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

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not.

OBJECTIVE

To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay.

METHODS

This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters.

RESULTS

Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952).

DISCUSSION

Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

An Exploration of the help-seeking experiences of patients in an allied professions-led rapid access chest pain pathway: a qualitative study

OBJECTIVE

A number of studies have explored delayed help-seeking practices for acute coronary syndrome (ACS) and have indentified multiple intersecting factors which may play a role, for example, attributing symptoms, age, gender, ethnicity and contextual influences. However, the pathway to diagnosis for suspected coronary heart disease (CHD) symptoms in a rapid access chest pain clinic (RACPC) context is underexplored. The objective of this study was to examine patients' help-seeking experiences of accessing RACPC services, from the point at which they notice and interpret symptoms, to their decision to seek help from their general practitioner.

DESIGN

Qualitative study.

SETTING

Interviews were conducted in the RACPC at Queen Mary's Roehampton Hospital, London, UK.

PARTICIPANTS

Maximum variation sampling was used to recruit 30 participants (15 men and 15 women) referred to a RACPC, using sampling dimensions of age, ethnicity and occupation.

METHODS

Semi-structured interviews focussed on the patient experience of their pathway to the RACPC. Thematic analysis was used to analyse the interview data.

RESULTS

Participant interpretation of symptoms was shaped by multiple influences; reluctance to seek help contributed to delay; various factors acted as drivers as well as barriers to help-seeking; and GP referrals to RACPC were based on symptoms as well as patients' need for reassurance.

CONCLUSION

We found complex issues shaped the patient's decision-making when accessing the RACPC, including making sense of symptoms and help-seeking practices. These findings can be used to develop health promotion literature to encourage early help-seeking and improve RACPC services.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

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.

Acute coronary syndromes in women and men

Evidence of sex-related disparities in the care and outcomes of patients with acute coronary syndrome (ACS) emerged >30 years ago, and yet the mechanisms behind these sex-specific differences remain unclear. In this Review, we discuss the current literature on differences between women and men in the clinical presentation, pathophysiology, evaluation, management, and outcomes of ACS. Although the symptoms of ACS and the benefits of therapy generally overlap between women and men, women continue to receive less-aggressive invasive and pharmacological therapy than men. In addition, young women in particular have worse short-term and long-term outcomes than men. To understand better the mechanisms behind these continued disparities, we have identified areas of future research that need to be urgently addressed in fields that range from clinical evaluation and management, to increasing representation of women in research.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Gender differences in symptom predictors associated with acute coronary syndrome: A prospective observational study

Signs and symptoms (typical and atypical symptoms) of acute coronary syndromes (ACS) differ between men and women. Identification of gender differences has implications for both health care providers and the general public. The aim of this study was to determine the symptom predictors of the acute coronary syndromes in men and women. In this prospective study, nurse data collectors directly observed 256 men and 182 women (N = 438) with symptoms suggestive of ACS in the Emergency Departments of eight hospitals in Tehran. ACS was eventually diagnosed in 183 (57.2%) men and 137 (42.8%) women on the basis of standard electrocardiogram and cardiac enzyme (CPK-MB) level. In men, chest symptoms (OR = 3.22, CI = 0.137-0.756, P = 0.009), dyspnea (OR = 2.65, CI = 1.78-4.123 P = 0.001) and diaphoresis (OR = 2.175, CI = 1.020-4.639, P = 0.044) were significantly associated with the diagnosis of ACS 3.78, 2.72 and 1.87 times more than in women having these symptoms, respectively. These results indicated that chest symptoms, diaphoresis and dyspnea were the more pronounced typical symptoms of ACS in men compared to women. Additionally, the numbers of typical symptoms can be considered as more predictive of ACS in men (OR = 1.673, CI = 1.211-2.224, P < 0.001) than women (OR = 1.271, CI = 1.157-2.331, P = 0.212). Therefore, clinicians need to take men showing typical symptoms into consideration carefully.

Gender differences in factors associated with prehospital delay among acute coronary syndrome patients in Pakistan

PURPOSE

To identify gender differences in prehospital delay time (PDT) and its associated factors among acute coronary syndrome (ACS) patients.

DESIGN

Descriptive cross-sectional comparative study.

METHODS

This study was conducted among 249 ACS patients at two tertiary care hospitals of a large metropolitan city of Pakistan. Data were collected through the modified Response to Symptoms Questionnaire.

RESULTS

The median PDT of women was found to be 7 hours, compared to 3.5 hours among men (p = .001). Results of the regression analysis indicated that most women delayed because of social factors, such as attendants' responses to their symptoms (p = .002), and because they were worried about expenses required for the treatment (p = .002); yet, most men delayed owing to individual factors, such as waiting for symptoms to subside (p< .001), and not recognizing the symptoms as being cardiac related (p< .001). Having anxiety and lack of knowledge about symptoms was associated with extended PDT among both genders.

CONCLUSION

Women delayed longer than men in seeking treatment for their ACS symptoms. Different factors were associated with PDT in women and men. This study may provide important insights for designing interventional studies to reduce PDT in Pakistani ACS patients.

Sensitivity, specificity, and sex differences in symptoms reported on the 13-item acute coronary syndrome checklist

Background

Clinical symptoms are part of the risk stratification approaches used in the emergency department (ED) to evaluate patients with suspected acute coronary syndromes (ACS). The objective of this study was to determine the sensitivity, specificity, and predictive value of 13 symptoms for a discharge diagnosis of ACS in women and men.

Methods and Results

The sample included 736 patients admitted to 4 EDs with symptoms suggestive of ACS. Symptoms were assessed with the 13‐item validated ACS Symptom Checklist. Mixed‐effects logistic regression models were used to estimate sensitivity, specificity, and predictive value of each symptom for a diagnosis of ACS, adjusting for age, obesity, diabetes, and functional status. Patients were predominantly male (63%) and Caucasian (70.5%), with a mean age of 59.7±14.2 years. Chest pressure, chest discomfort, and chest pain demonstrated the highest sensitivity for ACS in both women (66%, 66%, and 67%) and men (63%, 69%, and 72%). Six symptoms were specific for a non‐ACS diagnosis in both women and men. The predictive value of shoulder (odds ratio [OR]=2.53; 95% CI=1.29 to 4.96) and arm pain (OR 2.15; 95% CI=1.10 to 4.20) in women was nearly twice that of men (OR=1.11; 95% CI=0.67 to 1.85 and OR=1.21; 95% CI=0.74 to 1.99). Shortness of breath (OR=0.49; 95% CI=0.30 to 0.79) predicted a non‐ACS diagnosis in men.

Conclusions

There were more similarities than differences in symptom predictors of ACS for women and men.

Cognitive representations of symptoms of acute coronary syndrome and coping responses to the symptoms as correlates to pre-hospital delay in Omani women and men patients

The major purpose of this study was to describe gender-related cognitive representations of symptoms of acute coronary syndrome and coping responses to the symptoms as correlates to pre-hospital delay. Data were collected from 131 hospitalised Omani patients for acute coronary syndrome (81 men and 50 women) using a structured interview. Statistical analyses indicated that women perceived themselves as less susceptible to acute coronary syndrome than men. They reported the symptoms, shortness of breath and nausea/vomiting, more frequently than did men. Men who reported shorter pre-hospital delay were more likely to be free from diabetes, report neck pain, not experience left arm pain, attribute the symptoms to cardiac origin and not use the coping responses, ‘wait and see’ and ‘attempted to relax’. Whereas, women with shorter pre-hospital delay were more likely to experience sweating, perceive greater overall intensity of the symptoms and not report fear of diagnostic procedures as a barrier to seek healthcare early. The findings of this study suggest that, in women, the emotional aspect of the symptoms dominates the cognitive appraisal process, whereas the pathological aspect of the symptoms dominates the appraisal process in men.

Treatment-seeking delays in patients with acute myocardial infarction and use of the emergency medical service

OBJECTIVES

To investigate treatment-seeking delays in Chinese patients with acute myocardial infarction (AMI) and to compare sex differences in this behaviour.

METHODS

A descriptive cross-sectional study was undertaken in patients with AMI, admitted to one of three hospitals in Shanghai, China. A treatment-seeking behaviour questionnaire was administered to each patient within 48 h of hospital admission.

RESULTS

In total, 250 patients were included: 159 men and 91 women. The median time for patients with AMI to make a treatment-seeking decision was 130 min. Women took significantly longer to seek treatment than men (240 min versus 120 min). The majority of patients (70.8%) took >1 h to decide to seek treatment. The emergency medical service (EMS) was used by 77 (30.8%) of patients, and these patients had a significantly shorter prehospital delay time than those who transported themselves to hospital. Predictive factors for using the EMS were pain level and rating AMI symptoms as severe.

CONCLUSIONS

Chinese patients with AMI had a significant prehospital delay time and women took longer than men to seek treatment. Public awareness of the importance of seeking immediate medical assistance for AMI via the EMS needs to be increased in China.

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.

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

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

Physiological and anatomical bases for sex differences in pain and nausea as presenting symptoms of acute coronary syndromes

Acute coronary syndromes (ACS) are common in both men and women. Studies show that women have longer times before diagnosis and treatment in the Emergency Department and worse outcomes than men, which may be related to the differing symptom presentations of men and women. Men are more likely to have chest pain, whereas women are more likely to have dyspnea or nausea. However, women tend to be older and more likely to have diabetes mellitus, hypertension, and peripheral neuropathies. Men and women also exhibit differences in the neural receptors and pathways involved in pain and noxious-stimuli perception. Moreover, men and women may have subtle differences in the locations and sites of their atherosclerotic lesions, all of which may affect symptom presentation. The purposes of this review are to present: (1) the physiology of two common symptoms associated with ACS, ie, pain and nausea; (2) how these symptoms differ between men and women; and (3) how different comorbidities may affect the presentation of these symptoms.

Time to treatment for acute coronary syndromes: the cost of indecision

BACKGROUND AND RESEARCH OBJECTIVES

: Multiple sociodemographic and environmental factors have been associated with urgent treatment-seeking behaviors for patients experiencing acute coronary syndromes (ACSs). However, variables that directly affect the decision to seek care in the emergency department (ED) have been less well defined. The objective of this study was to explore the factors associated with a decision to seek care for symptoms of ACSs and to describe patient characteristics associated with time to presentation.

SUBJECTS AND METHODS

: A cross-sectional, descriptive design was used. The nonprobability sample included 256 patients admitted to the hospital with ACSs. The study was conducted on cardiac step-down units at 2 large urban medical centers. Reasons for seeking care were elicited during structured interviews in the patient's room. These factors and other patient characteristics were treated as predictor variables in an analysis of time from symptom onset to arrival in the ED.

RESULTS AND CONCLUSIONS

: Five categories of decision making were identified through descriptive content analyses and were labeled new onset of chest pain, ongoing evaluation of symptom severity, symptoms other than chest pain that worsened or were unrelieved, externally motivated, and internally motivated. Median time from symptom onset to arrival in the ED was 9.5 hours for women and 6 hours for men. Patients who experienced constant pain (hazard ratio, 1.44; P =.01) and those with ST-segment elevation myocardial infarction (hazard ratio, 1.59; P = .004) sought treatment significantly sooner than patients with intermittent pain. Older patients sought treatment later (hazard ratio, 0.99; P = .02). Patients who are older and experience intermittent pain should be encouraged to seek emergent treatment for symptoms that may represent ACSs. New evidence of patients' decision-making processes and dangerous delay in time to treatment provides knowledge needed to counsel patients about the benefits of seeking care quickly when symptoms begin.

Predictors of pre-hospital delay among patients with acute myocardial infarction

OBJECTIVE

To evaluate current literature on predictors of pre-hospital delay among patients with acute myocardial infarction (AMI).

METHODS

Medline, CINHAL, and Psych Info databases were searched using keywords: attitude to illness/health, health beliefs, help/health seeking behavior, health behavior, psychosocial factors, treatment delay, socioeconomic factors, time factors, pre-hospital delay, and symptoms. These keywords were combined with AMI to identify literature published during 1995-2008.

RESULTS

Twenty-six data-based research articles were identified. Delay varied across literature and median pre-hospital delay was often reported due to distribution skewness resulting from extremely prolonged values (1.5-15.2h). Six categories of predictors influenced pre-hospital delay; socio-demographic, symptom onset context, cognitive, affective/psychological, behavioral, and clinical factors. Pre-hospital delay was shortest when the decision to seek healthcare was facilitated by family members or coworkers and when symptoms suggestive of heart attack were continuous and severe.

CONCLUSION AND PRACTICE IMPLICATIONS

Developing interventions programs to reduce pre-hospital delay for high-risk patients is warranted. Because decision delay is the only modifiable part by intervention, it is recommended that future investigations and interventions attend to decision time as the primary variable of interest instead of combining it with transportation time. Moreover, content of patient education need to emphasize on symptom awareness and recognition, and prompt and proper patient actions for optimum results. Also, in order to eliminate sampling bias resulting from investigating surviving AMI patients, it is recommended that future studies incorporate data from both surviving and surrogates of non-surviving AMI patients.

Influence of Assessment Methods on Reports of Gender Differences in AMI Symptoms

The purpose of this secondary analysis was to compare gender differences in retrospective reports of acute myocardial infarction (AMI) symptoms resulting from two different assessment methods: the open-ended inquiry and the combined assessment approach. Women reported more atypical symptoms in their responses to the open-ended inquiry and a greater number of typical, atypical, and total symptoms in the combined assessment approach in which the open-ended inquiry was followed by a series of closed-ended questions. Women reported more jaw/neck pain, dyspnea, and palpitations in response to the open-ended inquiry. In the combined assessment, men reported more chest pain/discomfort than women, whereas women were more likely to report jaw/neck pain, dyspnea, back pain, fatigue, paroxysmal nocturnal dyspnea, and palpitations. The data suggest that careful attention to the type of questions used to assess AMI symptoms could lead to more definitive conclusions regarding gender differences in AMI symptoms.