exists.

METHODS

All patients with ACS in Alberta, Canada, between April 1, 1999, and March 31, 2001, were included. Prodromes reported during all physician visits in the 90 days before ACS presentation consisted of (1) pain (chest, arm, shoulder, neck, jaw, throat, or leg); (2) anxiety/fatigue; (3) gastrointestinal disturbances; (4) head-related conditions (dizziness, headache, visual disturbances); and (5) other (sweating, shortness of breath, heart racing, cough, numbness).

RESULTS

Of 14,230 patients with ACS, 2,268 (15.9%, 45.6% women) sought medical attention for at least one prodrome, with pain and anxiety/fatigue most common. Prodromes were associated with increased cardiac investigations before ACS in both sexes. After adjustment for baseline characteristics, a significant interaction between sex and prodromes was found (P [interaction] = .011). Prodromes were associated with improved 1-year survival in women (adjusted hazard ratio [HR] 0.74, 95% CI 0.58-0.95, P = .016, risk-adjusted mortality 8.7% vs 11.1% [without prodromes], P < .001) but not in men (adjusted hazard ratio 0.92, 95% CI 0.76-1.12, P = .422, 9.9% [with prodromes] vs 9.1% [without prodromes], P = .358).

CONCLUSIONS

A small proportion of patients with ACS seek medical attention for prodromal symptoms in the 90 days before ACS. Seeking help for these symptoms is associated with improved survival in women but not in men.

The association of diabetes and older age with the absence of chest pain during acute coronary syndromes

Cardiac autonomic neuropathy associated with diabetes can cause silent myocardial ischemia and may influence the way that patients perceive symptoms of acute coronary syndromes (ACS). The purpose of this study was to examine symptoms of ACS in patients with and without diabetes while controlling for length of time with diabetes. A convenience sample of 256 patients from two large medical centers in the Midwest participated. Patients with diabetes comprised 33.2% of the sample and reported significantly less chest pain and more unusual fatigue. Patients with diabetes of longer duration (10 or more years) reported more difficulty breathing than did patients with diabetes of shorter duration (fewer than 10 years). Older patients with the same diabetes status also reported less chest pain. For older patients and for patients with diabetes, lack of chest pain during ACS could delay treatment and is thus a concern.

Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested.

Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression.

Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient’s hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured.

Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01–0.49), palpitations (β = 0.31; CI = 0.06–0.56), nausea (β = 0.37; CI = 0.10–0.65), numbness in the hands (β = 0.29; CI = 0.02–0.57), and unusual fatigue (β = 0.60; CI = 0.27–0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women.

Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear.

Response to Signs and Symptoms of Acute Coronary Syndrome: Differences Between Lebanese Men and Women

Background Signs and symptoms of acute coronary syndromes differ between men and women, but whether men and women respond differently to these indications is not well understood. Such responses influence health outcomes because success of treatment depends on how quickly healthcare is sought.

Objective To explore differences between Lebanese men and women in cognitive, emotional, and behavioral responses to signs and symptoms of acute coronary syndromes.

Methods A convenience sample of 149 men and 63 women with unstable angina or acute myocardial infarction were interviewed within 72 hours of admission to coronary care in a tertiary center by using the Response to Symptoms Questionnaire. Demographic and clinical data were obtained from medical records.

Results Women were older, less educated, and more often widowed than men. More women had hypertension but more men were current smokers. Women had shoulder pain, dyspnea, nausea and vomiting, and palpitations more often than men did. Women’s signs and symptoms were rated more severe by the women than men’s were by the men. Women were less likely to know signs and symptoms of myocardial infarction than were men and delayed coming to the hospital longer than men did. Delay correlated with the characteristics of the signs and symptoms and not realizing their importance in men and with dyspnea and taking the “wait and see” approach in women.

Conclusion Factors related to promptness in seeking care for acute coronary syndromes differ between Lebanese men and women.

Beta-blocker medication usage in older women after myocardial infarction

PURPOSE

The purpose of this study was to assess demographic characteristics of women prescribed beta-blocker (beta-blocker) medication and compare to those not using beta-blocker medication, and to determine if there are differences in depression and fatigue among women who used beta-blockers compared to nonusers 6-12 months after myocardial infarction (MI).

DATA SOURCES

This was a descriptive cross-sectional study of 84 women (61 using beta-blockers and 23 not using beta-blockers) aged 65 and older who were 6-12 months post-MI. Women had their height and weight measured and completed a Demographic Health Form, the Geriatric Depression Scale, and the Revised Piper Fatigue Scale (RPFS).

CONCLUSIONS

While most of the women were taking beta-blockers after MI (74%), significantly fewer Black women were taking beta-blockers (chi(2) = 5.086, p = 0.032). Most of the beta-blocker users were overweight or obese. There were no significant differences in age, t(82) = 0.7, p = 0.486; body mass index, t(82) = 0.76, p = 0.445; income, chi(2)(df = 2) = 3.219, p = 0.075; mean depression, t(82) = 1.648, p = 0.103; or fatigue scores, t(82) = 0.993, p = 0.324, between beta-blocker users and nonusers. More of those not taking beta-blockers reported fatigue with significantly higher fatigue in the affective meaning dimension of the RPFS, t(82) = 2.272, p = 0.03.

IMPLICATIONS FOR PRACTICE

beta-Blocker medication continues to be underutilized in older women. Because no difference was noted in fatigue and depression in the two groups, these may mean that these side effects are not barriers in prescribing this medication post-MI. Nurse practitioners are in pivotal positions to monitor the ongoing physiological and psychological sequelae post-MI and implement interventions to improve their outcomes.

Differences Between Men and Women in Terms of Clinical Features of ST-Segment Elevation Acute Myocardial Infarction

BACKGROUND

Many studies have examined sex-related differences in the clinical features of acute myocardial infarction (AMI). However, prospective studies are scant, and sex-related differences in symptoms of AMI remain unclear. We examined differences between men and women in terms of the clinical features of ST-segment elevation AMI.

METHODS AND RESULTS

We studied 457 patients (106 women and 351 men) with ST-segment elevation AMI who were admitted within 24 h after symptom onset. The same cardiologist interviewed all patients within 48 h after admission. Women were older than men (72 vs 62 years, p<0.001) and had higher rates of hypertension (70 vs 56%, p=0.010), diabetes mellitus (36 vs 26%, p=0.047), and hyperlipidemia (51 vs 38%, p=0.019). Women were more likely than men to have non-specific symptoms (45 vs 34%, p=0.033), non-chest pain (pain in the jaw, throat, neck, shoulder, arm, hand, and back), mild pain (20 vs 7%, p<0.001), and nausea (49 vs 36%, p=0.013). On coronary angiography, the severity of coronary-artery lesions was similar in both sexes. In-hospital mortality was significantly higher in women than in men (6.6 vs 1.4%, p=0.003).

CONCLUSIONS

Clinical profiles and presentations differ between women and men with AMI. Women have less typical symptoms of AMI than men.

Black, Hispanic, and White women's knowledge of the symptoms of acute myocardial infarction

OBJECTIVE

To examine Black, Hispanic, and White women's knowledge of the symptoms of acute myocardial infarction.

DESIGN

Descriptive, nonexperimental design.

SETTING

Detroit, Michigan, and San Antonio, Texas, metropolitan areas.

PARTICIPANTS

A convenience sample of 78 ethnically diverse women. Hispanics (n = 26) were recruited from San Antonio, Texas; Blacks (n = 26) were recruited from Detroit, Michigan; and Whites were recruited from San Antonio, Texas (n = 13), and Detroit, Michigan (n = 13).

MAIN OUTCOME MEASURES

Participants ranked 10 acute symptoms they believed represented a myocardial infarction: anxiety, arms ache, change in thinking, chest pain, cough, fatigue, decreased appetite, headache, indigestion, and shortness of breath. Next, participants assigned a likelihood score for each acute symptom as representing a myocardial infarction.

RESULTS

Hispanic women were more likely than Black women to perceive the symptom of headache as indicative of a myocardial infarction. Women older than age 45 were more likely to assign a higher likelihood score to the symptom of shortness of breath than were women age 45 or younger.

CONCLUSIONS

Age and ethnic differences were noted in women's perception of the signs and symptoms indicative of a myocardial infarction.

Chest pain and associated symptoms of acute coronary syndromes

Coronary heart disease is the primary health risk for all Americans. Acute coronary syndromes (ACS) is the term used to denote any 1 of 3 clinical manifestations of coronary heart disease: unstable angina, non-ST elevation myocardial infarction, and ST-elevation MI. The major challenge to healthcare providers is the rapid and accurate identification of patients with ACS who would benefit from immediate thrombolysis or percutaneous coronary interventions. The purpose of this article is to describe the incidence, causes, risk factors, assessment, and diagnosis of patients presenting with ACS as well as current recommendations for nurses who treat patients with ACS.

Women, men and coronary heart disease: a review of the qualitative literature

AIM

This paper presents a review of the qualitative literature which examines the experiences of patients with coronary heart disease. The paper also assesses whether the experiences of both female and male patients are reflected in the literature and summarizes key themes.

BACKGROUND

Understanding patients' experiences of their illness is important for coronary heart disease prevention and education. Qualitative methods are particularly suited to eliciting patients' detailed understandings and perceptions of illness. As much previous research has been 'gender neutral', this review pays particular attention to gender.

METHODS

Published papers from 60 qualitative studies were identified for the review through searches in MEDLINE, EMBASE, CINAHL, PREMEDLINE, PsychINFO, Social Sciences Citation Index and Web of Science using keywords related to coronary heart disease.

FINDINGS

Early qualitative studies of patients with coronary heart disease were conducted almost exclusively with men, and tended to generalize from 'male' experience to 'human' experience. By the late 1990s this pattern had changed, with the majority of studies including women and many being conducted with solely female samples. However, many studies that include both male and female coronary heart disease patients still do not have a specific gender focus. Key themes in the literature include interpreting symptoms and seeking help, belief about coronary 'candidates' and relationships with health professionals. The influence of social roles is important: many female patients have difficulties reconciling family responsibilities and medical advice, while male patients worry about being absent from work.

CONCLUSIONS

There is a need for studies that compare the experiences of men and women. There is also an urgent need for work that takes masculinity and gender roles into account when exploring the experiences of men with coronary heart disease.

What's wrong with me? Women's coronary heart disease diagnostic experiences

Most women are unaware that that they may experience atypical coronary heart disease (CHD) symptoms. Women's atypical presentation often results in women having difficulty being diagnosed with CHD or myocardial infarction. Investigating women's CHD diagnostic experiences may reveal vital areas amenable to intervention. This secondary analysis explored women's CHD diagnostic experiences. Forty women completed in-depth interviews in their homes that were audiotaped and lasted 2-3 hours. Using content analysis and constant comparison, five themes emerged: awareness, seeking treatment, frustration, treatment decisions, and anger. Despite numerous symptoms and visits with clinicians, most women were not diagnosed with CHD before myocardial infarction. During the infarction, women with typical symptoms were easily diagnosed while those with atypical symptoms received a delayed diagnosis. Those who repeatedly sought treatment were angry about not being diagnosed earlier. Further research is needed to promote early symptom recognition, timely diagnosis, and efficacious treatment-keys to improving women's CHD outcomes and to preventing similar negative diagnostic experiences.

Women's interpretation of their coronary heart disease symptoms

BACKGROUND

Men and women are known to delay in seeking medical attention when experiencing acute cardiac symptoms. However, women are more likely to have had chronic undifferentiated symptoms prior to an acute episode and then when experiencing an acute episode delay longer than do men. Studies have shown once women do present they tend to be further along the disease trajectory than men.

AIMS

The aim of this study was to explore women's own interpretation of the presenting symptoms they experienced.

METHODS

Twenty-nine women consented to take part in semi-structured interviews that focussed on their experience of coronary heart disease (CHD). The women's narrative around the initial disruption of their illness was analysed focusing on routine and reconstructed forms of narration.

RESULTS

The results showed that many failed to recognise and act on their symptoms. Most only sought medical attention after family or friends intervened. None of the women had seen themselves at risk of developing coronary heart disease despite many have a strong family history.

CONCLUSION

The women's early symptoms of coronary heart disease were often undifferentiated and difficult to interpret by the women themselves. There is a need for further research to understand and recognise early symptoms of coronary heart disease in women. This will allow women and health professionals to assess risk and identify women with coronary heart disease early on in their disease trajectory so therapy to prevent the morbidity associated with coronary heart disease and acute life threatening episodes will be reduced.

Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms

Patients (n = 194) with confirmed acute myocardial infarction (AMI) were interviewed to determine sociodemographic, clinical, social, behavioral, cognitive and emotional factors that contribute to delay in seeking treatment for their symptoms. Initial symptom experience was similar for men and women: both were most commonly at home when symptoms began; both were most commonly in the presence of their spouse or other family member; few patients (<10%) called the emergency medical system as their first reaction. Several factors contributed similarly to delay in men and women. Factors that exerted a differential effect on delay between men and women were age, history of AMI, type of AMI (Q-wave and non-Q-wave), concerns about not wanting to trouble others, and prior knowledge of thrombolytics. There was no difference in delay between men and women (median 3.08 versus 3.10 h), but there are important gender differences in the reasons patients delay and in their patterns of decision-making that may assist clinicians trying to tailor interventions.

Accustomed to enduring: experiences of African-American women seeking care for cardiac symptoms

OBJECTIVE

Understand the meaning of delayed treatment seeking in African-American women with unstable angina and myocardial infarction.

METHODS

Phenomenologic analysis of in-depth interview data and field notes on 12 African-American women hospitalized with unstable angina or myocardial infarction.

RESULTS

Women's interpretation of and response to symptoms were informed by experiences of marginalization and their self-understanding as people who were strong and who had endured life's hardships. When hospitalized, some women experienced trivialization of their complaints by clinicians and a focus on technological procedures over respectfully attending to their concerns, which provided further disincentives to seeking care. Three major themes emerged: misrecognition and discounting of symptoms, enduring, and influence of faith.

CONCLUSIONS

Experiences of marginalization shape responses to symptoms, care-seeking behavior, and interpretation of subsequent care experiences for African-American women with cardiac disease, who may experience different symptoms as well as interpret them differently than members of other groups.

Fatigue and physical activity in older women after myocardial infarction

BACKGROUND

Within 6 years of a myocardial infarction (MI) more women (35%) than men (18%) will have another MI. Participation in physical activity is one of the most effective methods to reduce cardiac risks; however, few older women participate. One of the most frequently reported barriers to physical activity is fatigue.

OBJECTIVES

The specific aims of this study were to (1) describe factors related to fatigue in older women after MI and (2) examine the relationship of fatigue to physical activity in older women after MI.

METHODS

This descriptive correlational study examined the effects of age, body mass index, comorbidities, sleep, beta-blocker medication, depression, and social support on fatigue and physical activity in women (N = 84), ages 65 to 88 years old, 6 to 12 months post-MI. All women had their height and weight measured and completed (1) a health form on comorbidities, physical activity, and medication history; (2) the Geriatric Depression Scale; (3) the Epworth Sleepiness Scale; (4) the Revised Piper Fatigue Scale; and (5) the Social Provisions Scale.

RESULTS

The majority (67%) of the women reported fatigue that they perceived as different from fatigue before their MI. Moderately strong correlations were noted among depression, sleep, and fatigue, and multivariate analysis indicated that depression and sleep significantly accounted for 32.7% of the variance in fatigue. Although only 61% of the women reported participating in physical activity for exercise, most were meeting minimal kilocalories per week for secondary prevention. Fatigue was not significantly associated with participation in physical activity.

CONCLUSION

Describing correlates to fatigue and older women's participation in physical activity after MI are important to develop interventions targeted at increasing women's participation in physical activity, thus decreasing their risk for recurrent MIs.

Nursing Outcomes in Coronary Heart Disease

Nursing research has contributed to our knowledge of patients with coronary heart disease (CHD), although much of the research has focused on acute cardiac events. Active and ongoing programs of research into CHD patient outcomes are essential as significant gaps remain. Consistently effective strategies to help patients change risk behaviors, recognize salient symptoms, manage their CHD and ischemic symptoms, improve function and quality of life, and prevent subsequent coronary events are needed, especially in the elderly and those with multiple comorbidities.

Treatment-seeking delay among women with acute myocardial infarction: decision trajectories and their predictors

BACKGROUND

Women's delay in seeking treatment for acute myocardial infarction symptoms results in higher rates of mortality and morbidity for women.

OBJECTIVES

To describe decision trajectories used by women when experiencing symptoms of acute myocardial infarction, and to identify predictors of the decision trajectory used by women with acute myocardial infarction.

METHODS

A cross-sectional, descriptive design was used. The nonprobability sample included 52 women hospitalized for acute myocardial infarction. To elicit descriptions of decision making, focused, semistructured interviews were used in this mixed-methods study. Predictors of decision trajectories were measured with standardized instruments among the same women. Narrative analysis was used to examine the stories from the qualitative data and to identify decision trajectory types. Discriminant analysis was used to predict trajectory type membership.

RESULTS

The median delay time was 4.25 hours. Most of the women used one of two trajectory types: knowing (defined as those women who knew almost immediately that they would seek help, n = 25) and managing (those women who managed an alternative hypothesis or minimized their symptoms, n = 23). Discriminant analysis correctly classified 71% (chi [4] = 11.2; n = 48; p =.02) of the cases into trajectory types on the basis of four predictor variables: social support, personal control, heart disease threat, and neuroticism.

DISCUSSION

Women's behaviors during the period between onset of acute myocardial infarction symptoms and treatment seeking can be categorized into a small number of patterns termed decision trajectories. A profile of sociostructural and intrapersonal factors with potential for predicting behavior in relation to future coronary events was developed.

Symptoms in acute coronary syndromes: does sex make a difference?

BACKGROUND

Coronary heart disease is a major problem in both men and women, but several studies have shown sex differences in symptoms of acute coronary syndromes (ACS). Some findings, however, have been disparate and inadequate, and thus a comprehensive overview of this literature would be of value.

METHOD

Fifteen studies that identified symptoms of ACS for both women and men were examined through a review of the literature from 1989 to 2002. Terms used for the search included "myocardial infarction," "symptoms," "gender differences," and "acute coronary syndromes."

RESULTS

Although chest pain was the most common symptom in both men and women, several differences were also noted. In all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain and nausea and/or vomiting, dyspnea, palpitations, indigestion, dizziness, fatigue, loss of appetite, and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. The designs and methodologies of the studies varied considerably.

CONCLUSION

In addition to the typical symptom of chest pain in ACS, women experience other atypical symptoms more frequently than men. Thus, there may be sex differences in the symptoms of ACS, differences that have a bearing not only on clinical practice, but also on the interpretation of available clinical studies and the design of future investigations.

Women with coronary artery disease report worse health-related quality of life outcomes compared to men

BACKGROUND

Although there have been substantial medical advances that improve the outcomes following cardiac ischemic events, gender differences in the treatment and course of recovery for patients with coronary artery disease (CAD) continue to exist. There is a general paucity of data comparing the health related quality of life (HRQOL) in men and women undergoing treatment for CAD. The purpose of this study was to compare HRQOL outcomes of men and women in Alberta, at one-year following initial catheterization, after adjustment for known demographic, co-morbid, and disease severity predictors of outcome.

METHOD

The HRQOL outcome data were collected by means of a self-reported questionnaire mailed to patients on or near the one-year anniversary of their initial cardiac catheterization. Using the Seattle Angina Questionnaire (SAQ), 5 dimensions of HRQOL were measured: exertional capacity, anginal stability, anginal frequency, quality of life and treatment satisfaction. Data from the APPROACH registry were used to risk-adjust the SAQ scale scores. Two analytical strategies were used including general least squares linear modeling, and proportional odds modeling sometimes referred to as the "ordinal logistic modeling".

RESULTS

3392 (78.1%) patients responded to the follow-up survey. The adjusted proportional odds ratios for men relative to women (PORs > 1 = better) indicated that men reported significantly better HRQOL on all 5 SAQ dimensions as compared to women. (PORs: Exertional Capacity 3.38 (2.75-4.15), Anginal Stability 1.23 (1.03-1.47), Anginal Frequency 1.70 (1.43-2.01), Treatment Satisfaction 1.27 (1.07-1.50), and QOL 1.74 (1.48-2.04).

CONCLUSIONS

Women with CAD consistently reported worse HRQOL at one year follow-up compared to men. These findings underline the fact that conclusions based on research performed on men with CAD may not be valid for women and that more gender-related research is needed. Future studies are needed to further examine gender differences in psychosocial adjustment following treatment for CAD, as adjustment for traditional clinical variables fails to explain sex differences in health related quality of life outcomes.

Development of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey

BACKGROUND/OBJECTIVES

Coronary heart disease (CHD) is the number one cause of death in women, yet, little is known about women's symptoms. Early symptom recognition of CHD in women is essential but most instruments do not assess both prodromal and acute CHD symptoms. Our aims were to develop an instrument validly describing women's prodromal and acute symptoms of myocardial infarction and to establish reliability of the instrument, the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS).

METHODS

Four studies contributed to the content validity and reliability of this instrument. Two qualitative studies provided the list of symptoms that were confirmed in study 3. The resulting instrument assesses 37 acute and 33 prodromal symptoms. In study 4, 90 women were retested 7 to 14 days after their initial survey. We used the kappa statistic to assess agreement across administrations.

RESULTS

The women added no new symptoms to the MAPMISS. The average kappa of acute symptoms was 0.52 and 0.49 for prodromal. Next we calculated a weighted score. The mean acute score for time 1 was 19.4 (SD = 14.43); time 2 was 12.4 (SD= 8.79) with Pearson correlation indicating stability (r = .84; P < .01). The mean prodromal score at time 1 was 23.80 (SD= 24.24); time 2 was 26.79 (SD = 30.52) with a Pearson correlation of r = .72; P < .01.

CONCLUSIONS

The tool is comprehensive, has high content validity, and acceptable test-retest reliability. Low kappas were related to few women having those symptoms. The symptom scores remained stable across administrations.