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Symptoms of Men and Women Presenting With Acute Coronary Syndromes

2006; Elsevier BV; Volume: 98; Issue: 9 Linguagem: Inglês

10.1016/j.amjcard.2006.05.049

ISSN

1879-1913

Autores

Cynthia Arslanian‐Engoren, Amisha Patel, Jianming Fang, David Armstrong, Eva Kline‐Rogers, Claire S. Duvernoy, Kim A. Eagle,

Tópico(s)

Cardiac Health and Mental Health

Resumo

This study evaluated symptom similarities and differences between men and women presenting with acute coronary syndromes (ACSs) and determined whether differences in presentation are intrinsic to patient gender or to other factors. This study was a subgroup analysis of patients from an ACS registry. We compared differences in symptom presentation between men and women and analyzed them using binary logistic regression with all variables and 2 × 2 interactions. Patient gender was forced to remain in the models. Women comprised 35% of the 1,941 patients admitted with confirmed ACS. Men were more likely to present with chest pain, left arm pain, or diaphoresis. Nausea was more common in women. Dyspnea did not differ between groups. After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest or left arm pain. We found that differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness. In conclusion, gender should be considered when evaluating patients with symptoms of ACS. This study evaluated symptom similarities and differences between men and women presenting with acute coronary syndromes (ACSs) and determined whether differences in presentation are intrinsic to patient gender or to other factors. This study was a subgroup analysis of patients from an ACS registry. We compared differences in symptom presentation between men and women and analyzed them using binary logistic regression with all variables and 2 × 2 interactions. Patient gender was forced to remain in the models. Women comprised 35% of the 1,941 patients admitted with confirmed ACS. Men were more likely to present with chest pain, left arm pain, or diaphoresis. Nausea was more common in women. Dyspnea did not differ between groups. After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest or left arm pain. We found that differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness. In conclusion, gender should be considered when evaluating patients with symptoms of ACS. Women and the elderly take longer to seek medical care when acute coronary syndrome (ACS) symptoms start.1Gibler W.B. Armstrong P.W. Ohman E.M. Weaver W.D. Stebbins A.L. Gore J.M. Newby L.K. Califf R.M. Topol E.J. Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) Investigators Persistence of delays in presentation and treatment for patients with acute myocardial infarction: the GUSTO-I and GUSTO-III experience.Ann Emerg Med. 2002; 39: 123-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 2Dracup K. Moser D.K. Beyond sociodemographics: factors influencing the decision to seek treatment for symptoms of acute myocardial infarction.Heart Lung. 1997; 26: 253-262Abstract Full Text PDF PubMed Scopus (170) Google Scholar, 3Yarzebski J. Col N. Pagley P. Savageau J. Gore J.M. Goldberg R.J. Gender differences and factors associated with the receipt of thrombolytic therapy in patients with acute myocardial infarction: a community-wide perspective.Am Heart J. 1996; 131: 43-50Abstract Full Text PDF PubMed Scopus (66) Google Scholar When they finally present at the emergency department for management of ACS, women have further delays in the completion of an electrocardiogram and in the initiation of life-saving therapy, i.e., thrombolytics or balloon angioplasty.4Hasdai D. Porter A. Rosengren A. Behar S. Boyko V. Battler A. Effect of gender on outcomes of acute coronary syndromes.Am J Cardiol. 2003; 91: 1466-1469Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 5Kudenchuk P.J. Maynard C. Martin J.S. Wirkus M. Weaver W.D. Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry).Am J Cardiol. 1996; 78: 9-14Abstract Full Text PDF PubMed Scopus (266) Google Scholar In a telephone survey, men and women reported similar knowledge of symptoms of a heart attack, with chest pain as the predominant symptom.6Goff Jr, D.C. Sellers D.E. McGovern P.G. Meischke H. Goldberg R.J. Bittner V. Hedges J.R. Allender P.S. Nichaman M.Z. Knowledge of heart attack symptoms in a population survey in the United States: the REACT trial.Arch Intern Med. 1998; 158: 2329-2338Crossref PubMed Scopus (147) Google Scholar Similarly, computer algorithms and decision aids for predicting ACS in the emergency department rely on chest pain as the major symptom predictor.7Selker H.P. Beshansky J.R. Griffith J.L. Aufderheide T.P. Ballin D.S. Bernard S.A. Crespo S.G. Feldman J.A. Fish S.S. Gibler W.B. et al.Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia.Ann Intern Med. 1998; 129: 845-855Crossref PubMed Google Scholar, 8Boufous S. Kelleher P.W. Pain C.H. Dann L.M. Ieraci S. Jalaludin B.B. Gray A.L. Harris S.E. Juergens C.P. Impact of a chest-pain guideline on clinical decision-making.Med J Aust. 2003; 178: 375-380PubMed Google Scholar However, not all patients with ACS have chest pain, and those who do not, have delayed treatment and worse outcomes: more hospital morbidity, higher mortality, and fewer evidence-based therapies, including revascularization, anticoagulation, β blockade, statins, and antiplatelet agents.9Brieger D. Eagle K.A. Goodman S.G. Steg P.G. Budaj A. White K. Montalescot G. GRACE InvestigatorsAcute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group.Chest. 2004; 126: 461-469Crossref PubMed Scopus (376) Google Scholar One possible reason for women's delayed arrival to the emergency department and for less aggressive triage and care in the emergency department is that ACS symptoms differ between men and women. This study evaluated symptom similarities and differences between men and women presenting with ACS and determined if any differences in presentation are intrinsic to the gender of the patient or can be explained on the basis of age, co-morbidities, history, and location of myocardial ischemia. This study was an analysis of patients from the Acute Coronary Syndrome Registry at the University of Michigan (Ann Arbor, Michigan). Full details of the project have been previously published.10Mehta R.H. Das S. Tsai T. Nolan B.M. Kearly G.E. Eagle K.A. Quality improvement initiative and its impact on the management of patients with acute myocardial infarction.Arch Int Med. 2000; 160: 3057-3062Crossref PubMed Scopus (62) Google Scholar, 11The Grace InvestigatorsRationale and design of the GRACE (Global Registry of Acute Coronary Events) project: a multinational registry of patients hospitalized with acute coronary syndromes.Am Heart J. 2001; 141: 190-199Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar The study complied with the Declaration of Helsinki and was approved by the institutional review board. Patients gave written consent.11The Grace InvestigatorsRationale and design of the GRACE (Global Registry of Acute Coronary Events) project: a multinational registry of patients hospitalized with acute coronary syndromes.Am Heart J. 2001; 141: 190-199Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar Consecutive admissions for ACS were enrolled. All patients in the registry were ≥18 years old, admitted alive to the hospital with a presumptive diagnosis of ACS, and had ≥2 of the following: electrocardiographic changes consistent with ACS, serial increases in serum enzymes consistent with ACS, or documentation of coronary artery disease. In addition, patients with a hospital discharge diagnosis of noncardiac chest pain or non-ACS presentation were excluded. A trained research coordinator used a standardized case report form to retrospectively identify demographics, medical history, and presenting symptoms. Definitions were standardized.11The Grace InvestigatorsRationale and design of the GRACE (Global Registry of Acute Coronary Events) project: a multinational registry of patients hospitalized with acute coronary syndromes.Am Heart J. 2001; 141: 190-199Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar Differences between men and women were assessed using the chi-square or Fisher's exact test for categorical variables, and the Student's t test was used for continuous variables. Binary logistic regression with forward selection was used. A p value <0.2 was required for entry into the models. All demographic, historical, presentation, electrocardiographic, and laboratory variables and the possible 2 level interactions were examined for inclusion. Time from symptom onset to presentation was divided into 3 categories: 6 hours, which was the reference. Type of coronary event was also divided into 3 categories: ST-elevation myocardial infarction, non–ST-elevation myocardial infarction, and unstable angina, which was the reference. Gender was forced to remain in the models. An odds ratio whose 95% confidence interval excluded 1 and with a p value <0.05 was taken to be statistically significant. SAS (SAS Institute, Cary, North Carolina) was used for all statistics. One thousand nine hundred forty-one patients were admitted with confirmed ACS, 72% of whom had myocardial infarction and 28% had unstable angina. Women comprised only 35% of the total population. Demographics were generally similar between men and women, except women were significantly older than men. Elderly women were more likely to be obese, but younger women were more likely to be lean compared with men of the same age. Elderly women were less likely to have smoked. Women were more likely than men to have hypertension. Despite similar rates of previous angina, myocardial infarction, and positive stress test results, men were more likely to have previously undergone coronary angiography or coronary artery bypass grafting (Table 1).Table 1Demographics and medical historyVariableAllMen (n = 1,258)Women (n = 683)All<65 Years (n = 722)≥65 Years (n = 536)<65 Years (n = 270)≥65 Years (n = 413)Age (yrs)61 ± 11p <0.01, all men versus all women.52 ± 8§p <0.01, <65- versus ≥65-year-old men.74 ± 7§p <0.01, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.53 ± 9∥p <0.01, <65- versus ≥65-year-old women.76 ± 7∥p <0.01, <65- versus ≥65-year-old women.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.67 ± 12p <0.01, all men versus all women.BMI (kg/m2)28.7 ± 2.729.6 ± 5.8§p <0.01, <65- versus ≥65-year-old men.27.5 ± 7.4§p <0.01, <65- versus ≥65-year-old men.30.2 ± 8.3∥p <0.01, <65- versus ≥65-year-old women.28.0 ± 6.6∥p <0.01, <65- versus ≥65-year-old women.28.9 ± 2.9 <25287 (23%)p <0.01, all men versus all women.121 (18%)§p <0.01, <65- versus ≥65-year-old men.#p <0.01, <65-year-old men versus <65-year-old women.166 (35%)§p <0.01, <65- versus ≥65-year-old men.67 (29%)∥p <0.01, <65- versus ≥65-year-old women.#p <0.01, <65-year-old men versus <65-year-old women.137 (40%)∥p <0.01, <65- versus ≥65-year-old women.204 (30%)p <0.01, all men versus all women. 25–30438 (35%)p <0.01, all men versus all women.250 (38%)188 (40%)⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.74 (32%)93 (27%)⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.167 (24%)p 30407 (32%)290 (44%)§p <0.01, <65- versus ≥65-year-old men.117 (25%)§p <0.01, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.92 (39%)115 (33%)⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.207 (30%)Ever smoked866 (69%)p <0.01, all men versus all women.518 (72%)‡p <0.05, <65- versus ≥65-year-old men.348 (65%)‡p <0.05, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.186 (69%)∥p <0.01, <65- versus ≥65-year-old women.159 (39%)∥p <0.01, <65- versus ≥65-year-old women.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.345 (51%)p <0.01, all men versus all women.Hypertension⁎Defined as previously diagnosed systemic hypertension treated or untreated.786 (62%)p <0.01, all men versus all women.410 (57%)§p <0.01, <65- versus ≥65-year-old men.#p <0.01, <65-year-old men versus <65-year-old women.376 (71%)§p <0.01, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.179 (67%)∥p <0.01, <65- versus ≥65-year-old women.#p <0.01, <65-year-old men versus <65-year-old women.331 (80%)∥p <0.01, <65- versus ≥65-year-old women.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.510 (75%)p <0.01, all men versus all women.Dyslipidemia†Defined as previously diagnosed hyperlipidemia or use of lipid-lowering medication.784 (62%)465 (65%)319 (60%)163 (61%)237 (58%)400 (59%)Angina pectoris670 (53%)369 (52%)301 (56%)141 (52%)206 (50%)347 (51%)Myocardial infarction526 (42%)281 (39%)‡p <0.05, <65- versus ≥65-year-old men.245 (46%)‡p <0.05, <65- versus ≥65-year-old men.97 (36%)174 (42%)271 (40%)Congestive heart failure207 (16%)p <0.01, all men versus all women.77 (11%)§p <0.01, <65- versus ≥65-year-old men.130 (24%)§p <0.01, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.40 (15%)∥p <0.01, <65- versus ≥65-year-old women.137 (33%)∥p <0.01, <65- versus ≥65-year-old women.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.177 (26%)p <0.01, all men versus all women.Stroke or transient ischemic attack133 (11%)p <0.05, all men versus all women.47 (7%)§p <0.01, <65- versus ≥65-year-old men.86 (16%)§p <0.01, <65- versus ≥65-year-old men.21 (8%)∥p <0.01, <65- versus ≥65-year-old women.76 (18%)∥p <0.01, <65- versus ≥65-year-old women.97 (14%)p <0.05, all men versus all women.Peripheral vascular disease181 (14%)65 (9%)§p <0.01, <65- versus ≥65-year-old men.116 (22%)§p <0.01, <65- versus ≥65-year-old men.35 (13%)75 (18%)110 (16%)Diabetes mellitus363 (29%)195 (27%)¶p <0.05, <65-year-old men versus <65-year-old women.168 (31%)92 (34%)¶p <0.05, <65-year-old men versus <65-year-old women.131 (32%)223 (33%)Positive stress test240 (19%)130 (18%)110 (21%)44 (17%)72 (18%)116 (17%)Coronary angiogram619 (49%)p <0.01, all men versus all women.326 (46%)§p <0.01, <65- versus ≥65-year-old men.#p <0.01, <65-year-old men versus <65-year-old women.293 (55%)§p <0.01, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.97 (36%)#p <0.01, <65-year-old men versus <65-year-old women.181 (44%)⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.278 (41%)p <0.01, all men versus all women.Coronary angioplasty362 (29%)p <0.05, all men versus all women.213 (30%)149 (28%)64 (24%)101 (25%)165 (24%)p <0.05, all men versus all women.Coronary bypass325 (26%)p <0.01, all men versus all women.137 (19%)§p <0.01, <65- versus ≥65-year-old men.#p <0.01, <65-year-old men versus <65-year-old women.188 (35%)§p <0.01, <65- versus ≥65-year-old men.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.30 (11%)∥p <0.01, <65- versus ≥65-year-old women.#p <0.01, <65-year-old men versus <65-year-old women.79 (19%)∥p <0.01, <65- versus ≥65-year-old women.⁎⁎p <0.01, ≥65-year-old men versus ≥65-year-old women.109 (16%)p <0.01, all men versus all women.BMI = body mass index. Defined as previously diagnosed systemic hypertension treated or untreated.† Defined as previously diagnosed hyperlipidemia or use of lipid-lowering medication.‡ p <0.05, <65- versus ≥65-year-old men.§ p <0.01, <65- versus ≥65-year-old men.∥ p <0.01, <65- versus ≥65-year-old women.¶ p <0.05, <65-year-old men versus <65-year-old women.# p <0.01, <65-year-old men versus <65-year-old women. p <0.01, ≥65-year-old men versus ≥65-year-old women.†† p <0.05, all men versus all women.‡‡ p <0.01, all men versus all women. Open table in a new tab BMI = body mass index. Elderly men and women were more likely than their younger same-gender counterparts to have non–ST-segment elevation myocardial infarctions. There was no difference between men and women in type of myocardial infarction. However, women on average delayed coming to the hospital longer after initial symptoms started than men did (Table 2).Table 2Acute coronary syndrome presentationVariableAllMen (n = 1,258)Women (n = 683)All<65 Years (n = 722)≥65 Years (n = 536)<65 Years (n = 270)≥65 Years (n = 413)Time to presentation (h)12.1 ± 17.1¶p <0.01, all men versus all women.11.6 ± 15.0‡p <0.05, <65-year-old men versus <65-year-old women.12.7 ± 19.514.4 ± 20.4¶p <0.01, all men versus all women.14.3 ± 25.8‡p <0.05, <65-year-old men versus <65-year-old women.14.5 ± 15.8 <1170 (14%)95 (13%)75 (14%)§p <0.05, ≥65-year-old men versus ≥65-year-old women.43 (16%)†p <0.05, <65- versus ≥65-year-old women.40 (10%)†p <0.05, <65- versus ≥65-year-old women.§p <0.05, ≥65-year-old men versus ≥65-year-old women.83 (12%) 1–6531 (42%)¶p <0.01, all men versus all women.319 (44%)‡p <0.05, <65-year-old men versus <65-year-old women.212 (40%)95 (35%)‡p <0.05, <65-year-old men versus <65-year-old women.147 (36%)242 (35%)¶p 6547 (43%)¶p <0.01, all men versus all women.303 (42%)244 (46%)§p <0.05, ≥65-year-old men versus ≥65-year-old women.130 (49%)223 (54%)§p <0.05, ≥65-year-old men versus ≥65-year-old women.353 (52%)¶p <0.01, all men versus all women.Type of ACS ST-elevated myocardial infarction229 (18%)143 (20%)86 (16%)47 (14%)60 (15%)107 (16%) Non–ST-elevated myocardial infarction680 (54%)368 (51%)⁎p <0.05, <65- versus ≥65-year-old men.312 (58%)⁎p <0.05, <65- versus ≥65-year-old men.135 (50%)†p <0.05, <65- versus ≥65-year-old women.238 (57%)†p <0.05, <65- versus ≥65-year-old women.373 (55%) Unstable angina pectoris349 (28%)211 (29%)138 (26%)88 (33%)115 (28%)203 (30%)ST-segment deviation296 (24%)166 (23%)130 (25%)64 (24%)85 (21%)149 (22%) ST elevation221 (18%)139 (19%)82 (15%)47 (17%)53 (13%)100 (15%) Anterior98 (8%)53 (7%)45 (8%)23 (9%)22 (5%)45 (7%) Inferior112 (9%)∥p <0.05, all men versus all women.78 (11%)34 (6%)19 (7%)25 (6%)44 (6%)∥p <0.05, all men versus all women. Lateral54 (4%)33 (5%)21 (4%)14 (5%)16 (4%)30 (4%) ST depression164 (13%)78 (11%)86 (16%)39 (14%)51 (12%)90 (13%) Anterior70 (6%)38 (5%)32 (6%)12 (4%)25 (6%)37 (5%) Inferior46 (4%)20 (3%)26 (5%)14 (5%)14 (3%)28 (8%) Lateral85 (7%)33 (5%)52 (10%)20 (7%)35 (8%)55 (8%) p <0.05, <65- versus ≥65-year-old men.† p <0.05, <65- versus ≥65-year-old women.‡ p <0.05, <65-year-old men versus <65-year-old women.§ p <0.05, ≥65-year-old men versus ≥65-year-old women.∥ p <0.05, all men versus all women.¶ p <0.01, all men versus all women. Open table in a new tab Men were more likely to present with chest pain, although the incidence of chest pain decreased with advancing age in men and women. Similarly, left arm pain and diaphoresis were more common in men, whereas nausea was more common in women. Right arm pain was more common in older men than in men who were <65 years of age. Dyspnea did not differ between groups. Among the rarer symptoms, jaw pain, neck pain, back pain, and emesis were more common in women (Table 3).Table 3Acute coronary syndrome symptoms by patient genderVariableAllMen (n = 1,258)Women (n = 683)All<65 Years (n = 722)≥65 Years (n = 536)<65 Years (n = 270)≥65 Years (n = 413)Chest pain1,123 (89%)¶p <0.01, all men versus all women.665 (92%)⁎p <0.01, <65- versus ≥65-year-old men.458 (85%)⁎p <0.01, <65- versus ≥65-year-old men.§p <0.01, ≥65-year-old men versus ≥65-year-old women.238 (88%)†p <0.01, <65- versus ≥65-year-old women.324 (78%)†p <0.01, <65- versus ≥65-year-old women.§p <0.01, ≥65-year-old men versus ≥65-year-old women.562 (82%)¶p <0.01, all men versus all women.Dyspnea607 (48%)338 (47%)269 (50%)137 (51%)213 (52%)350 (51%)Diaphoresis478 (38%)¶p <0.01, all men versus all women.303 (42%)⁎p <0.01, <65- versus ≥65-year-old men.‡p <0.01, <65-year-old men versus <65-year-old women.175 (33%)⁎p <0.01, <65- versus ≥65-year-old men.83 (31%)‡p <0.01, <65-year-old men versus <65-year-old women.116 (28%)199 (29%)¶p <0.01, all men versus all women.Left arm pain374 (30%)∥p <0.05, all men versus all women.239 (33%)⁎p <0.01, <65- versus ≥65-year-old men.135 (25%)⁎p <0.01, <65- versus ≥65-year-old men.79 (29%)93 (23%)172 (25%)∥p <0.05, all men versus all women.Nausea317 (25%)∥p <0.05, all men versus all women.195 (27%)‡p <0.01, <65-year-old men versus <65-year-old women.122 (23%)98 (36%)†p <0.01, <65- versus ≥65-year-old women.‡p <0.01, <65-year-old men versus <65-year-old women.103 (25%)†p <0.01, <65- versus ≥65-year-old women.201 (29%)∥p <0.05, all men versus all women.Right arm pain113 (9%)79 (11%)⁎p <0.01, <65- versus ≥65-year-old men.34 (6%)⁎p <0.01, <65- versus ≥65-year-old men.25 (9%)31 (8%)56 (8%) p <0.01, <65- versus ≥65-year-old men.† p <0.01, <65- versus ≥65-year-old women.‡ p <0.01, <65-year-old men versus <65-year-old women.§ p <0.01, ≥65-year-old men versus ≥65-year-old women.∥ p <0.05, all men versus all women.¶ p <0.01, all men versus all women. Open table in a new tab After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest, left arm, or right arm pain or dyspnea (Table 4). Anterior wall ST-segment depression was negatively associated with dyspnea (Table 4), whereas inferior ST-segment elevation was the strongest predictor of nausea (Table 4).Table 4Predictors of chest pain, left arm pain, right arm pain, diaphoresis, dyspnea, and nauseaFactorOdds Ratio95% Confidence Intervalp ValuePredictors of chest pain Age (yrs)0.9640.953–0.976<0.0001 Angina pectoris3.1902.286–4.453<0.0001 Heart failure0.4360.305–0.623<0.0001 Renal failure0.2400.113–0.5110.0002 Diabetes mellitus0.6700.489–0.9190.0129 Positive stress test result0.4530.295–0.6940.0003 Previous cardiac catheterization1.9441.356–2.7870.0003 Initial high troponin level0.5640.402–0.7900.0009 Pulse (beats/min)0.9850.979–0.991<0.0001 Diastolic blood pressure (mm Hg)1.0121.004–1.0200.0052 Non–ST-elevated myocardial infarction vs unstable angina0.5730.351–0.9370.0264 Female gender0.8610.632–1.1720.3407Predictors of left arm pain Smoker3.7511.968–7.147 6 h)1.6441.316–2.054<0.0001 Age × smoking interaction0.9830.973–0.9930.0008 Female gender0.9310.744–1.1640.5277Predictors of right arm pain Smoker1.7801.232–2.5730.0021 Angina pectoris1.5671.119–2.1930.0089 Heart failure0.4880.293–0.8130.0058 Positive stress test result0.5370.319–0.9040.0192 Non–ST-elevated myocardial infarction versus unstable angina1.8191.188–2.7850.0059 Female gender1.0440.736–1.4820.8084Predictors of diaphoresis Female gender0.7630.617–0.9440.0128 Age (yrs)0.9890.982–0.9970.0041 Smoker1.3381.084–1.6500.0066 Previous coronary angioplasty0.6770.535–0.8550.0011 Presentation time ( 6 h)1.8691.387–2.518 6 h)1.5591.264–1.923<0.0001 ST-elevated myocardial infarction versus unstable angina1.8461.365–2.497<0.0001 Pulse (beats/min)0.9950.991–0.99970.0368Predictors of dyspnea Smoker1.4071.137–1.7420.0017 Heart failure2.8951.952–4.295<0.0001 Coronary angioplasty0.7460.604–0.9210.0065 Previous coronary bypass1.3001.032–1.6380.0258 Anterior ST-segment depression0.5440.359–0.8240.0041 Pulse (beats/min)1.0061.001–1.0100.0098 Smoker × heart failure interaction0.4800.294–0.7840.0033 Female gender1.1010.902–1.3420.3441Predictors of nausea Female gender1.4771.186–1.8400.0005 Age0.9840.976–0.991 6 h)1.3751.100–1.7180.0119 Age × smoking interaction1.0051.002–1.0090.0038 Open table in a new tab Because of time wasted between onset of myocardial ischemia and initiation of appropriate therapy, patients with ACS are exposed to unnecessary risks of arrhythmias, heart failure, asystole, and larger than hoped for myocardial infarctions. Thus, it is important that (1) patients promptly recognize their symptoms as being important enough to seek medical evaluation, (2) triage nurses promptly recognize patients' symptoms as being cardiac related and obtain an electrocardiogram, and (3) physicians promptly interpret the electrocardiogram and institute therapy. Failure to correctly interpret symptoms of a cardiac nature on the part of the patient or care team will lead to delays in obtaining electrocardiograms and in instituting therapy. In our study, we found that on average, men and women presented with somewhat different symptoms of ACS. Specifically, men were more likely to present with chest pain, although the incidence of chest pain decreased with advancing age in men and women. However, after multivariable analysis, patient gender was no longer a predictor of chest pain. The difference in chest pain occurrence could be explained by other factors, such as women's older age and diabetes mellitus being more common in younger women (Table 1). Similarly, left arm pain and diaphoresis were more common in men, whereas nausea was more common in women. After multivariable analysis, only diaphoresis and nausea persisted as being predicted by patient gender (Table 4). Among the less common symptoms, jaw pain, neck pain, back pain, and emesis were more common in women. (Binary logistic regression was not completed on these symptoms because of the small number of patients with these symptoms.) These observations are similar to results from several other investigators.9Brieger D. Eagle K.A. Goodman S.G. Steg P.G. Budaj A. White K. Montalescot G. GRACE InvestigatorsAcute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group.Chest. 2004; 126: 461-469Crossref PubMed Scopus (376) Google Scholar, 12Meshack A.F. Goff D.C. Chan W. Ramsey D. Linares A. Reyna R. Pandey D. Comparison of reported symptoms of acute myocardial infarction in Mexican Americans versus non-Hispanic Whites (the Corpus Christi Heart Project).Am J Cardiol. 1998; 82: 1329-1332Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 13Milner K.A. Vaccarino V. Arnold A.L. Funk M. Goldberg R.J. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study).Am J Cardiol. 2004; 93: 606-608Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 14Everts B. Karlson B.W. Wahrborg P. Hedner T. Herlitz J. Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction.Heart Lung. 1996; 25: 430-437Abstract Full Text PDF PubMed Scopus (99) Google Scholar, 15Schillinger M. Sodek G. Meron G. Janata K. Nikfardjam N. Rauscha F. Laggner A.N. Domanovits H. Acute chest pain—identification of patients at low risk for coronary events The impact of symptoms, medical history and risk factors.Wien Klin Wochenschr. 2004; 116: 83-89Crossref PubMed Scopus (16) Google Scholar Meshack et al12Meshack A.F. Goff D.C. Chan W. Ramsey D. Linares A. Reyna R. Pandey D. Comparison of reported symptoms of acute myocardial infarction in Mexican Americans versus non-Hispanic Whites (the Corpus Christi Heart Project).Am J Cardiol. 1998; 82: 1329-1332Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar found that women were more likely than men to report having fatigue, dyspnea, dizziness, upper back pain, palpitations, and cough as their presenting symptoms in acute myocardial infarction, but less likely to have chest pain. They also found that the occurrence of most symptoms progressively decreased in older patients. In the Worcester Heart Attack Study, the incidence of chest pain as the chief complaint of patients hospitalized with acute myocardial infarction was less in women than in men matched by age groups. This relation persisted after multivariable adjustment. The incidence of chest pain decreased with advancing age in men and women.13Milner K.A. Vaccarino V. Arnold A.L. Funk M. Goldberg R.J. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study).Am J Cardiol. 2004; 93: 606-608Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar A large study of 20,881 patients admitted with ACS found that most patients presented with chest pain, but that 8.4% presented without chest pain. These patients were more likely to be older or women or to have diabetes mellitus, hypertension, or congestive heart failure. However, they were less likely to be smokers or to have hyperlipidemia.9Brieger D. Eagle K.A. Goodman S.G. Steg P.G. Budaj A. White K. Montalescot G. GRACE InvestigatorsAcute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group.Chest. 2004; 126: 461-469Crossref PubMed Scopus (376) Google Scholar Among Swedish patients with acute myocardial infarction, women were more likely to have neck and back pain.14Everts B. Karlson B.W. Wahrborg P. Hedner T. Herlitz J. Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction.Heart Lung. 1996; 25: 430-437Abstract Full Text PDF PubMed Scopus (99) Google Scholar More generally, Schillinger et al15Schillinger M. Sodek G. Meron G. Janata K. Nikfardjam N. Rauscha F. Laggner A.N. Domanovits H. Acute chest pain—identification of patients at low risk for coronary events The impact of symptoms, medical history and risk factors.Wien Klin Wochenschr. 2004; 116: 83-89Crossref PubMed Scopus (16) Google Scholar showed that the presence of ≥4 "typical" symptoms, vegetative signs, history, and risk factors was only weakly predictive of acute myocardial infarction in patients presenting to the emergency department with chest pain, whereas having ≥4 "atypical" criteria was strongly associated with excluding the diagnosis of acute myocardial infarction. They also showed that there was a significant gender-related interaction, in that the positive predictive value of the atypical criteria for excluding acute myocardial infarction was higher in women than in men. In contradistinction, Milner et al16Milner K.A. Funk M. Arnold A. Vaccarino V. Typical symptoms are predictive of acute coronary syndromes in women.Am Heart J. 2002; 143: 283-288Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar found no statistically significant difference in typical symptoms between men and women presenting to the emergency department with ACS. However, the study was relatively underpowered, with only 213 patients enrolled. In a larger multicenter study of patients presenting with ACS, Zucker et al17Zucker D.R. Griffith J.L. Beshansky J.R. Selker H.P. Presentations of acute myocardial infarction in men and women.J Gen Intern Med. 1997; 12: 79-87Crossref PubMed Google Scholar found that women were older than men, more likely to be African-American, more likely to have diabetes mellitus or hypertension, and less likely to have angina or previous myocardial infarction. Women were more likely to present with nausea/vomiting or shortness of breath. Although the occurrence of chest pain was similar between men and women (76% vs 75%, p = 0.13), men were slightly more likely to report chest pain as their chief complaint (69% vs 66%, p <0.01). Abdominal pain and dizziness did not differ between genders. Information on other presenting symptoms was not provided.17Zucker D.R. Griffith J.L. Beshansky J.R. Selker H.P. Presentations of acute myocardial infarction in men and women.J Gen Intern Med. 1997; 12: 79-87Crossref PubMed Google Scholar Our univariable results are consistent with those of other studies that found small but statistically significant differences in the symptoms that men and women have when presenting with ACS. However, our study and others like it also found small but consistent differences in age, co-morbidities, and location of ACS between men and women. These factors, rather than a patient's gender, explain many of the differences that have been noted in our study and other reports.

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