Typical Symptoms Are Predictive of Acute Coronary Syndromes in Women


Am Heart J. 2002;143(2) 

In This Article


The results of this prospective study indicate that typical symptoms are the strongest symptom predictors of ACS in women and are as important in women as in men. In contrast, we found no significant associations between atypical symptoms and ACS in women, whereas some atypical symptoms (dizziness or faintness) were inversely associated with ACS in men.

By comparing the symptom prevalence in women and men with ACS, previous research[3,4,5,6,7,8] has not addressed the issue of whether symptoms are associated with ACS differently in women and men. In fact, we found that atypical symptoms such as nausea or vomiting and indigestion, which are reported in the literature[3,6,7,8,9] as more common in women with ACS, were not significantly associated with a diagnosis of ACS.

After controlling for age, diabetes, and number of presenting symptoms, we found that typical symptoms, such as diaphoresis and chest pain or discomfort, carried significant or borderline-significant positive relative risk for ACS in women. In contrast, typical symptoms were not significantly associated with ACS in men. In men, only dizziness/faintness was an independent negative symptom predictor of ACS. This unexpected finding may reflect the broad inclusion criteria of our study rather than truly signifying a protective characteristic in men with this symptom.

In contrast with our results, investigators for the Multicenter Chest Pain study found that diaphoresis, substernal chest pain, and pressing chest pain carried significant positive relative risks for AMI in both women and men.[2] A possible explanation for the difference in findings may be the result of different study enrollment criteria. Patients in the Multicenter Chest Pain study had to have a chief complaint of chest pain to be included, whereas the current study included all patients with symptoms suggestive of ACS, even if these symptoms did not include chest pain. In addition, we examined symptom predictors of ACS, which included both AMI and acute ischemia.

The Acute Cardiac Ischemia Time-Intensive Predictive Instrument (ACI-TIPI) trial found that the presence of chest pain, a chief complaint of chest pain, and nausea/vomiting were positive predictors of AMI in patients seen in the ED with symptoms suggestive of acute cardiac ischemia, whereas dizziness was a negative predictor of AMI.[10] These investigators found no sex-symptom interactions, indicating that these symptoms predicted AMI in women and men equally. A large number of patients (n = 2044, 19%) were excluded from the ACI-TIPI trial because of missing data (eg, no electrocardiogram reading), and this may in part explain the differences in findings in our study. Another difference from our study is the fact that we examined symptom predictors of AMI and acute ischemia rather than only AMI.

Our study has several limitations. First, we were unable to distinguish the chief complaint that prompted the patient to seek care from other associated symptoms. Identification of the chief complaint may be a more accurate measure to use when identifying symptom predictors of ACS. Second, patients with acute ischemia and AMI were collapsed into one group for our analyses to obtain an adequate sample size. Subtle differences in symptom predictors in women and men may exist, depending on whether a patient has acute ischemia or AMI. Third, our sample size may have been insufficient to detect less-strong predictors of ACS in women and in men, as well as significant sex differences in presentation with typical symptoms. Fourth, patients who were not diagnosed with ACS and were discharged to home from the ED did not receive further follow-up. It is possible that some of these patients might have had coronary ischemia that was missed. However, the proportion of missed diagnoses for acute ischemia in the ED is small.[1]

In conclusion, our results do not support the suspicion that in women atypical symptoms are more strongly related to ACS than in men. In contrast, typical symptoms are the strongest symptom predictors of ACS in women. These findings indicate that attention to typical symptoms of acute ischemia or AMI can provide the most important symptom-based clues on the pretest probability of ACS in women. Clinicians need to take very seriously any woman who has typical symptoms, pursue a full workup, and not dismiss her symptoms as more likely the result of some other psychogenic, gastrointestinal, or musculoskeletal cause.


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