Meta-analytic evaluation of gender differences and symptom measurement strategies in acute coronary syndromes

Women Acute Myocardial Infarction-Identifying and Understanding the Gender Gap (WAMy-GAP): A Study Protocol

Barriers to accessing care and misinterpretations of ischemic heart disease symptoms due to lack of awareness contribute to women's delay in seeking care. Women may delay seeking treatment for up to 3 h or even up to 5 days. They often perceive themselves to be at low risk of cardiovascular disease (CVD) and prioritize family responsibilities or household chores. The causes of this delay are multifactorial and influence the decision-making process, particularly in the pre-hospital phase. The objective of this study protocol is to evaluate prodromal symptoms and identify risk behaviors in women with acute myocardial infarction (AMI). This is a protocol for a multicenter study that will be conducted using the mixed-method methodology using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) to evaluate symptoms and semi-structured interviews to investigate behaviors. This study protocol is intended to fill an important knowledge gap on premonitory and acute symptoms of AMI in women in Italy, as well as to understand the causes and mechanisms underlying delays in accessing healthcare services during an acute event such as AMI. The investigation of this issue will facilitate the removal of gender-related inequalities in the diagnosis and treatment of acute myocardial infarction while also fostering dialogue on the barriers to behavior change.

Impact of COVID-19 Pandemic on Sex and Racial Disparities in Chest Pain Presentation and Management Through the Emergency Department

Background

Sex and racial disparities in the presentation and management of chest pain persist, however, the impact of coronavirus disease 2019 (COVID-19) on these disparities have not been studied. We sought to determine whether the COVID-19 pandemic contributed to pre-existing sex and racial disparities in the presentation, management, and outcomes of patients presenting to the emergency department (ED) with chest pain.

Methods

We conducted an observational cohort study with retrospective data collection of patients between January 1, 2016, and May 1, 2022. This was a single study conducted at a quaternary academic medical center of all patients who presented to the ED with a complaint of chest pain or chest pain equivalent symptoms. Patient were further segregated into different groups based on sex (male, female), race, ethnicity (Asian, Black, Hispanic, White, and other), and age (18 - 40, 41 - 65, > 65). We compared diagnostic evaluations, treatment decisions, and outcomes during prespecified time points before, during, and after the COVID-19 pandemic.

Results

This study included 95,764 chest pain encounters. Total chest pain presentations to the ED fell about 38% during the early pandemic months. Females presented significantly less than males during initial COVID-19 (48% vs. 52%, P < 0.001) and Asian females were least likely to present. There was an increase in the total number of troponins and echocardiograms ordered during peak COVID-19 across both sexes, but females were still less likely to have these tests ordered across all timepoints. The number of coronary angiograms did not increase during peak COVID-19, and females were less likely to undergo coronary angiogram during all timepoints. Finally, females with chest pain were less likely to be diagnosed with acute myocardial infarction (AMI) during all timepoints, while in-hospital deaths were similar between males and females during all timepoints.

Conclusions

During COVID-19, females, especially Asian females, were less likely to present to the ED for chest pain. Non-White patients were less likely to present to the ED compared to White patients prior to and during the pandemic. Disparities in management and outcomes of chest pain encounters remained similar to pre-COVID-19, with females receiving less cardiac workup and AMI diagnoses than males, but in-hospital mortality remaining similar between groups and timepoints.

The role of sex and gender in somatic complaints among patients with coronary heart disease: A longitudinal study on acute and long-term changes

BACKGROUND

Somatic complaints are persistently reported in patients with coronary heart disease (CHD). Sex and gender influence health and well-being in a variety of ways, but it is unknown how they affect somatic complaints over time after percutaneous coronary intervention (PCI). Therefore, we examined the association between sex and gender on somatic health complaints during the first month (acute) and the first two years (recovery) after PCI.

METHODS

514 patients (Mage = 64.2 ± 8.9, 84.2% male) completed the somatic scale of the Health Complaints Scale (including the subscales: cardiopulmonary complaints, fatigue, sleep problems) at baseline, one, 12-, and 24-months post-PCI. In a follow-up study, they filled in additional questionnaires to gauge gender norms, traits, and identity. Linear mixed modeling analyses were used to assess the influence of sex, gender, their interaction, and covariates on somatic complaints for the acute and recovery phases separately.

RESULTS

A general decline in somatic complaints over time was observed during the acute phase, followed by a stabilization in the recovery phase. Females and individuals with more feminine traits, norms, and identities reported increased somatic complaints. Males with more pronounced feminine norms and females with more masculine norms likewise reported more somatic, cardiopulmonary, and fatigue complaints. Furthermore, age, cardiac history, and comorbid diseases partly explained the associations with somatic complaints.

CONCLUSION

While somatic complaints improve post-PCI, there are still conspicuous sex and gender differences that need to be considered. Future research should further elaborate upon these discrepancies and incorporate sex and gender in prevention and develop tailored interventions to diminish somatic complaints.

Just Like a Woman: Gender Role Stereotypes in Forensic Psychiatry

The relationship between violence, gender and mental health is a complex one which is yet to be fully understood. Gender role stereotypes are social constructs that can powerfully influence and regulate human behaviour, including violence; and so it is likely that they also influence the nexus of violence management and mental health which is at the core of forensic psychiatry. In this article, we examine how gender role stereotypes might influence the practice of forensic psychiatry: specifically, in relation to women as violent offenders, as patients in secure psychiatric care and as clinicians working in forensic settings. We identify areas of development in women's forensic mental health services, and examine whether patriarchal influences and gender role stereotypes may have inadvertently impacted upon these changes. We also consider whether these changes may maintain pre-existing barriers to treatment for both men and women.

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

OBJECTIVES

Gender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

We analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03-6.03 years).

RESULTS

There were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p < 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p < 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders.

CONCLUSIONS

Females were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.

Characteristic differences of chest pain in male and female patients with acute coronary syndrome: A pilot study

Background: The typical sign or main symptom in acute coronary syndrome (ACS) patients is chest pain, which is an initial benchmark or early sign for diagnosis. Certain factors, such as gender differences, the presence of diabetes mellitus or other clinical conditions, may make the patient not realize they have ACS. Therefore, this study aims to identify the characteristics of chest pain symptoms in male and female patients with ACS.

Design and Methods: This is a non-experimental quantitative study, namely analytical observation using a cross-sectional approach within 4 months (January-April 2019). Furthermore, the samples were 53 ACS patients (28 male and 25 female).

Results: The chest pain characteristics that have a significant relationship with gender differences in ACS patients are shown based on the aspects of location, pain duration and quality. Male patients are more likely to feel pain at the left or middle chest, the duration is between <20 to >20 min with moderate pain quality, which tends to become severe, while females are more likely to feel pain at the chest which radiates to the neck and chin, the duration is usually >20 min, with mild to moderate pain quality.

Conclusions: The result showed a significant difference in chest pain characteristics in male and female patients with ACS. Regarding location, duration and quality of chest pain, male ACS patients mostly have more typical symptoms, while females’ symptoms are atypical.

A feasibility study for CODE-MI: High-sensitivity cardiac troponin-Optimizing the diagnosis of acute myocardial infarction/injury in women

BACKGROUND

CODE-MI is a pan-Canadian, multicentre, stepped-wedge, cluster randomized trial that evaluates the impact of using the female-specific 99th percentile threshold for high-sensitivity cardiac troponin (hs-cTn) on the diagnosis, treatment and outcomes of women presenting to the emergency department (ED) with symptoms suggestive for myocardial ischemia. A feasibility study was conducted to estimate the number of eligible patients, the rate of the study's primary outcome under control conditions, and the statistical power to detect a clinically important difference in the primary outcome.

METHODS

Using linked administrative data from 11 hospitals in Ontario, Canada, from October 2014 to September 2017, the following estimates were obtained: number of women presenting to the ED with symptoms suggestive of myocardial ischemia and a 24-hour peak hs-cTn value within the female-specific and overall thresholds (ie, primary cohort); the rate of the 1-year composite outcome of all-cause mortality, re-admission for nonfatal myocardial infarction, incident heart failure, or emergent/urgent coronary revascularization. Study power was evaluated via simulations.

RESULTS

Overall, 2,073,849 ED visits were assessed. Among women, chest pain (with or without cardiac features) and shortness of breath were the most common complaints associated with a diagnosis of acute coronary syndrome. An estimated 7.7% of women with these complaints are eligible for inclusion in the primary cohort. The rate of the 1-year outcome in the primary cohort varied significantly across hospitals with a median rate of 12.2% (95%CI: 7.9%-17.7%). With 30 hospitals, randomized at 5-month intervals in 5 steps, approximately 19,600 women are expected to be included in CODE-MI, resulting in >82% power to detect a 20% decrease in the odds of the primary outcome at a 0.05 significance level.

CONCLUSIONS

This feasibility study greatly enhanced the design of CODE-MI, allowed accurate evaluation of the study power, and demonstrated the strength of using linked administrative health data to guide the design of pragmatic clinical trials.

Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta-analysis

Background Timely recognition of patients with acute coronary syndromes (ACS) is important for successful treatment. Previous research has suggested that women with ACS present with different symptoms compared with men. This review assessed the extent of sex differences in symptom presentation in patients with confirmed ACS. Methods and Results A systematic literature search was conducted in PubMed, Embase, and Cochrane up to June 2019. Two reviewers independently screened title-abstracts and full-texts according to predefined inclusion and exclusion criteria. Methodological quality was assessed using the Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% CI of a symptom being present were calculated using aggregated and cumulative meta-analyses as well as sex-specific pooled prevalences for each symptom. Twenty-seven studies were included. Compared with men, women with ACS had higher odds of presenting with pain between the shoulder blades (OR 2.15; 95% CI, 1.95-2.37), nausea or vomiting (OR 1.64; 95% CI, 1.48-1.82) and shortness of breath (OR 1.34; 95% CI, 1.21-1.48). Women had lower odds of presenting with chest pain (OR 0.70; 95% CI, 0.63-0.78) and diaphoresis (OR 0.84; 95% CI, 0.76-0.94). Both sexes presented most often with chest pain (pooled prevalences, men 79%; 95% CI, 72-85, pooled prevalences, women 74%; 95% CI, 72-85). Other symptoms also showed substantial overlap in prevalence. The presence of sex differences has been established since the early 2000s. Newer studies did not materially change cumulative findings. Conclusions Women with ACS do have different symptoms at presentation than men with ACS, but there is also considerable overlap. Since these differences have been shown for years, symptoms should no longer be labeled as "atypical" or "typical."

Sex-Specific Management in Patients With Acute Myocardial Infarction and Cardiogenic Shock: A Substudy of the CULPRIT-SHOCK Trial

BACKGROUND

Women are more likely to suffer and die from cardiogenic shock (CS) as the most severe complication of acute myocardial infarction. Data concerning optimal management for women with CS are scarce. Aim of this study was to better define characteristics of women experiencing CS and to the influence of sex on different treatment strategies.

METHODS

In the CULPRIT-SHOCK trial (The Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), patients with CS complicating acute myocardial infarction and multivessel coronary artery disease were randomly assigned to one of the following revascularization strategies: either percutaneous coronary intervention of the culprit-lesion-only or immediate multivessel percutaneous coronary intervention. Primary end point was composite of death from any cause or severe renal failure leading to renal replacement therapy within 30 days. We investigated sex-specific differences in general and according to the revascularization strategies.

RESULTS

Among all 686 randomized patients included in the analysis, 24% were women. Women were older and had more often diabetes mellitus and renal insufficiency, whereas they had less often history of previous acute myocardial infarction and smoking. After 30 days, the primary clinical end point was not significantly different between groups (56% women versus 49% men; odds ratio, 1.29 [95% CI, 0.91-1.84]; P=0.15). There was no interaction between sex and coronary revascularization strategy regarding mortality and renal failure (P_interaction=0.11). The primary end point occurred in 56% of women treated by the culprit-lesion-only strategy versus 42% men, whereas 55% of women and 55% of men in the multivessel percutaneous coronary intervention group.

CONCLUSIONS

Although women presented with a different risk profile, mortality and renal replacement were similar to men. Sex did not influence mortality and renal failure according to the different coronary revascularization strategies. Based on these data, women and men presenting with CS complicating acute myocardial infarction and multivessel coronary artery disease should not be treated differently. However, further randomized trials powered to address potential sex-specific differences in CS are still necessary. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01927549.

Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria

Background

Sex‐specific criteria are recommended for the diagnosis of myocardial infarction, but the impact of these on presenting characteristics is unknown.

Methods and Results

We evaluated patient‐reported symptoms in 1941 patients (39% women) with suspected acute coronary syndrome attending the emergency department in a substudy of a prospective trial. Standardized criteria defined typical and atypical presentations based on pain nature, location, radiation, and additional symptoms. Diagnosis of myocardial infarction was adjudicated using a high‐sensitivity cardiac troponin I assay with sex‐specific thresholds (>16 ng/L women, >34 ng/L men). Patients identified who were missed by the contemporary assay with a uniform threshold (≥50 ng/L) were reclassified by this approach. Type 1 myocardial infarction was diagnosed in 16% (184/1185) of men and 12% (90/756) of women, with 9 (5%) men and 27 (30%) women reclassified using high‐sensitivity cardiac troponin I and sex‐specific thresholds. Chest pain was the presenting symptom in 91% (1081/1185) of men and 92% (698/756) of women. Typical symptoms were more common in women than in men with myocardial infarction (77% [69/90] versus 59% [109/184]; P=0.007), and differences were similar in those reclassified (74% [20/27] versus 44% [4/9]; P=0.22). The presence of ≥3 typical features was associated with a positive likelihood ratio for the diagnosis of myocardial infarction in women (positive likelihood ratio, 1.18; 95% CI, 1.03–1.31) but not in men (positive likelihood ratio 1.09; 95% CI, 0.96–1.24).

Conclusions

Typical symptoms are more common and have greater predictive value in women than in men with myocardial infarction whether or not they are diagnosed using sex‐specific criteria.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier NCT01852123.

See Editorial Alraies and Piña

Associations of depression severity with heart rate and heart rate variability in young adults across normative and clinical populations

Limitations of current depression treatments may arise from a lack of knowledge about unique psychophysiological processes that contribute to depression across the full range of presentations. This study examined how individual variations in heart rate (HR) and heart rate variability (HRV) are related to depressive symptoms across normative and clinical populations in 152 young adults (aged 18-35 years). Moderating effects of sex and antidepressant medication status were considered. Electrocardiogram data were collected during "vanilla" baseline and in response to positive and negative emotional cues. Linear regressions and repeated-measures mixed models were used to assess the relationships between Beck Depression Inventory-II (BDI-II) scores, sex, antidepressant use, and cardiovascular outcomes. Baseline models yielded significant main effects of BDI-II and sex on HR and significant interactions between antidepressant medication status and BDI-II on HRV outcomes. The main effects of BDI-II and sex on HR were no longer significant after controlling for cardiorespiratory fitness. Participants who denied current antidepressant use (n = 137) exhibited a negative association and participants who endorsed current antidepressant (n = 15) use exhibited a positive association between BDI-II scores and HRV. Emotional reactivity models were largely non-significant with the exception of a significant main effect of antidepressant medication status on high-frequency HRV reactivity. Results indicated antidepressant medication use may moderate the relationship between depression severity and cardiovascular functioning, but this requires replication given the modest proportion of medicated individuals in this study. Overall, findings suggest cardiovascular processes and cardiorespiratory fitness are linked to depression symptomatology and may be important to consider in depression treatment.

No time to delay reperfusion: A cross-sectional study of primary percutaneous coronary intervention times

AIMS AND OBJECTIVES

To establish and report cross-sectional data of reperfusion times for emergency primary percutaneous coronary interventions (PPCI) and to examine factors associated with times to reperfusion.

BACKGROUND

Rapid coronary reperfusion can salvage myocardial tissue, preserve left ventricular function and reduce mortality. PPCI is the gold standard of management. Researchers have reported on international median reperfusion times, but this is the first Irish study to do so.

METHODS

This observational, prospective, cross-sectional study included patients diagnosed with ST-segment elevation myocardial infarction (STEMI) and admitted for emergency PPCI. Descriptive and inferential statistics were used. The study was ethically approved. We adopted the STROBE guidelines.

RESULTS

All patients (N = 133) who met the inclusion criteria were included initially. Of these, 105 (79%) were diagnosed with STEMI and received emergency PPCI. The majority of STEMIs were diagnosed by paramedics and most (67%) were reperfused within 120 min, with a median time of 96 min. The results suggested that younger patients achieved timelier PPCI and source of referral was also significant in that more of those transferred directly to the coronary catheterisation laboratory achieved reperfusion within 120 min, compared with those who presented to the emergency department.

CONCLUSION

A timely reperfusion service is achieved for the majority. Attention is needed in respect of the ageing and those admitted directly to the emergency departments with STEMI.

RELEVANCE TO CLINICAL PRACTICE

Further international research is recommended to compare current reperfusion times against guidelines and to identify areas for improvement. Clinicians should be mindful of the importance of rapid reperfusion and the implications of its delay for patients with STEMI. Those presenting to emergency departments with chest pain should be prioritised.

Gender bias in clinical decision making emerges when patients with coronary heart disease symptoms also have psychological symptoms

BACKGROUND

Delayed treatment may contribute to women's relatively higher morbidity and mortality from coronary heart disease (CHD). We tested whether disparities in treatment may be due to bias in diagnosis and treatment recommendations for women with psychological symptoms.

METHODS

Fourth year medical students (N = 225) from 13 U.S. medical schools were randomly assigned to make clinical decisions (CHD risk judgments, diagnosis, treatment recommendations) about one of four experimental vignette patients (male or female; with symptoms of depression and anxiety or without). Vignettes were presented as text via an online survey platform.

RESULTS

The female patient with psychological symptoms was perceived to be at lowest risk for CHD. Perceptions of risk partly mediated lower likelihood of recommending the female patient with psychological symptoms be seen in an emergency department, take medication, or receive nutrition or exercise advice relative to the male patient with psychological symptoms.

CONCLUSIONS

There was a gender bias in CHD clinical decision-making when patients had concurrent psychological symptoms.

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.

Fatigue and acute coronary syndrome: a systematic review of contributing factors

Fatigue is a symptom of ACS, but it remains unclear who is at risk and what factors contribute to fatigue. The purpose of the systematic review was to identify factors that influence fatigue in patients with ACS. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature published from 1981 to 2017 was reviewed, and of 983 articles screened, 36 met inclusion criteria. Variables contributing to fatigue fell into 3 categories: demographic characteristics, clinical characteristics, and other factors. More fatigue was found in women than men, and significant differences in fatigue were identified by race. Additionally, sleep deprivation, depression, and anxiety were associated with higher levels of fatigue. The findings highlight the importance of demographic, clinical, and other factors' impact on fatigue in ACS patients. Fatigue is an important symptom in ACS and healthcare providers must recognize how patient variables affect symptom expression.

Gender differences in symptom presentation of ST-elevation myocardial infarction - An observational multicenter survey study

BACKGROUND

Symptom presentation has been sparsely studied from a gender perspective restricting the inclusion to ST elevation myocardial infarction (STEMI) patients. Correct symptom recognition is vital in order to promptly seek care in STEMI where fast reperfusion therapy is of utmost importance. Female gender has been found associated with atypical presentation in studies on mixed MI populations but it is unclear whether this is valid also in STEMI.

OBJECTIVES

We assessed whether there are gender differences in symptoms and interpretation of these in STEMI, and if this is attributable to sociodemographic and clinical factors.

METHODS

SymTime was a multicenter observational study including a validated questionnaire and data from medical records. Eligible STEMI patients (n = 532) were enrolled within 24 h after admittance at five Swedish hospitals.

RESULTS

Women were older, more often single and had lower educational level. Chest pain was less prevalent in women (74 vs 93%, p < 0.001), whereas shoulder (33 vs 15%, p < 0.001), throat/neck (34 vs 18%, p < 0.001), back pain (29 versus 12%, p < 0.001) and nausea (49 vs 29%, p < 0.001) were more prevalent. Women less often interpreted their symptoms as of cardiac origin (60 vs 69%, p = 0.04). Female gender was the strongest independent predictor of non-chest pain presentation, odds ratio 5.29, 95% confidence interval 2.85-9.80.

CONCLUSIONS

A striking gender difference in STEMI symptoms was found. As women significantly misinterpreted their symptoms more often, it is vital when informing about MI to the society or to high risk individuals, to highlight also other symptoms than just chest pain.

Sex differences in long-term mortality among acute myocardial infarction patients: Results from the ISAR-RISK and ART studies

BACKGROUND

Mortality rates in females who survived acute myocardial infarction (AMI) exceed those in males. Differences between sexes in age, cardiovascular risk factors and revascularization therapy have been proposed as possible reasons.

OBJECTIVE

To select sets of female and male patients comparable in respect of relevant risk factors in order to compare the sex-specific risk in a systematic manner.

METHODS

Data of the ISAR-RISK and ART studies were investigated. Patients were enrolled between 1996 and 2005 and suffered from AMI within 4 weeks prior to enrolment. Patients of each sex were selected with 1:1 equivalent age, previous AMI history, sinus-rhythm presence, hypertension, diabetes mellitus, smoking status, left ventricular ejection fraction (LVEF), and revascularization therapy. Survival times were compared between sex groups in the whole study cohort and in the matched cohort.

RESULTS

Of 3840 consecutive AMI survivors, 994 (25.9%) were females and 2846 (74.1%) were males. Females were older and suffered more frequently from hypertension and diabetes mellitus. In the whole cohort, females showed an increased mortality with a hazard ratio (HR) of 1.54 compared to males (p<0.0001). The matched cohort comprised 802 patients of each sex and revealed a trend towards poorer survival in females (HR for female sex 1.14; p = 0.359). However, significant mortality differences with a higher risk in matched females was observed during the first year after AMI (HR = 1.61; p = 0.045) but not during the subsequent years.

CONCLUSION

Matched sub-groups of post-AMI patients showed a comparable long-term mortality. However, a female excess mortality remained during first year after AMI and cannot be explained by differences in age, cardiovascular risk factors, and modes of acute treatment. Other causal factors, including clinical as well as psychological and social aspects, need to be considered. Female post-AMI patients should be followed more actively particularly during the first year after AMI.

Association of Serum Prealbumin with Angiographic Severity in Patients with Acute Coronary Syndrome

Background

Serum prealbumin (PA), which is a nutritional index, has been found to be associated with severities and prognoses of various diseases. However, there are no reports about the relationship between PA and angiographic severity of coronary artery disease.

Material/Methods

This cross-sectional study included 867 patients with acute coronary syndrome (ACS) who underwent coronary angiography. Patients were divided into quartiles of PA and coronary artery stenosis was determined by angiographic Gensini score, the presence of high Gensini score (Gensini score ≥120), and triple-vessel disease. Multivariate linear and logistic regression analyses were performed to explore the relationship between PA and disease severity in a coronary angiogram.

Results

There was a significant and independent negative correlation between PA and Gensini score in multivariate linear regression (p=0.015). Logistic regression analysis revealed that crude odds ratios of triple-vessel disease and high Gensini score were 2.47 (95% CI: 1.66–3.67) and 1.83 (95% CI: 1.50–3.49), respectively, in the first quartile of PA compared with the fourth quartile and the results remained significant for high Gensini score after adjustment for confounding factors. In addition, estimated glomerular filtration rate, liver function, and high-sensitivity C-reactive protein (hs-CRP) had no interactive relationships in the above associations. Patients with lower levels of albumin or higher levels of hs-CRP or the ratio of hs-CRP to PA (hs-CRP/PA) also had more severe coronary atherosclerosis.

Conclusions

PA is negatively and independently associated with angiographic severity in patients with ACS, indicating for potential use in estimating the burden of coronary atherosclerosis.

[ST segment elevation myocardial infarction in women]

In France, coronary disease is responsible for 11.9 deaths/100,000 women aged 35 to 74 years old every year. In France, the number of hospitalizations and deaths for myocardial infarction (MI) increases more significantly in women, particularly under 65. To date, women with MI were 5-10 years older than men, with more risk factors and comorbidities, especially regarding diabetes, high blood pressure and lipid profile. However, a recent comparative study of the FAST-MI registry notes a change in the characteristics of these patients with more and more young women, active smoking and obesity. Their symptoms include more often atypics ones. They also have the particularity of a higher frequency of MI without obstructive lesion. Though, even at the same age, women have a worse prognosis with significantly higher mortality rate, especially early, in-hospital, than those of men. However, there are means to implement in order to reduce complications rate and improve the prognosis through information campaign and primary prevention screening and appropriate care and correction of risk factors. It is also important to raise awareness of general population and care actors about women MI risk even young, about its atypical forms and the necessity of to rapid and aggressive care processes. A better understanding of specific pathophysiological mechanisms appears mandatory and should be supported by prospective dedicated studies.

A Biobehavioral Framework to Address the Emerging Challenge of Multimorbidity

Multimorbidity, the co-occurrence of multiple physical or psychological illnesses, is prevalent particularly among older adults. The number of Americans with multiple chronic diseases is projected to increase from 57 million in 2000 to 81 million in 2020. However, behavioral medicine and health psychology, while focusing on the co-occurrence of psychological/psychiatric disorders with primary medical morbidities, have historically tended to ignore the co-occurrence of primary medical comorbidities, such as diabetes and cancer, and their biopsychosocial implications. This approach may hinder our ecologically valid understanding of the etiology, prevention, and treatment for individual patients with multimorbidity. In this selective review, we propose a heuristic behavioral framework for the etiology of multimorbidity. More acknowledgment and systematic research on multiple, co-existing disorders in behavioral medicine are consistent with the biopsychosocial model's emphasis on treating the "whole person," which means not considering any single illness, its symptoms, risk factors, or mechanisms, in isolation. As systems analytics, big data, machine learning, and mixed-model trajectory analyses, among others, come online and become more widely available, we may be able to tackle multimorbidity more holistically, efficiently, and satisfactorily.

Using decision trees for measuring gender equity in the timing of angiography in patients with acute coronary syndrome: a novel approach to equity analysis

BACKGROUND

Methods to measure or quantify equity in health care remain scarce, if not difficult to interpret. A novel method to measure health equity is presented, applied to gender health equity, and illustrated with an example of timing of angiography in patients following a hospital admission for an acute coronary syndrome.

METHODS

Linked administrative hospital discharge and survey data was used to identify a retrospective cohort of patients hospitalized with Acute Coronary Syndrome (ACS) between 2002 and 2008 who also responded to the Canadian Community Health Survey (CCHS), was analyzed using decision trees to determine whether gender impacted the delay to angiography following an ACS.

RESULTS

Defining a delay to angiography as 1 day or more, resulted in a non-significant difference in an equity score of 0.14 for women and 0.12 for men, where 0 and 1 represents perfect equity and inequity respectively. Using 2 and 3 day delays as a secondary outcome resulted in women and men producing scores of 0.19 and 0.17 for a 2 day delay and 0.22 and 0.23 for a 3 day delay.

CONCLUSIONS

A technique developed expressly for measuring equity suggests that men and women in Ontario receive equitable care in access to angiography with respect to timeliness following an ACS.

Trends in Gender Differences in Cardiac Care and Outcome After Acute Myocardial Infarction in Western Sweden: A Report From the Swedish Web System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART)

BACKGROUND

Cardiovascular disease is the most common cause of death for both genders. Debates are ongoing as to whether gender-specific differences in clinical course, diagnosis, and management of acute myocardial infarction (MI) exist.

METHODS AND RESULTS

We compared all men and women who were treated for acute MI at cardiac care units in Västra Götaland, Sweden, between January 1995 and October 2014 by obtaining data from the prospective SWEDEHEART (Swedish Web-System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry. We performed unadjusted and adjusted Cox proportional hazards and logistic regression analyses on complete case data and on imputed data sets. Overall, 48 118 patients (35.4% women) were diagnosed with acute MI. Women as a group had better age-adjusted prognosis than men, but this survival benefit was absent for younger women (aged <60 years) and for women with ST-segment elevation MI. Compared with men, younger women and women with ST-segment elevation MI were more likely to develop prehospital cardiogenic shock (adjusted odds ratio 1.67, 95% CI 1.30 to 2.16, P<0.001 and adjusted odds ratio 1.31, 95% CI 1.16 to 1.48, P<0.001) and were less likely to be prescribed evidence-based treatment at discharge (P<0.001 for β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, and P2Y12 antagonists). Differences in treatment between the genders did not decrease over the study period (P>0.1 for all treatments).

CONCLUSIONS

Women on average have better adjusted prognosis than men after acute MI; however, younger women and women with ST-segment elevation MI have disproportionately poor prognosis and are less likely to be prescribed evidence-based treatment.

Thoughts and behaviors of women with symptoms of acute coronary syndrome

OBJECTIVE

Women delay seeking care for symptoms of acute coronary syndrome (ACS) because of atypical symptoms, perceptions of invulnerability, or keeping symptoms to themselves. The purpose of this study was to explore how women recognized and interpreted their symptoms and subsequently decided whether to seek treatment within the context of their lives.

METHOD

Grounded theory was used to provide the methodological basis for data generation and analysis. Data were collected using in-depth interviews with 9 women with ACS.

RESULTS

All participants went through a basic social process of searching for the meaning of their symptoms which informed their decisions about seeking care. Stages in the process included noticing symptoms, forming a symptom pattern, using a frame of reference, finding relief, and assigning causality. The evolving MI group (n = 5) experienced uncertainty about bodily cues, continued life as usual, until others moved them toward care. The immediately recognizable MI group (n = 4) labeled their condition quickly, yet delayed, as they prepared themselves and others for their departure.

CONCLUSIONS

All women delayed, regardless of their ability to correctly label their symptoms. Education aimed at symptom recognition/interpretation addresses only part of the problem. Women should also be educated about the potential danger of overestimating the time they have to seek medical attention.

Long enough to act? Symptom and behavior patterns prior to out-of-hospital sudden cardiac death

BACKGROUND

Sudden cardiac death is a major cause of death in the United States. Most cases occur outside the hospital, yet little is known about the symptoms and actions of individuals who die before reaching the hospital.

OBJECTIVE

The purpose of this study was to describe the symptoms, symptom management, and care-seeking patterns in sudden cardiac death victims.

METHODS

This cross-sectional study used qualitative and quantitative data collection methods to obtain descriptions of symptoms and treatment-seeking delay from family members and bystanders (respondents) in 140 cases of sudden cardiac death due to presumed myocardial infarction. Decedents were identified from death certificate data from the state of Oregon in the United States. Respondents completed a survey of demographics and myocardial infarction symptoms and an in-depth interview. Narrative analysis was used to analyze qualitative data.

RESULTS

Three behavior patterns or trajectory types were developed focusing on key characteristics of the symptom patterns, the meanings attributed to those symptoms, the actions taken by the decedents and their family members or bystanders, and the time course of events. Each case was categorized as 1 trajectory type. The trajectory types are Normal Day (n = 49), Something Not Right (n = 62), and Thought It Was Something Else (n = 29). The key distinction across the trajectory types is the perception and interpretation of symptoms and the resulting actions between symptom perception and death.

CONCLUSIONS

This study is 1 of the first to describe what victims of sudden cardiac death are doing and thinking during the period between symptom onset and collapse. The trajectory types identified in this study suggest that misinterpretation of symptoms (the Something Not Right and Thought It Was Something Else groups) is common among victims and bystanders.

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.

Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality

CONTEXT

Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality.

OBJECTIVE

To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI.

DESIGN, SETTING, AND PATIENTS

Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men).

MAIN OUTCOME MEASURES

We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality.

RESULTS

The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P < .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001).

CONCLUSION

In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

Patient-reported symptoms in acute myocardial infarction: differences related to ST-segment elevation: the MONICA/KORA Myocardial Infarction Registry

OBJECTIVES

The early recognition of symptoms of myocardial infarction (MI) is crucial for patients with both ST-segment elevation (STEMI) and non-STEMI (NSTEMI). However, to date, only a few studies have examined the differences between patients with STEMI and NSTEMI with regard to the range of presenting MI symptoms.

DESIGN

The study population comprised 889 individuals with STEMI and 1268 with NSTEMI, aged 25-74, hospitalized with a first-time MI between January 2001 and December 2006 recruited from a population-based MI registry. The occurrence of 13 symptoms was recorded during a standardized patient interview.

RESULTS

Patients with STEMI were significantly younger, more likely to be smokers and less likely to have a history of hypertension or sleep disturbances prior to the acute MI (AMI) event than those with NSTEMI. A total of 50% of the patients attributed their experienced symptoms to the heart. Logistic regression modelling revealed that patients with STEMI were significantly more likely than patients with NSTEMI to complain of vomiting [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.76-3.05], dizziness (OR 1.63, 95% CI 1.30-2.03) and diaphoresis (OR 1.49, 95% CI 1.23-1.81). Furthermore, patients with STEMI were less likely to experience dyspnoea (OR 0.81, 95% CI 0.68-0.98) or pain in the throat/jaw (OR 0.80, 95% CI 0.66-0.98).

CONCLUSIONS

Only half of all patients correctly attributed their symptoms to the heart. Patients with STEMI and NSTEMI showed differences regarding several presenting symptoms. Further research is needed to replicate our results, and public awareness of AMI symptoms needs to be improved.

Sex differences in patient-reported symptoms associated with myocardial infarction (from the population-based MONICA/KORA Myocardial Infarction Registry)

Many studies have examined gender-related differences in symptoms of acute myocardial infarction (AMI). However, findings have been inconsistent, largely because of different study populations and different methods of symptom assessment and data analysis. This study was based on 568 women and 1,710 men 25 to 74 years old hospitalized with a first-ever AMI from January 2001 through December 2006 recruited from a population-based AMI registry. Occurrence of 13 AMI symptoms was recorded using standardized patient interview. After controlling for age, migration status, body mass index, smoking, some co-morbidities including diabetes, and type and location of AMI through logistic regression modeling, women were significantly more likely to complain of pain in the left shoulder/arm/hand (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.10 to 1.69), pain in the throat/jaw (OR 1.78, 95% CI 1.43 to 2.21), pain in the upper abdomen (OR 1.39, 95% CI 1.02 to 1.91), pain between the shoulder blades (OR 2.22, 95% CI 1.78 to 2.77), vomiting (OR 2.23, 95% CI 1.67 to 2.97), nausea (OR 1.94, 95% CI 1.56 to 2.39), dyspnea (OR 1.45, 95% CI 1.17 to 1.78), fear of death (OR 2.17, 95% CI 1.73 to 2.72), and dizziness (OR 1.49, 95% CI 1.16 to 1.91) than men. Furthermore, women were more likely to report >4 symptoms (OR 2.14, 95% CI 1.72 to 2.66). No significant gender differences were found in chest pain, feelings of pressure or tightness, diaphoresis, pain in the right shoulder/arm/hand, and syncope. In conclusion, women and men did not differ regarding the chief AMI symptoms of chest pain or feelings of tightness or pressure and diaphoresis. However, women were more likely to have additional symptoms.