Development of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey

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.

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Symptom Presentation among Women with Suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA)

Identifying ischemic heart disease (IHD) in women based on symptoms is challenging. Women are more likely to endorse non-cardiac symptoms. More than 50% of women with suspected ischemia have no obstructive coronary disease (and thus, INOCA) and impaired outcomes during follow-up. We aimed to identify symptoms having predictive capacity for INOCA in women with clinical evidence of coronary ischemia. We included 916 women from the original WISE cohort (NCT00000554) who had coronary angiography performed for suspected ischemia and completed a 65-item WISE symptom questionnaire. Sixty-two percent (n = 567) had suspected INOCA. Logistic regression models using a best subsets approach were examined to identify the best predictive model for INOCA based on Score χ2 and AICc. A 10-variable, best-fit model accurately predicted INOCA (AUC 0.72, 95% CI 0.68, 0.75). The model indicated that age ≤ 55 years, left side chest pain, chest discomfort, neck pain, and palpitations had independent, positive relationship (OR > 1) to INOCA (p < 0.001 to 0.008). An inverse relationship (OR < 1) was observed for impending doom, and pain in the jaw, left or bilateral arm, and right hand, interpreted as INOCA associated with the absence of these symptoms (p ≤ 0.001 to 0.023). Our best-fit model accurately predicted INOCA based on age and symptom presentation ~72% of the time. While the heterogeneity of symptom presentation limits the utility of this unvalidated 10-variable model, it has promise for consideration of symptom inclusion in future INOCA prediction risk modeling for women with evidence of symptomatic ischemia.

Patient-centered care in Coronary Heart Disease: what do you want to measure? A systematic review of reviews on patient-reported outcome measures

Background

The number of published articles on Patient-Reported Outcomes Measures (PROMs) in Coronary Heart Disease (CHD), a leading cause of disability-adjusted life years lost worldwide, has been growing in the last decades. The aim of this study was to identify all the disease-specific PROMs developed for or used in CHD and summarize their characteristics (regardless of the construct), to facilitate the selection of the most adequate one for each purpose.

Methods

A systematic review of reviews was conducted in MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews. PROQOLID and BiblioPRO libraries were also checked. PROMs were classified by construct and information was extracted from different sources regarding their main characteristics such as aim, number of items, specific dimensions, original language, and metric properties that have been assessed.

Results

After title and abstract screening of 1224 articles, 114 publications were included for full text review. Finally, we identified 56 PROMs: 12 symptoms scales, 3 measuring functional status, 21 measuring Health-Related Quality of Life (HRQL), and 20 focused on other constructs. Three of the symptoms scales were specifically designed for a study (no metric properties evaluated), and only five have been included in a published study in the last decade. Regarding functional status, reliability and validity have been assessed for Duke Activity Index and Seattle Angina Questionnaire, which present multiple language versions. For HRQL, most of the PROMs included physical, emotional, and social domains. Responsiveness has only been evaluated for 10 out the 21 HRQL PROMs identified. Other constructs included psychological aspects, self-efficacy, attitudes, perceptions, threats and expectations about the treatment, knowledge, adjustment, or limitation for work, social support, or self-care.

Conclusions

There is a wide variety of instruments to assess the patients’ perspective in CHD, covering several constructs. This is the first systematic review of specific PROMs for CHD including all constructs. It has practical significance, as it summarizes relevant information that may help clinicians, researchers, and other healthcare stakeholders to choose the most adequate instrument for promoting shared decision making in a trend towards value-based healthcare.

Sex Differences in Prodromal Symptoms and Individual Responses to Acute Coronary Syndrome

BACKGROUND

Although researchers have shown that prodromal symptoms can predict acute coronary events, the ability of patients with acute coronary syndrome (ACS) to identify these symptoms in a timely manner is limited.

OBJECTIVES

We aimed to assess prodromal symptoms in Chinese patients with ACS and their responses to symptoms by sex.

DESIGN

This cross-sectional, multicenter study involved 5 teaching hospitals in China and included 806 patients admitted for ACS between June 2013 and February 2014. The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (Chinese version) was used to gather data.

RESULTS

Among 806 patients (including 483 women), 688 (85.4%) experienced at least 1 prodromal symptom before ACS onset. Using adjusted logistic regression models, we determined that women were significantly more likely than men to report back pain, between- or under-shoulder blade pain/discomfort, sleep disturbances, anxiousness, or heart racing. The prevalence of generalized chest pain and loss of appetite was higher among men than women. Only 41% of patients attributed their prodromal symptoms to the heart, and women were more likely than men to attribute prodromal symptoms to a heart attack.

CONCLUSIONS

More than two-thirds of patients with ACS reported at least 1 prodromal symptom, with some significant sex differences. Most patients do not attribute their symptoms to an impending ACS event.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 3: Patient Perspectives

In recent years, public awareness campaigns have targeted knowledge gaps and inequities in care while focusing on the unique female experience and heightened cardiovascular disease (CVD) risk profile. Recognizing and understanding the sex and gender constructs, barriers, facilitators, and factors that affect access, treatment, and recovery after an acute cardiac event from the unique patient perspective is a key step in transforming clinical practice and care patterns. The aim of this atlas chapter is to provide a knowledge review and to identify gaps regarding the experience of living with CVD from the perspective of the female survivor. The sections are as follows: (1) experiencing and living with CVD as a woman; (2) "stopped at the gate": barriers to accessing acute cardiovascular care; and (3) action items to "open the gate" to women: what our patients want and need. The final section culminates with targeted recommendations stemming from recent literature and most importantly, from women with the lived experience of CVD.

Evaluation of the cardiovascular symptom index for midlife women in multiethnic/racial midlife women

The authors' purpose of this study was to evaluate the validity and reliability of the Cardiovascular Symptom Index for Midlife Women in four ethnic/racial groups of midlife women in the U.S. Data from two internet surveys were used for this secondary analysis. In the construct validity test, five factors were extracted among White and Hispanic women, while more than five factors were extracted among Asian and African American women. In the convergent validity test, all ethnic/racial groups showed similar patterns. Adequate internal consistency among was shown. The Cardiovascular Symptom Index for Midlife Women is useful for assessing cardiovascular symptoms in multiethnic/racial women.

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.

The Association between Risk Factors and Prodromal Myocardial Infarction Symptoms: A Cross-Sectional Study in Iran

Background

Prodromal symptoms in individuals with risk factors remain challenging, even though myocardial infarction has been noted in research. This study determined the association of risk factors with patients' baseline myocardial infarction related prodromal symptoms.

Methods

In a cross-sectional study, 154 Iranian men and women, mean age 59.62 ± 12.74 years were assessed in 2016-2017. The frequency besides severity of 33 prodromal symptoms and risk factors was assessed using McSweeney Prodromal Myocardial Infarction Symptom Survey.

Results

The main cardiac prodromal symptoms experienced by patients were chest pain/discomfort (n = 99, 64.30%), unusual fatigue (n = 78, 50.60%), and sleep disturbance (n = 33, 20.40%). Women experienced more prodromal symptoms than men (33.26 ± 21.88 vs. 25.48 ± 17.75). Among risk factors, only sex was associated with prodromal symptoms score (P < 0.05).

Conclusion

The frequently experienced prodromal symptoms, i.e., before MI were chest pain/discomfort, unusual fatigue, and sleep disturbance. A crucial finding was the significant association between sex and prodromal symptoms. Identifying prodromal symptoms in patients with risk factors can prevent the incidence of myocardial infarction.

Gender difference of symptoms of acute coronary syndrome among Chinese patients: a cross-sectional study

BACKGROUND

The incidence of acute coronary syndrome is increasing in China.

OBJECTIVE

To investigate gender differences in Chinese patients' acute coronary syndrome symptoms, attribution of symptoms and reasons for seeking medical service.

METHODS

This was a cross-sectional, multicentre study. Acute coronary syndrome patients were recruited from five university hospitals located in four cities, between June 2013 and February 2014. Data were collected using the McSweeney acute and prodromal myocardial infarction symptom survey.

RESULTS

A total of 806 patients with acute coronary syndrome (323 men, 483 women) participated in the study. Adjusted (diabetes, smoking, age) logistic regression models revealed that women were significantly more likely to have pain or discomfort in the: central high chest; back, between, or under the shoulder blades; neck or throat; or arms relative to men. Women were also more likely to have unusual fatigue, weakness, shortness of breath or difficulty breathing, or dizziness relative to men. Conversely, women were significantly less likely to have generalised chest pain relative to men. Gender difference in the attribution of symptoms was largely driven by women's attribution to having a heart attack more frequently than men. Finally, women were more often told by a friend to seek medical help or they knew their symptoms were different, while men more frequently sought medical help because their symptoms did not go away.

CONCLUSIONS

There were gender differences in pain, discomfort and other symptoms. Both potential patients and healthcare providers need to be more aware of potential gender differences in acute coronary syndrome symptoms and decisions to seek care to ensure quick access.

Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey to Predict the Occurrence of Short-Term Coronary Heart Disease Events in Women

BACKGROUND

Few instruments capture symptoms that predict cardiac events in the short-term. This study examines the ability of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey to predict acute cardiac events within 3 months of administration and to identify the prodromal symptoms most associated with short-term risk in women without known coronary heart disease.

METHODS

The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey was administered to 1,097 women referred to a cardiologist for initial coronary heart disease evaluation. Logistic regression models were used to examine prodromal symptoms individually and in combination to identify the subset of symptoms most predictive of an event within 3 months.

RESULTS

Fifty-one women had an early cardiac event. In bivariate analyses, 4 of 30 prodromal symptoms were significantly associated with event occurrence within 90 days. In adjusted analyses, women reporting arm pain or discomfort and unusual fatigue were more likely (OR, 4.67; 95% CI, 2.08-10.48) to have a cardiac event than women reporting neither.

CONCLUSIONS

The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey may assist in predicting short-term coronary heart disease events in women without known coronary heart disease.

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.

Sex differences in prodromal symptoms in acute coronary syndrome in patients aged 55 years or younger

BACKGROUND

Studies suggest that young women are at highest risk for failing to recognise early symptoms of acute coronary syndrome (ACS).

OBJECTIVES

To examine sex differences in prodromal symptoms occurring days and weeks prior to the acute presentation of ACS. We also examined health-seeking behaviours and prehospital management in young patients.

METHODS

Prospective cross-sectional analysis of 1145 patients (368 women) hospitalised for ACS, aged ≤55 years, from the GENdEr and Sex DetermInantS of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary SYndrome cohort study (January 2009-April 2013). Prodromal symptoms were determined using the McSweeney Acute and Prodromal Myocardial Infarction Symptom questionnaire. Health-seeking behaviour and prehospital care were determined by questionnaires.

RESULTS

The median age was 49 years. The prevalence of prodromal symptoms was high and more women reported symptoms than men (85% vs 72%, p<0.0001). Symptoms were similar between sexes and included unusual fatigue, sleep disturbances, anxiety and arm weakness/discomfort. Chest pain was less common in both sexes (24%). Women were more likely to seek care (49% vs 42%, p=0.04). Among those who sought care, women were more likely to use an ambulance for their ACS compared with men (52% vs 39%). Cardiovascular risk-reduction therapy use was low (≤40%) in all patients and less than half perceived their care provider suspected a cardiac source.

CONCLUSIONS

Prior to ACS, women were more likely to experience prodromal symptoms and seek medical attention than men. Prehospital care was generally similar between sexes but demonstrated underutilisation of risk-reduction therapies in at-risk young adults.

Selecting symptom instruments for cardiovascular populations

The purpose of this review is to provide a guide for researchers and clinicians in selecting an instrument to measure four commonly occurring symptoms (dyspnea, chest pain, palpitations, and fatigue) in cardiac populations (acute coronary syndrome, heart failure, arrhythmia/atrial fibrillation, and angina, or patients undergoing cardiac interventions). An integrative review of the literature was conducted. A total of 102 studies summarizing information on 36 different instruments are reported in this integrative review. The majority of the instruments measured multiple symptoms and were used for one population. A majority of the symptom measures were disease-specific and were multi-dimensional. This review summarizes the psychometrics and defining characteristics of instruments to measure the four commonly occurring symptoms in cardiac populations. Simple, psychometrically strong instruments do exist and should be considered for use; however, there is less evidence of responsiveness to change over time for the majority of instruments.

Symptom Trajectories After an Emergency Department Visit for Potential Acute Coronary Syndrome

BACKGROUND

Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge-regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking.

OBJECTIVES

The aim of this study was to identify common trajectories of symptom severity in the 6 months after an ED visit for potential ACS.

METHODS

This was a secondary analysis of data from a larger observational, prospective study conducted in five U.S. EDs. Patients (N = 1005) who had electrocardiogram and biomarker testing ordered, and were identified by the triage nurse as potentially having ACS, were enrolled. Symptom severity was assessed in the hospital after initial stabilization and by telephone at 30 days and 6 months using the validated 13-item ACS Symptom Checklist. Growth mixture modeling was used for the secondary analysis. The eight most commonly reported symptoms (chest discomfort, chest pain, chest pressure, light-headedness, shortness of breath, shoulder pain, unusual fatigue, and upper back pain) were modeled across the three study time points. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices.

RESULTS

The sample was 62.6% male with a mean age of 60.2 years (SD = 14.17 years), and 57.1% ruled out for ACS. Between two and four distinct trajectory classes were identified for each symptom. The seven different types of trajectories identified across the eight symptoms were labeled "tapering off," "mild/persistent," "moderate/persistent," "moderate/worsening," "moderate/improving," "late onset, "and "severe/improving." Trajectories differed on age, gender, and diagnosis.

DISCUSSION

Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.

Predicting coronary heart disease events in women: a longitudinal cohort study

BACKGROUND

More than 240 000 women in the United States die of coronary heart disease annually. Identifying women's symptoms that predict a coronary heart disease event such as myocardial infarction (MI) could decrease mortality.

OBJECTIVE

For this longitudinal observational study, we recruited 1097 women, who were either clinician referred or self-referred to a cardiologist and undergoing initial evaluation by a cardiologist, to assess the utility of the prodromal symptoms (PS) section of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) in predicting the occurrence of cardiac events in women.

METHODS AND RESULTS

Seventy-seven women experienced events (angioplasty, stent placement, coronary artery bypass, MI, death) during the 2-year follow up. The most common events were stents alone (38.9%) or in combination with angioplasty (18.2%). Ten women had MIs; 4 experienced cardiac death. Cox proportional hazards was used to model time to event. The prodromal score was significantly associated with risk of an event (hazard ratio, 1.10; 95% confidence interval, 1.06-1.13), as was the number of PSs endorsed by each woman per visit. After covariate adjustment, 5 symptoms were significantly associated with increased risk: discomfort in jaws/teeth, unusual fatigue, arm discomfort, shortness of breath, and general chest discomfort (hazard ratio, 3.97; 95% confidence interval, 2.32-6.78). Women reporting 1 or more of these symptoms were 4 times as likely to experience a cardiac event as women with none.

CONCLUSIONS

Both the MAPMISS PS scores and number of PS were significantly associated with cardiac events, independent of risk factors, suggesting that there are specific PSs that can be easily assessed using the MAPMISS. This instrument could be an important component of a predictive screen to assist clinicians in deciding the course of management for women.

Health care contact is higher in the week preceding a first myocardial infarction: A review of medical records in Northern Sweden in 2007

BACKGROUND

Prodromal symptoms before myocardial infarction (MI) are common, but there are limited data regarding health care contact prior to the acute onset of MI and the impact of gender on early presentation to health care.

AIMS

The purpose of this study was to describe and analyse prodromal symptoms reported in medical records and study health care contact in the week before the acute onset of MI in comparison to the general population.

METHODS

From the Northern Sweden MONICA Study we accessed the medical records of 359 patients aged 32-74 years with a first MI in the county of Norrbotten in 2007. We identified those patients' health care contact during the seven days before the MI and compared them with the weekly number of contacts in the general population aged 45-74 years in the county during 2007.

RESULTS

We found that 23.1% of the women and 17.6% of the men had at least one contact the week before the MI. With the exception of the 14 women aged 45-55 years, health care consumption in both women and men in all age groups between 45- 74 years of age was 75%-165% higher in the week prior to the MI than in the general population of the same ages. In the first health care contact, pain-related symptoms were most frequent (43%), and fatigue was present in 8% of patients. There were no differences between women and men in health care consumption or presenting symptoms.

CONCLUSION

Both women and men with a first MI are in contact more frequently than the general population in the week prior to the event.

Reliability of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey among black and white women

BACKGROUND

Coronary heart disease (CHD) mortality rates are higher among women, particularly black, than men. Women's mortality rates may reflect difficulty in recognizing CHD prodromal symptoms (PS) but reliable screening instruments for women are scarce. The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) captures women's PS presentation, but has limited testing among black women.

AIM

To assess the test-retest reliability of the MAPMISS PS section for black and white women.

METHODS

The sample was recruited from women enrolled in a longitudinal study examining the predictive validity of the MAPMISS. The MAPMISS was re-administered to 42 women (22 white, 20 black) 3-5 days after baseline assessment.

RESULTS

Women endorsed an average of 7.5 PS (SD 4.8; range 0-20) initially and 7.6 (SD 4.7; range 0-20) at retest. Over half of the women (54.8%) of both races endorsed the same number of PS at test and retest; for 69%, the number endorsed at both testings differed by no more than one. Percentage agreement and kappa statistics on the number ofPS endorsed were excellent overall and by race. PS test and retest scores, reflecting PS intensity and frequency, were highly correlated overall (r = 0.92, p < 0.001) and separately for white (r = 0.93, p < 0.001) and black women (r = 0.91,p < 0.001). Racial differences were insignificant.

CONCLUSIONS

Findings indicate (i) the MAPMISS PS score has excellent test-retest reliability (r = 0.92) when administered to women without a history of CHD, and (ii) test-retest reliability is as strong for black (r = 0.91) as for white women (r = 0.93).

Sleep disturbance in women before myocardial infarction

OBJECTIVE

The study objective was to describe the prevalence and correlates of sleep disturbances among women who retrospectively reported sleep disturbance before their myocardial infarction (MI). MI is frequently unrecognized in women because they may have only vague symptoms, such as sleep disturbance. Describing correlates of sleep disturbance before MI may assist in recognizing women at risk for coronary heart disease.

METHODS

A secondary analysis was performed of a dataset derived from 15 sites.

RESULTS

Of 1270 women experiencing initial MI, 632 reported new onset of or worsening sleep disturbance before MI. Prevalence was similar across racial groups. Women reporting prodromal sleep disturbance were more likely to be older, to be heavier, and to report cognitive changes (adjusted odds ratio [OR], 1.47), new or increasing anxiety (adjusted OR, 2.21), and unusual fatigue (adjusted OR, 2.16).

CONCLUSION

Subjective reports of sleep disturbance preceding MI seem to be prevalent in women of all races and may be an important warning sign for MI in women.

GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: From bench to beyond-Premature Acute Coronary SYndrome)

BACKGROUND

Previous research has not adequately addressed the topic of sex and gender differences in occurrence of premature acute coronary syndrome (ACS). This study will investigate the clinical presentation, prognosis, and health care use in young men and women with ACS.

METHODS

We have set up a prospective, multicenter study of 1,576 patients aged 18-55 years and admitted to hospital with ACS. At baseline, questionnaires will be administered, and anthropometric and biological measurements will be performed. The patients will be observed for at least 1 year, with additional questionnaires being administered at 1, 6, and 12 months post-discharge. A review of medical records will be performed both at baseline and during follow-up.

CONCLUSIONS

This study will provide important evidence on the roles that a wide range of behavioral, environmental, and biological factors play in premature ACS and will help determine to what extent these roles depend on the individual's sex and gender. Ultimately, the knowledge derived from this study may facilitate accurate diagnosis and effective prevention and management of ACS in young women and men.

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.

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.

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.

Symptom clusters predict event-free survival in patients with heart failure

BACKGROUND

Physical symptoms are likely to occur in clusters that may be associated with adverse outcome in patients with heart failure (HF). Despite the importance of early recognition of worsening symptoms in HF management, the impact of physical symptoms on adverse outcome has not been explored in the context of symptom clusters.

PURPOSE

The purposes of this study were to explore which physical symptom clusters occur in HF patients and to determine the impact of symptom clusters on event-free survival.

METHODS

A total of 421 patients (60% male; 62 [SD, 14] years; 72% New York Heart Association class II/III) completed the modified Memorial Symptom Assessment Scale-Heart Failure to measure physical symptoms during an index hospitalization in Seoul, Korea. Times to first event of cardiac rehospitalization and cardiac death were collected for 12 months after discharge and confirmed by review of hospital records. An agglomerative hierarchical clustering approach with Ward's method was used to identify symptom clusters. Hierarchical Cox hazard regression was used to determine the impact of symptom clusters on cardiac rehospitalization and cardiac mortality.

RESULTS

Two distinct symptom clusters, the dyspneic and the weary symptom clusters, occurred in patients with HF. Shortness of breath, difficulty breathing when lying flat, and waking up breathless at night comprised the dyspneic symptom cluster. Lack of energy, lack of appetite, and difficulty sleeping comprised the weary symptom cluster. In hierarchical Cox hazard regression, elevated distress from the weary symptom cluster independently predicted cardiac rehospitalization (hazard ratio, 1.45; 95% confidence interval, 1.09-1.93), and increased distress from the dyspneic symptom cluster independently predicted cardiac mortality (hazard ratio, 2.00; 95% confidence interval, 1.16-3.34).

CONCLUSION

The weary and the dyspneic symptom clusters predicted cardiac rehospitalization and cardiac mortality, respectively. Patient education for self-monitoring of symptoms should focus on symptom clusters rather than single symptom.

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.

Rural Black women's thoughts about exercise

This ethnographic study explored 20 southern rural Black women's thoughts about and practices of exercise. Qualitative analysis revealed four factors: (a) exercise and the heart, (b) barriers to exercise, (c) reasons to exercise, and (d) taking action. Findings may assist clinicians and researchers to develop prevention interventions for this population.

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.

Sex differences in prodromal symptoms of patients with acute coronary syndrome: a pilot study

Increasing evidence suggests that there are sex/gender differences in the presentation and prodromal symptoms of acute coronary syndrome (ACS). The purpose of this pilot study was to identify sex differences in the prodromal symptoms of ACS using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS). Telephone surveys using the MAPMISS were conducted between 4 and 6 months after the ACS event. Seventy-six patients (24 women) participated in the study. The women generally reported higher prodromal scores. Moreover, scores demonstrated differences in prodromal symptoms based on menopausal status. The premenopausal and perimenopausal women reported a greater number and higher frequency of symptoms compared with the men and menopausal women. The results of this study suggest that both men and women report nontraditional prodromal symptoms of ACS. In addition, there appears to be a difference in the frequency and number of symptoms reported based on menopausal status.

Women's prehospital delay associated with myocardial infarction: does race really matter?

BACKGROUND/RESEARCH OBJECTIVE: Well-documented disparities in cardiovascular health account for approximately one third of the difference in life expectancy between blacks and whites. Mortality from cardiovascular disease is greater among black women than among white women, and black women report longer delays in treatment seeking following onset of symptoms of acute myocardial infarction (AMI). Despite this disparate burden, there is little race-specific data on correlates of delay for black or white women. This secondary data analysis compares duration and correlates of delay in treatment seeking by race following onset of AMI symptoms.

SUBJECTS/METHODS

We analyzed self-report data from 509 black and 500 white women, interviewed 4 to 6 months after AMI, using multivariable logistic and linear regression.

RESULTS/CONCLUSIONS

Median delay time was nonsignificantly shorter for black than for white women (1.0 vs 1.5 hours). Equal proportions of black and white women (57% vs 54%) sought treatment within 2 hours of symptom onset. In multivariable analyses, correct attribution of symptoms to AMI was a significant predictor of treatment seeking within 2 hours of symptom onset for black and white women (odds ratios = 2.79 and 3.86, respectively); eligibility for public insurance was a significant predictor for black women only (odds ratio = 2.3). Common comorbidities, AMI risk factors, and other demographics were not significantly associated with delay time. Insurance coverage and the correct attribution of symptoms to cardiac causes are substantial and modifiable predictors of delay in seeking treatment of AMI.

Psychometric testing of the heart failure somatic awareness scale

BACKGROUND

Self-management of heart failure relies on patients to assess their symptoms, but their ability to do so is often difficult to determine. The 12-item self-report Heart Failure Somatic Awareness Scale (HFSAS) was developed to measure awareness of and distress secondary to heart failure symptoms. The purpose of this study was to test the psychometric properties of the HFSAS.

METHODS AND RESULTS

Feasibility and discriminant validity of the HFSAS were tested in 49 patients admitted for an exacerbation of heart failure. The HFSAS was acceptable to patients and discriminated between heart failure symptoms and anxiety (r = 0.25, P = .08). When reliability and validity were tested in 201 patients with acute heart failure, theta reliability was adequate (0.71). The HFSAS was low to moderately correlated with general bodily awareness (r = 0.48). No difference was found based on gender, but younger patients had higher mean and median HFSAS scores (more distress). The HFSAS was a significant predictor of symptom duration prior to seeking care for heart failure; higher scores were associated with longer delay before seeking care.

CONCLUSION

The HFSAS is reliable with content, discriminant, and construct validity. Evaluation of its usefulness in teaching patients to monitor daily symptoms is needed.

Assisting Women to Learn Myocardial Infarction Symptoms

OBJECTIVE

The purpose of this study was to test how teaching format (factual versus storytelling) and restructuring the social norm of caring for others to caring for self affects how women learn to identify and respond to myocardial infarction (MI) symptoms.

DESIGN

The study was a randomized pretest posttest full factorial experiment.

SAMPLE

One hundred and thirteen women participated.

MEASURES

Before and after reading the intervention pamphlet, the women wrote all the MI symptoms that they knew and rated their intention to call 911 if symptoms occurred.

INTERVENTION

The women read one of the four MI pamphlets corresponding to the four conditions.

RESULTS

No significant effects for learning MI symptoms resulted from teaching format or social norms. Women learned three additional MI symptoms. All responded with high intention to call 911 if MI symptoms occurred.

CONCLUSIONS

Women can learn additional MI symptoms from reading a brief pamphlet about MI symptoms. Use of a storytelling format and the social norm of caring for self might not impact how many MI symptoms women learn. Studies using audiovisuals and larger samples are needed to clarify whether storytelling format and the social norm of caring for self-impact learning MI symptoms.

Differential symptoms of acute myocardial infarction in patients with kidney disease: a community-wide perspective

BACKGROUND

Patients seeking care for acute myocardial infarction (AMI) present with multiple symptoms. The objectives of our community-wide study are to examine the symptom profile of patients with, as compared with those without, kidney disease who present to the hospital with independently confirmed AMI.

METHODS

The symptom profile of 4,482 patients from the Worcester, MA, metropolitan area hospitalized with independently validated AMI at all 11 area medical centers during the 4 study years of 1997, 1999, 2001, and 2003 was examined. Factor analysis was used to aggregate the relevant symptoms of AMI. Logistic regression analysis was used to examine differences in symptoms of AMI according to the presence of kidney disease while controlling for several potentially confounding demographic and clinical factors.

RESULTS

Patients with kidney disease were less likely to report chest pain (adjusted odds ratio, 0.57; 95% confidence interval, 0.46 to 0.70), arm pain (odds ratio, 0.52; 95% confidence interval, 0.42 to 0.64), shoulder pain (odds ratio, 0.53; 95% confidence interval, 0.40 to 0.72), or neck pain (odds ratio, 0.54; 95% confidence interval, 0.41 to 0.70), while being more likely to report shortness of breath (odds ratio, 1.35; 95% confidence interval, 1.13 to 1.62), in comparison to patients without kidney disease in the setting of AMI.

CONCLUSION

Kidney disease impacts on the manner in which patients present with AMI. Although patients with kidney disease are at known increased risk for several diseases, this study suggests that kidney disease also might change how these patients experience these diseases, including acute coronary disease.