Atypical presentation of acute myocardial infarction in 3 age groups

[Delirium-an interdisciplinary challenge]

BACKGROUND

Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients.

DIAGNOSTIC

Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential.

TREATMENT

In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.

Symptom Severity as a Predictor of Reported Differences of Prehospital Delay between Medical Records and Structured Interviews among Patients with AMI

Background: The time interval from symptom onset to hospital arrival can guide the decision to start reperfusion for patients with acute myocardial infarction (AMI).

Aims: The aims of the study were 1) to examine the consistency and agreement of prehospital delay time between medical record review and structured patient interview and 2) to identify whether symptom severity is an independent predictor of differences in reported prehospital delay between these two data sources.

Methods: In this cross-sectional study, a convenience sample of 155 patients with AMI in Japan was recruited. The time and date of symptom onset were obtained from medical record review and a structured patient interview. The interviewer asked about severity of symptoms, using a scale on 0 to 10 scale, with 0 being “no symptom” and 10 being “the most severe symptoms imaginable”.

Results: The prehospital delay time from the medical record was significantly shorter than from the structured interview. Perfect agreement of reported prehospital delay time between two data sources was found in 46% of patients. Patients with symptom severity scores of greater than 8 on a 10-point scale were 2.2 times (95% CI: Odds Ratio 1.1 to 5.1) more likely to report different symptom onset time.

Conclusions: Prehospital delay time documented in the medical record was shorter than that identified from a structured interview. In addition, the discrepancy between the two data sources may be larger in those patients with severe AMI symptoms.

Patient and organizational characteristics predict a long length of stay in the emergency department - a Swedish cohort study

BACKGROUND

Emergency departments (EDs) constitute a central part of the healthcare system that receives patients with complaints of varied urgency. A long length of stay (LOS) in the ED is associated with crowding, low patient satisfaction and poor patient outcomes. Therefore, it is important to understand the key drivers and patient characteristics associated with long LOS.

AIMS

To identify patient-related and organization-related characteristics associated with the longest ED LOS.

METHODS

All adult visits (n=19 503) to the ED at Karolinska University Hospital in Solna, Sweden, between 8 a.m. and 9 p.m. during 2012 were divided into quartiles on the basis of their LOS. The quartile with the longest LOS (n=4876) was compared with the two intermediate quartiles (n=9752) and the shortest quartile (n=4875). Differences in patient and organizational characteristics were assessed using multivariate logistic regression models to achieve odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The patient-related factors associated with long LOS were female sex (OR 1.22, 95% CI 1.14-1.30), age 65-79 (OR 1.82, 95% CI 1.67-1.97), age 80 or older (OR 2.76, 95% CI 2.52-3.02) and the chief complaint of dyspnoea (OR 1.55, 95% CI 1.39-1.73).

CONCLUSION

Long LOS in the ED is associated with both patient and organizational characteristics and the elderly are at particular risk of long LOS. These insights may be used to improve patient outcome metrics and enhance ED efficiency. Further studies are needed to clarify the role of additional factors as well as the causality of the studied factors.

The Interdisciplinary Management of Acute Chest Pain

BACKGROUND

Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory.

METHODS

This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed.

RESULTS

History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention.

CONCLUSION

Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.

Craniofacial Pain as the Sole Sign of Prodromal Angina and Acute Coronary Syndrome: A Review and Report of a Rare Case

Orofacial pain can arise from different regions and etiologies. Some of the most debilitating pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). The problem with referred pain is the misdiagnosis and unnecessary therapy directed to the pain location instead of its origin. When craniofacial pain is the sole sign of myocardial ischemia, failure to recognize its cardiac source can endanger the patient. In particular, apart from unnecessary dental treatments, patients with acute myocardial infarction who do not experience chest pain run a very high risk of misdiagnosis and death. As endodontists, each of us may face many patients complaining of pain sensation in the teeth with the main source being other craniofacial/visceral organs. This review plots a diagnostically challenging case paving the way for further literature presentation in this regard. The aim of this compendious review was to gain knowledge about the prevalence, clinical characteristics and possible mechanisms of craniofacial pain of cardiac origin, in order to improve the clinician’s ability to make a correct diagnosis.

Clinical value of chest pain presentation and prodromes on the assessment of cardiovascular disease: a cohort study

OBJECTIVES

The recognition of coronary artery disease (CAD) among patients who report chest pain remains difficult in primary care. This study investigates the association between chest pain (specified, unspecified or musculoskeletal) and prodromes (dyspepsia, fatigue or dyspnoea), with first-ever acute CAD, and increased longer term cardiovascular risk.

DESIGN

Cohort study.

SETTING

Anonymised clinical data recorded electronically by general practitioners from 140 primary care surgeries in London (UK) between April 2008 and April 2013.

PARTICIPANTS

Data were extracted for all patients aged 30 years and over at the beginning of the study period, registered in the surgeries.

MAIN OUTCOME MEASURES

Clinical data included chest pain, dyspepsia, dyspnoea and fatigue, first-ever CAD and long-term cardiovascular risk (QRisk2). Regression models were used to analyse the association between chest pain together with prodromes and CAD and QRisk2≥20%.

RESULTS

354,052 patients were included in the study. 4842 patients had first-ever CAD of which 270 reported chest pain in the year before the acute event. 257,019 patients had QRisk2 estimations. Chest pain was associated with a higher risk of CAD. HRs: 21.12 (16.68 to 26.76), p<0.001; 7.51 (6.49 to 8.68), p<0.001; and 1.84 (1.14 to 3.00), p<0.001 for specified, unspecified and musculoskeletal chest pain. Dyspepsia, dyspnoea or fatigue was also associated with a higher risk of CAD. Chest pain of all subtypes, dyspepsia and dyspnoea were also associated with an increased 10-year cardiovascular risk of 20% or more.

CONCLUSIONS

All patients with chest pain, including those with atypical symptoms, require careful assessment for acute and longer term cardiovascular risk. Prodromes may have independent diagnostic value in the estimation of cardiovascular disease risk.

[Delirium]

Delirium in older patients is also associated with persistent functional and cognitive impairment. Nevertheless, it frequently remains unrecognized or misinterpreted by treating physicians and this is particularly true in cases of hypoactive delirium. Screening and assessment instruments are helpful in the identification of patients with delirium. A multifactorial model of a combination of predisposing and precipitating factors best explains the etiology of delirium and avoidance is crucial for its prevention. Whenever delirium is suspected, immediate diagnosis and therapy of the precipitating condition are of primary importance. Non-pharmacological interventions, for example environmental modifications, play an important role in managing behavioral symptoms of delirium. Pharmacological interventions are merely symptomatic and should be limited to patients with severe symptoms when non-pharmacological means fail.

Cluster dyads of risk factors and symptoms are associated with major adverse cardiac events in patients with acute myocardial infarction

The purpose of this study was to examine the cluster dyads of risk factors and symptoms and their impact on the incidence of 12 month major adverse cardiac events (MACEs) among patients with first-time myocardial infarction (MI). In a descriptive study, a total of 522 patients completed semi-structured interviews for data on risk factors and symptoms. Patients were followed for 12 months to determine MACEs. Latent class cluster analysis was performed to identify risk factor clusters and symptom clusters. Logistic regression analysis was performed to determine the impact of cluster dyads on 12 month MACEs. There were 436 event-free survivors and 86 patients with MACEs for 12 months. Ten risk factors and 14 symptoms were clustered into two (dyslipidemia/smoking, hypertension/diabetes dominant) and three (typical, multiple, atypical) memberships, respectively. Six cluster dyads which were generated based on the association between risk factors and symptom clusters were a significant predictor of 12 month MACEs, with the incidence occurring three times higher in a dyad of hypertension/diabetes-and-atypical symptoms than a dyad of dyslipidemia/smoking-and-typical symptoms (odds ratio = 3.10, P = 0.01), after adjustment for age, gender and a type of MI diagnosis. The information on cluster dyads suggests that health-care providers need to consider both risk factors and symptoms at hospital presentation for risk stratification to prevent adverse outcomes.

Women and cardiovascular disease: at a social disadvantage?

BACKGROUND

Cardiovascular disease is the most common cause of death in Australian women. The genesis and progression of cardiovascular disease is modulated by a complex interplay of genetic, physiological, social and economic circumstances. Increasingly the impact of racial, ethic, social and economic inequalities is identified as predictors of cardiovascular disease outcome. Despite important advances over the last 30 years in reducing age adjusted mortality from cardiovascular disease, it continues to represent a major social and economic burden nationally and internationally.

AIM

This paper provides a critical review of the social issues impacting upon women in Australia. It also identifies areas for future interventions with a view to improving outcomes in women with cardiovascular disease.

METHOD

The bibliographic databases; CINAHL, MEDLINE, PsycARTICLES, were searched for relevant studies using the search terms 'women', 'cardiovascular disease', and 'socio-economic status'.

FINDINGS

While some gains have been made in reducing the risk factor profile and rates of death from cardiovascular disease, it is clear that gender, race and socioeconomic disparities persist.

CONCLUSIONS

New approaches are required to improve health differentials for CVD, and reduce the impact of gender, racial, ethic, social and economic factors on health disparities.

Atypical symptom cluster predicts a higher mortality in patients with first-time acute myocardial infarction

Background and Objectives

Identifying symptom clusters of acute myocardial infarction (AMI) and their clinical significance may be useful in guiding treatment seeking behaviors and in planning treatment strategy. The aim of this study was to identify clusters of acute symptoms and their associated factors that manifested in patients with first-time AMI, and to compare clinical outcomes among cluster groups within 1-year of follow-up.

Subjects and Methods

A total of 391 AMI patients were interviewed individually using a structured questionnaire for acute and associated symptoms between March 2008 and June 2009 in Korea.

Results

Among 14 acute symptoms, three distinct clusters were identified by Latent Class Cluster Analysis: typical chest symptom (57.0%), multiple symptom (27.9%), and atypical symptom (15.1%) clusters. The cluster with atypical symptoms was characterized by the least chest pain (3.4%) and moderate frequencies (31-61%) of gastrointestinal symptoms, weakness or fatigue, and shortness of breath; they were more likely to be older, diabetic and to have worse clinical markers at hospital presentation compared with those with other clusters. Cox proportional hazards regression analysis showed that, when age and gender were adjusted for, the atypical symptom cluster significantly predicted a higher risk of 1-year mortality compared to the typical chest pain cluster (hazard ratio 3.288, 95% confidence interval 1.087-9.943, p=0.035).

Conclusion

Clusters of symptoms can be utilized in guiding a rapid identification of symptom patterns and in detecting higher risk patients. Intensive treatment should be considered for older and diabetic patients with atypical presentation.

Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes

Patients with acute coronary syndromes (ACS) who are accompanied by atypical symptoms are frequently misdiagnosed and under-treated. This study was conducted to examine and compare the factors associated with atypical symptoms other than chest pain in younger (<70 yr) and older (> or =70 yr) patients with first-time ACS. Data were obtained from the electronic medical records of the patients (n=931) who were newly diagnosed as ACS and hospitalized from 2005 to 2006. The 7.8% (n=49) of the younger patients and 13.4% (n=41) of the older patients were found to have atypical symptoms. Older patients were more likely to complain of indigestion or abdominal discomfort (P=0.019), nausea and/or vomiting (P=0.040), and dyspnea (P<0.001), and less likely to have chest pain (P=0.007) and pains in the arm and shoulder (P=0.018). A logistic regression analysis showed that after adjustment made for the gender and ACS type, diabetes and hyperlipidemia significantly predicted atypical symptoms in the younger patients. In the older patients, the co-morbid conditions such as stroke or chronic obstructive pulmonary disease were positive predictors. Health care providers need to have an increased awareness of possible presence of ACS in younger persons with diabetes and older persons with chronic concomitant diseases when evaluating patients with no chest pain.

Should acute myocardial infarction be considered in the differential diagnosis of headache?

AIM

Headache as the only presenting symptom of acute myocardial infarction (MI) is an extremely uncommon phenomenon. The aim of this report is to describe a 61 year-old female patient with exertional headaches being the solely presentation of acute MI.

METHODS

As there were no complaints of chest pains or any other symptoms suggestive for MI, she underwent extensive neurological work-up. The correct diagnosis, however, was established only after a detailed description of the localization and radiation of her pains was obtained.

CONCLUSION

The importance of a thoroughly obtained anamnesis for the early recognition of cases with MI presenting with headaches, as well as the difference of opinion concerning the correct diagnosis which may occur between the internist and the cardiologist, are discussed.

Women's descriptions of symptoms and delay reasons in seeking medical care at the time of a first myocardial infarction: A qualitative study

BACKGROUND

Coronary heart disease (CHD) is a major cause of mortality in women. Women have also been identified as late presenters in seeking medical care.

AIM

The aim of this study was to explore and describe women's symptoms and the reasons for delay in seeking medical care at the time of the first myocardial infarction (MI).

METHODS

The study had an explorative and descriptive design based on content analysis approach. Nineteen women were interviewed at the hospital 2 or 3 days after hospitalisation.

RESULTS

The result showed that the women had difficulties interpreting, understanding and linking the symptoms to CHD. They tried to handle the discomfort and even the chest pain, rather then ask for professional help. The women had problems with making the final decision.

CONCLUSION

Women need to be made aware of the clinical symptoms of CHD, in order to understand the consequences of delay in seeking medical care following an MI.

The elderly in the emergency department: a critical review of problems and solutions

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians' difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.

'It was not chest pain really, I can't explain it!' An exploratory study on the nature of symptoms experienced by women during their myocardial infarction

AIMS AND OBJECTIVES

This study sought to explore the presenting nature of cardiac symptoms as experienced by women diagnosed with a myocardial infarction. The objectives were to use the participants' own words to gain a detailed understanding of how they perceived their evolving symptoms.

BACKGROUND

Women with coronary heart disease tend to delay seeking help despite experiencing symptoms. The classic hallmarks used to diagnose a myocardial infarction have been based on research primarily involving white middle-aged men with a focus on specific descriptions of chest pain. Whether these hallmarks apply to women in the same way as they apply to men is an area of increasing contention.

DESIGN

Using a purposive sample, a qualitative design was used to investigate the nature of cardiac symptoms experienced by women prior to and at the time of their myocardial infarction.

METHOD

Twelve women participated in semi-structured in-depth tape-recorded interviews conducted while they were in hospital.

RESULTS

Three interlinking themes emerged, which reflect a changing dynamic status in health, mediated by the perceived threat of individual symptoms. These included gradual awareness, not having pain in the chest and reactions to symptoms.

CONCLUSIONS

It would appear that symptom presentation and distribution amongst women may not follow the pattern traditionally associated with current understanding of a 'typical' myocardial infarction. These differences together with perceptions about their cardiac symptoms may influence their health-seeking behaviours.

RELEVANCE TO CLINICAL PRACTICE

Women with a myocardial infarction may present with non-specific chest symptoms, which are difficult to interpret or recognize by patients and health professionals alike. Skill in recording history and in performing a comprehensive assessment of initial and current symptoms will enable nurses to identify women with a differential diagnosis of chest pain readily. Additionally, to increase awareness of coronary heart disease, nurses must use any opportunity to educate women of all age groups.

Ischaemic symptoms, quality of care and mortality during myocardial infarction

OBJECTIVE

To study in myocardial infarction (MI) whether documentation of ischaemic symptoms is associated with quality of care and outcomes, and to compare patient reports of ischaemic symptoms during interviews with chart documentation.

DESIGN

Observational acute MI study from 2003 to 2004 (Prospective Registry Evaluating Myocardial Infarction: Event and Recovery).

SETTING

19 diverse US hospitals.

PATIENTS

2094 consecutive patients with MI (10 911 patients screened; 3953 patients were eligible and enrolled) with both positive cardiac enzymes and other evidence of infarction (eg, symptoms, electrocardiographic changes). Transferred patients and those with confounding non-cardiac comorbidity were not included (n = 1859).

MAIN OUTCOME MEASURES

Quality of care indicators and adjusted in-hospital survival.

RESULTS

The records of 10% of all patients with MI (217/2094) contained no documented ischaemic symptoms at presentation. Patients without documented symptoms were less likely (p<0.05) to receive aspirin (89% vs 96%) or beta-blockers (77% vs 90%) within 24 hours, reperfusion therapy for ST-elevation MI (7% vs 58%) or to survive their hospitalisation (adjusted odds ratio = 3.2, 95% CI 1.8 to 5.8). Survivors without documented symptoms were also less likely (p<0.05) to be discharged with aspirin (87% vs 93%), beta-blockers (81% vs 91%), ACE/ARB (67% vs 80%), or smoking cessation counselling (46% vs 66%). In the subset of 1356 (65%) interviewed patients, most of those without documented ischaemic symptoms (75%) reported presenting symptoms consistent with ischaemia.

CONCLUSIONS

Failure to document patients' presenting MI symptoms is associated with poorer quality of care from admission to discharge, and higher in-hospital mortality. Symptom recognition may represent an important opportunity to improve the quality of MI care.

Elderly Women Diagnosed with Nonspecific Chest Pain May Be at Increased Cardiovascular Risk

BACKGROUND

Women are more likely than men to have nonspecific chest pain (NSCP) symptoms. The long-term outcomes in women discharged with a diagnosis of NSCP are unknown.

METHODS

The Women's Health Initiative Observational Study enrolled postmenopausal women aged 50-79 years. After excluding those with prior cardiovascular disease (CVD), 83,622 women were studied. NSCP cases were defined as having an initial primary hospital discharge diagnosis of NSCP (ICD-9 codes 786.50, 786.51, 786.59) without a prior diagnosis of coronary heart disease (CHD). Risks of subsequent CHD events were estimated from Cox proportional hazard ratio (HR) models stratified by clinic and adjusted for baseline age, cardiovascular risk factors, and hormone use.

RESULTS

Over an average of 8 years of follow-up, 11% (230 of 2,092) of women with NSCP experienced a cardiovascular event compared with 9.5% (7,724 of 81,530) who did not. Compared with women without a hospitalization for NSCP during follow-up, those with NSCP had a greater than 2-fold higher risk of a subsequent hospitalization for clinically diagnosed angina (HR 2.18, 95% CI 1.66-2.86) and at least a 1.5-fold higher risk of nonfatal myocardial infarction (MI) (HR 1.59, 1.10-2.31), revascularization (HR 1.67, 1.28-2.20), and congestive heart failure (HR 1.75, 1.27-2.41). Women with NSCP who subsequently experienced a CHD event were more likely to be over age 65 or to have cardiovascular risk factors.

CONCLUSIONS

Older women discharged with a diagnosis of NSCP may be at increased risk of CHD morbidity. Further research is needed to replicate these findings in other populations.

Can symptom presentation predict unstable angina/non-ST-segment elevation myocardial infarction in a moderate-risk cohort?

BACKGROUND

Accurate recognition of acute coronary syndromes (ACS) on initial presentation is key to minimizing morbidity and mortality. The wide spectrum of symptom presentation in ACS complicates recognition. Unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) may be particularly difficult to diagnose as patients often do not exhibit initial high-risk features, leaving the clinician with symptom presentation alone, on which to base decisions regarding further investigation and treatment.

PURPOSE

The aim of this study was to compare typical symptom presentation (classic description of angina) and atypical presentation in a cohort presenting with symptoms suggestive of UA/NSTEMI.

METHOD

A prospective cohort design was used to evaluate 100 patients enrolled in an Emergency Department Chest Pain Program.

RESULTS

Although patients with typical presentation were more likely to have UA/NSTEMI, atypical presentation did not rule out this diagnosis. Of the 31 patients with UA/NSTEMI, most (n=23, 74.2%) had atypical symptoms. Male gender, symptom location, and history of ischemic heart disease were significantly associated with UA/NSTEMI. Of those with a final diagnosis of UA/NSTEMI, there was no difference in symptom presentation based on age or gender.

CONCLUSION

Clinicians should not rely on classic descriptions of angina when evaluating patients suspected of UA/NSTEMI.

Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events

STUDY OBJECTIVES

The clinical manifestations of acute coronary syndromes (ACSs) vary, and patients present frequently with symptoms other than chest pain. In this analysis, a large contemporary database has been accessed to define the frequency, clinical characteristics, and outcomes of patients presenting without chest pain across different diagnostic categories of ACS.

DESIGN AND SETTING

The Global Registry of Acute Coronary Events is a multinational, prospective, observational study involving 14 countries.

PATIENTS

Patients presenting to the hospital with a suspected ACS were stratified according to whether their predominant presenting symptoms included chest pain (ie, typical) or did not (ie, atypical). Demographics, medical history, hospital management, and outcomes were compared.

MEASUREMENTS AND RESULTS

Of the 20,881 patients in this analysis, 1,763 (8.4%) presented without chest pain, 23.8% of whom were not initially recognized as having an ACS. They were less likely to receive effective cardiac medications, and experienced greater hospital morbidity and mortality (13% vs 4.3%, respectively; p < 0.0001) than did patients with typical symptoms. After adjusting for potentially confounding variables, increased hospital mortality rates were noted in patients with dominant presenting symptoms of presyncope/syncope (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4 to 2.9), nausea or vomiting (OR, 1.6; 95% CI, 1.1 to 2.4), and dyspnea (OR, 1.4; 95% CI, 1.1 to 1.9), and in those with painless presentations of unstable angina (OR, 2.2; 95% CI, 1.4 to 3.5) and ST-segment elevation myocardial infarction (OR, 1.7; 95% CI, 1.2 to 2.2).

CONCLUSION

Patients with ACSs who present without chest pain are frequently misdiagnosed and undertreated. With the exception of diaphoresis, each dominant presenting symptom independently identifies a population that is at increased risk of dying. These patients experience greater morbidity and a higher mortality across the spectrum of ACSs.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.

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.

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.

Women's early warning symptoms of acute myocardial infarction

BACKGROUND

Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women.

METHODS AND RESULTS

Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology.

CONCLUSIONS

Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events.

Symptom reflections of women with cardiac disease and advanced practice nurses: a descriptive study

The purpose of this descriptive study was to explore the experiences of women with cardiac disease in regard to cardiac risk factors, symptoms, and symptom interpretation. Interviews with a convenience sample of 21 African American and Caucasian female patients, aged 40-81 years with cardiac diagnoses, were taped and transcribed. Three advanced practice nurses with experience in cardiovascular nursing were interviewed individually for background. Analyses of symptoms indicated that women experienced a range of prodromal symptoms other than chest pain prior to hospitalization such as: edema, shortness of breath, lightheadedness, dry cough, and exhaustion. Atypical symptoms delayed recognition of a cardiac problem for some women. The lack of symptom consistency underscores the need for thorough assessment and screening of women at risk for cardiac problems. Advanced practice nurses are aware of current cardiac disease research in women but they must continue to be vigilant for atypical symptoms.

A review of symptoms of coronary artery disease in women

BACKGROUND

Research on heart disease has increasingly included information on women's experiences. A number of recent studies present frequencies and comparisons of symptoms between men and women and there appears to be some variability in the symptoms especially among women. Even with acute myocardial infarction (AMI) where anticipated symptoms are more clear-cut, women can have vague or nonclassic symptoms.

AIM AND METHOD

Selected medical and nursing research on cardiac symptoms is examined for information on the cardiac warning symptom experiences unique to women. A search of the literature between 1995 and 2000 was done using CINAHL and MEDLINE. Terms used for the search included: cardiac symptoms, women's symptoms and symptom perception. The findings from this review are used to suggest implications for clinical practice.

FINDING

Women experiencing AMI present with a variety of symptoms including chest pain. Less obvious symptoms include; fatigue, shortness of breath, back pain, oedema, and transient non-specific chest discomfort. These less dramatic and non-specific symptoms do not necessarily prompt further assessment for coronary disease in women.

CONCLUSION

Cardiac screening of women who present with cardiac risk factors and careful attention to less anticipated symptoms are critical factors that can improve the rapid identification of coronary disease in women. The unique physiological and sociological differences between women and men make further study of women's symptom experiences and perceptions important for health care providers. Further study of gender and ethnic differences in symptom patterns and recognition will help to improve screening and earlier identification of cardiac problems in women patients especially those without chest pain as a prodromal symptom.