The vast majority of patients 55 and younger who were diagnosed with an acute coronary syndrome (ACS) presented with chest pain, although women were more likely than men to present without that symptom, researchers found.
The rate of presentation without chest pain was 19% in women and 13.7% in men (P=0.03), Louise Pilote, MD, PhD, of McGill University in Montreal, and colleagues reported online in JAMA Internal Medicine.
Those rates are much lower than those seen in a previous registry study of patients 65 and older, which showed that 41% of men and 47% of women presented without chest pain.
"Our findings indicate that chest pain is the predominant symptom that should direct diagnostic evaluation for ACS and be used for public health messages for young women and men, similar to older patients," Pilote and colleagues wrote. "However, healthcare providers should still maintain a high degree of suspicion for ACS in young patients, particularly women, given that one in five women with diagnosed ACS do not report chest pain."
Because most of the patients without chest pain experienced at least one other symptom, "standardized collection of all ACS-related symptoms is needed," they wrote.
"Limiting such an effort are the many at-risk ACS candidates who do not seek preventive or acute medical care, especially in this younger age group," Akintunde Akinkuolie, MBBS, MPH, and Samia Mora, MD, MHS, of Brigham and Women's Hospital in Boston, wrote in an accompanying editorial. "Furthermore, diagnosis of any disease with a lower prevalence but higher mortality, such as coronary artery disease in younger women, is more challenging."
But public health messages about ACS should not be gender specific, Sharonne Hayes, MD, of the Mayo Clinic in Rochester, Minn., told MedPage Today
“I think what we need to do as healthcare providers is to continue to emphasize that chest pain is the cardinal symptom of a heart attack for men and for women – and that includes younger men and women. But we need to probe, to have a higher level of alert with women because they are more likely to have nonchest pain symptoms, such as shortness of breath, flushing, or tachycardia,” Hayes said.
Pilote and colleagues examined data from 1,015 patients 55 and younger (median age 49; 30% women) who were hospitalized for ACS and who were enrolled in the ongoing GENESIS PRAXY study from January 2009 to September 2012. The study was conducted at 24 centers in Canada and one each in the U.S. and Switzerland.
While in the hospital, the patients took the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, which catalogs 37 acute myocardial infarction symptoms.
Chest pain was the most common symptom, reported by 86.3% of men and 81% of women (P=0.03 for the sex difference).
Nonchest pain symptoms also were frequently reported by both men and women, although a greater number were experienced by women (average 5.3 versus 4.3, P<0.001). The most common in both sexes were weakness, feeling hot or flushed, shortness of breath, cold sweats, and pain in the left arm or shoulder.
After accounting for numerous potential confounders -- including ACS severity -- there were only two factors independently associated with presentation without chest pain: female sex (OR 1.95, 95% CI 1.23-3.11) and tachycardia (OR 2.07, 95% CI 1.20-3.56).
ACS type, troponin levels, and coronary stenosis -- all indicative of the severity of ACS -- were not predictive of presentation with or without chest pain.
More research is needed to better understand the sex differences in both ACS symptom presentation and outcomes, Akinkuolie and Mora wrote in their editorial.
"Meanwhile, it is prudent for public health messages to target both men and women regarding ACS symptom presentation with or without chest pain so as to encourage earlier and more widespread access to appropriate and lifesaving care," they wrote.
The study authors acknowledged that their analysis was limited by the inclusion of patients with a final diagnosis of ACS only, the inability to interview patients who died either in the ER or shortly after admission, and the lack of statistical power to examine sex differences within each category of ACS type.
From the American Heart Association:
- 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
- 15-Year Trends in Awareness of Heart Disease in Women: Results of a 2012 National Survey
- Guidelines for the Prevention of Cardiovascular Disease in Women -- 2011 Update
Primary source: JAMA Internal Medicine
Source reference: Khan N, et al "Sex differences in acute coronary syndrome symptom presentation in young patients" JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.10149.
Additional source: JAMA Internal Medicine
Source reference: Akinkuolie A, Mora S "Are there sex differences in acute coronary syndrome presentation? A guide through the maze" JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.807.