ACS Chest Pain Less Common, Not Rare, in Younger Women vs Men

September 17, 2013

MONTREAL — It's been long observed that women are more likely than men not to have chest pain when presenting with acute coronary syndrome (ACS); that's based on data largely from older patients. But the same appears to be true in younger populations, those 55 years or younger, suggests an analysis in which, nonetheless, chest pain was far from rare in younger women[1]. Indeed, the rate difference between women and men was only around six percentage points.

"Chest pain is still the most common symptom in the presentation," according to senior author Dr Louise Pilote (McGill University, Montreal, QC). And when it's absent in ACS, "it seems like the other symptoms are overlooked, especially in lower-risk groups like young women," she said to heartwire . That leads some clinicians to discount an ACS diagnosis in those cases.

But in the current analysis of patients age <55 with a subsequently confirmed ACS diagnosis, the absolute difference in chest-pain prevalence between women and men "was not that high," Pilote said, even though it reached significance. Almost a fifth of the women reported no chest pain, compared with 13.7% of men (p=0.03).

"If a woman with many risk factors for heart disease presents to the emergency room with, [perhaps], shortness of breath, nausea, or extreme fatigue, even though [she may be] young, [she] should not be dismissed as not having an ACS."

The analysis was published online September 16, 2013 in JAMA Internal Medicine with lead author Dr Nadia A Khan (University of British Columbia, Vancouver). Of note, its observed sex-related absolute difference in chest-pain prevalence was only half as large as that in a recent analysis of the National Registry of Myocardial Infarction (NRMI) database.

For the current study, the group looked at 1015 men and women who were aged 55 or younger (median 49) when hospitalized with ACS and were participants in the ongoing Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond--Premature Acute Coronary Syndrome (GENESIS PRAXY) prospective cohort study. Eligibility required a diagnosis based at least partly on either ECG changes characteristic of ACS or elevation in troponin or creatine kinase; 30% of the cohort were women. Of the 24 represented urban tertiary-care centers and community hospitals, 22 were in Canada.

The patients self-characterized their symptom features and intensity during hospitalization but prior to ACS diagnosis using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS).

In general, patients who felt no chest pain reported fewer symptoms than those with chest pain, and "no discernible pattern of nonchest pain symptoms was found, nor did they differ significantly from those with chest pain in terms of ACS type, troponin-level elevation, or coronary stenosis."

Women were more likely than men to present without chest pain (19.0% vs 13.7%) and ultimately to have a diagnosis of non-ST-segment-elevation MI (37.5% vs 30.7%); p=0.03 for both differences. Both women and men without chest pain had significantly fewer symptoms than their corresponding groups with chest pain. Women without chest pain averaged 3.5 symptoms compared with 5.8 symptoms for those with chest pain; for men it was 2.2 and 4.7 symptoms, respectively (p<0.001 for the difference in both groups).

Odds Ratio (95% CI) for ACS Presentation Without Chest Pain, Multivariate Analysis

Observed significant predictors, by group OR (95% CI)
In overall cohort  
Female 1.95 (1.23–3.11)
Tachycardia 2.07 (1.20–3.56)
Among patients undergoing angiography*  
Female 1.83 (1.11–3.02)
Tachycardia 1.93 (1.08–3.44)
Higher household income 1.80 (1.06–3.05)
Left-main disease 1.94 (1.04–3.63)

*638 men and 271 women had available angiographic data

"The study by Khan et al extends the prior literature by demonstrating that sex-specific differences in ACS presentation occur earlier in life" than suggested by other studies, which were largely in older populations, notes an accompanying editorial from Drs Akintunde O Akinkuolie and Samia Mora (Brigham and Women’s Hospital, Boston, MA)[2]].

"Although all participants in the study . . . were admitted for ACS, their results shed light on the potential for physicians to miss a case of ACS when the cardinal symptom of chest pain is not experienced or elicited," they write. They also highlight the need for future research to clarify the source of ACS-presentations differences between women and men.

"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."

The study was funded by the Canadian Institutes of Health Research (CIHR) and the Heart and Stroke Foundations of Quebec, Nova Scotia, Alberta, Ontario, Yukon, and British Columbia. The authors had no disclosures. The editorial contained no disclosures.

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