Gender differences in symptoms associated with acute myocardial infarction: A review of the research

doi:10.1016/j.hrtlng.2004.12.004

Heart & Lung

Volume 34, Issue 4, July–August 2005, Pages 240-247

https://doi.org/10.1016/j.hrtlng.2004.12.004 Get rights and content

Recognizing similarities and differences in symptom experiences of acute myocardial infarction (AMI) between men and women has implications for both health care providers and the general public. Rapid accurate diagnosis is necessary to implement timely lifesaving treatment. The purpose of this article is to critically review and evaluate studies that have compared symptoms of AMI between men and women. Research to date has demonstrated that during AMI, women are more likely than men to report shortness of breath, nausea, vomiting, back pain, jaw pain, neck pain, cough, and fatigue, but less likely than men to report chest pain and sweating. However, the findings were inconsistent across studies. These inconsistent findings could be attributable to methodological issues such as collecting data from medical records, small sample sizes, and controversial eligibility criteria for studies. More studies are needed to confirm gender differences in symptom experiences of AMI.

Section snippets

Data source: Chart reviews

Cunningham and colleagues¹² performed a subset analysis of data from the Multicenter Chest Pain Study. The primary purpose of their study was to examine gender differences in the incidence of AMI in patients presenting to the emergency department (ED) for acute chest pain in 3 university and 4 community hospitals in the United States between December 1983 and August 1985. Included in the convenience sample were all patients aged 30 years or older who presented to EDs primarily because of

Summary

In summary, a comprehensive review of the literature showed important gender differences in symptoms associated with AMI. However, findings were inconsistent among 10 of the 11 studies that showed gender differences. Compared with men, women with AMI were more likely to report shortness of breath (6/10 studies), nausea (5/8 studies), vomiting (2/3 studies), arm/shoulder pain (1/5 studies), abdominal pain (1/6 studies), back pain (5/6 studies), jaw pain (2/4 studies), neck pain (3/5 studies),

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Cited by (67)

Characteristics associated with patient delay during the management of ST-segment elevated myocardial infarction, and the influence of awareness campaigns
2021, Archives of Cardiovascular Diseases
The delay between the occurrence of symptoms and the call seeking medical assistance is an important component of the pain-to-balloon delay in patients with ST-segment elevation myocardial infarction (STEMI). Factors affecting this “patient delay” have been poorly studied, and campaigns to raise emergency call awareness have barely been evaluated.
To evaluate the factors related to patient delay, and the effects of public awareness campaigns undertaken in our region.
Data from the regional registry of STEMI in Limousin, France, were analysed, and we performed a survey to assess medical history, clinical signs, context, socioeconomic situation and perception and behaviour of the patient. “Late callers” (i.e. third tertile, > 154 minutes) were compared with “early callers” (i.e. first and second tertiles, ≤ 154 minutes) using univariate and multivariable statistical methods. The influence of public awareness campaigns was studied by comparing the patient delays before and after a regional campaign.
Among 481 patients, the median patient delay was 87 minutes. “Late callers” were older (odds ratio [OR] 1.02 per year, 95% confidence interval [CI] 1.00 to 1.03), more often had symptom onset between 00:00 and 05:59 a.m. (OR 1.86, 95% CI 1.10 to 3.12) and more often sought assistance from a general practitioner (OR 2.58, 95% CI 1.66 to 4.04) or attended the emergency room (OR 4.10, 95% CI 2.04 to 8.32). Sweats and considering the situation to be severe were factors associated with a reduced delay. After awareness campaigns, there was no change in patient delay, but the proportion of patients calling the Emergency Medical Services increased from 55% to 62% (P < 0.001).
Patient delay is multifactorial. The impact of previous campaigns is mixed. Psychological and behavioural aspects are determinant, and should be taken into consideration to develop awareness messages that target specific groups.
Le délai patient, entre le début des symptômes et le premier contact médical, représente une large partie du délai douleur-ballon chez les victimes de syndromes coronariens aigus avec élévation du segment ST (SCA ST + ).
Nous avons évalué les facteurs liés au délai patient et les effets d’une campagne régionale de sensibilisation.
Les données provenaient du registre régional des SCA ST+ du Limousin (France) et nous avons de plus recueilli par questionnaire les antécédents, les signes cliniques, le contexte, les conditions socioéconomiques, la perception et comportement des patients. Des groupes « appel précoce » (1^e et 2^e tertile, < 154 minutes) et « appel tardifs » (3^e tertile > 154 minutes) ont été comparés par analyse univariée, puis multivariée. L’influence de la sensibilisation a été étudiée en comparant les délais avant et après ces campagnes régionales.
Sur 481 patients, le délai d’appel médian était de 87 minutes. Les facteurs indépendamment liés au délai tardif étaient : l’âge (OR 1,02, IC 95 % 1,00 à 1,03), l’horaire entre 0 h et 6 h (OR 1,86, IC 95 % 1,10 à 3,12), le recours à un médecin généraliste (OR 2,58, IC 95 % 1,66 à 4,04) ou au service des urgences (OR 4,10, IC 95 % 2,04 à 8,32). Le symptôme « sueurs » et le sentiment de gravité étaient associés à un délai précoce. Après les campagnes de sensibilisation, le délai patient n’était pas modifié mais la part d’appel au 15 est passée de 55 % à 62 % (p < 0,001).
L’allongement du délai patient est multifactoriel. L’impact des campagnes de sensibilisations est mitigé. Les aspects psychologiques et comportementaux semblent déterminants et devraient être pris en considération pour adresser des messages ciblés vers des publics spécifiques.
Psychological and cognitive factors related to prehospital delay in acute coronary syndrome: A systematic review
2020, International Journal of Nursing Studies
Citation Excerpt :
However, there are several differences in the factors related to prehospital delay between men and women. Perhaps the most often explored reason for this gender gap has been symptom presentation: women often report different or more “atypical” symptoms, although findings have been mixed (Chen et al., 2005). In addition, whereas in men longer prehospital delays were related to low education, symptom onset at home, not asking for help, having early musculoskeletal pain, or lack of consistency between expected and experienced symptoms, in women longer prehospital delay were related to older age, being single, having a history of MI, being alone during symptom onset, and not wanting to trouble anyone (Nguyen et al., 2010).
In acute coronary syndrome the time elapsed between the start of symptoms and the moment the patient receives treatment is an important determinant of survival and subsequent recovery. However, many patients do not receive treatment as quickly as recommended, mostly due to substantial prehospital delays such as waiting to seek medical attention after symptoms have started.
To conduct a systematic review with meta-analysis of the relationship between nine frequently investigated psychological and cognitive factors and prehospital delay.
A protocol was preregistered in PROSPERO [CRD42018094198] and a systematic review was conducted following PRISMA guidelines.
The following databases were searched for quantitative articles published between 1997 and 2019: Medline (PubMed), Web of Science, Scopus, Psych Info, PAIS, and Open grey.
Study risk of bias was assessed with the NIH Quality Assessment Tool for Observational, Cohort, and Cross-Sectional Studies. A best evidence synthesis was performed to summarize the findings of the included studies.
Forty-eight articles, reporting on 57 studies from 23 countries met the inclusion criteria. Studies used very diverse definitions of prehospital delay and analytical practices, which precluded meta-analysis. The best evidence synthesis indicated that there was evidence that patients who attributed their symptoms to a cardiac event (n = 37), perceived symptoms as serious (n = 24), or felt anxiety in response to symptoms (n = 15) reported shorter prehospital delay, with effect sizes indicating important clinical differences (e.g., 1.5–2 h shorter prehospital delay). In contrast, there was limited evidence for a relationship between prehospital delay and knowledge of symptoms (n = 18), concern for troubling others (n = 18), fear (n = 17), or embarrassment in asking for help (n = 14).
The current review shows that symptom attribution to cardiac events and some degree of perceived threat are fundamental to speed up help-seeking. In contrast, social concerns and barriers in seeking medical attention (embarrassment or concern for troubling others) may not be as important as initially thought. The current review also shows that the use of very diverse methodological practices strongly limits the integration of evidence into meaningful recommendations. We conclude that there is urgent need for common guidelines for prehospital delay study design and reporting.
Controversies in the Treatment of Women with ST-Segment Elevation Myocardial Infarction
2016, Interventional Cardiology Clinics
Citation Excerpt :
Furthermore, when women seek medical attention for CAD, they present with unstable angina/non–STEMI more frequently than men and manifest different symptoms of cardiac ischemia than men.6,8–11 Among AMI patients, women are less likely to present with substernal chest pain and are more likely to complain of atypical chest pain with or without shortness of breath, abdominal pain, nausea, or fatigue.12–20 In addition, ischemia is more often silent,21,22 and MI is frequently unrecognized in women compared with men.23,24
Time to standardize and broaden the criteria of acute coronary syndrome symptom presentations in women
2014, Canadian Journal of Cardiology
Citation Excerpt :
Chest pain/discomfort is generally regarded as the hallmark symptom of ACS in women and men.3,7-12 There are, however, a considerable number of ACS patients who will not have this cardinal symptom,3,7-12 and the absence of chest pain/discomfort is generally seen in a higher proportion of women than in men.3,7-9,12 The symptoms of ACS are not mutually exclusive by sex and are generally found in women and men.
Early recognition of the signs and symptoms of acute coronary syndromes (ACS) is essential to improving patient management and associated outcomes. It is widely reported that women might have a different ACS symptom presentation than men. Multiple review articles have examined sex differences in symptom presentation of ACS and these studies have yielded inconclusive results and/or inconsistent recommendations. This is largely because these studies have included diverse study populations, different methods of assessing the chief complaint and associated coronary symptoms, relatively small sample sizes of women and men, and lack of adequate adjustment for age or other potentially confounding differences between the sexes. There is a substantial overlap of ACS symptoms that are not mutually exclusive according to sex, and are generally found in women and men. However, there are apparent differences in the frequency and distribution of ACS symptoms among women and men. Women, on average, are also more likely to have a greater number of ACS-related symptoms contributing to the perception that women have more atypical symptoms than men. In this review, we address issues surrounding whether women should have a different ACS symptom presentation message than men, and provide general recommendations from a public policy perspective. In the future, our goal should be to standardize ACS symptom presentation and to elucidate the full range of ACS and myocardial infarction symptoms considering the substantial overlap of symptoms among women and men rather than use conventional terms such as “typical” and “atypical” angina.
Le dépistage précoce des signes et des symptômes des syndromes coronariens aigus (SCA) est essentiel à l’amélioration de la prise en charge des patients et des résultats associés. On rapporte souvent que les femmes pourraient manifester de façon différente les symptômes liés au SCA par rapport aux hommes. De nombreux articles de revues ont examiné les différences entre les sexes dans la manifestation des symptômes liés au SCA, et ces études ont abouti à des résultats peu concluants ou à des recommandations contradictoires, ou les deux. C’est en grande partie parce que ces études ont inclus des populations diverses, des méthodes différentes pour évaluer les principales plaintes et les symptômes coronariens associés, des échantillons relativement petits de femmes et d’hommes, et le manque d’ajustement adéquat en fonction de l’âge ou d’autres différences de facteurs potentiellement confusionnels entre les sexes. Il existe un important chevauchement des symptômes liés au SCA, qui ne s’excluent pas mutuellement selon le sexe, et qui sont généralement observés chez les femmes et les hommes. Cependant, il existe des différences évidentes dans la fréquence et la distribution des symptômes liés au SCA entre les femmes et les hommes. En moyenne, les femmes sont également plus susceptibles d’avoir un plus grand nombre de symptômes liés au SCA, ce qui contribue à la perception que les femmes ont plus de symptômes atypiques que les hommes. Dans cette revue, nous abordons les questions à savoir si les femmes devraient recevoir un message différent au sujet de la manifestation des symptômes liés au SCA par rapport à celui des hommes, et fournissons des recommandations générales du point de vue des politiques publiques. Dans le futur, notre but devrait être de standardiser la manifestation des symptômes liés au SCA et d’élucider l’étendue complète des symptômes liés au SCA et à l’infarctus du myocarde en tenant compte du chevauchement important des symptômes des femmes et des hommes plutôt que d’utiliser les expressions conventionnelles comme angine « typique » et angine « atypique ».
Transcending the gender perspective in coronary disease symptoms
2013, Revista Colombiana de Cardiologia
Gendered symptom presentation in acute coronary syndrome: A cross sectional analysis
2012, International Journal of Nursing Studies
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.
This study examines whether gendered symptom presentation exists in a well-defined sample of men and women with ACS.
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.
: 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.
Patients were interviewed 2–4 days following their ACS event and data was gathered using the ACS response to symptom index.
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.
Although chest pain is the most commonly experienced symptom by men and women, other ACS symptomology may differ significantly between genders.

View all citing articles on Scopus

: This research was supported by an Institutional National Research Service Award from the National Institutes of Nursing Research (2 T32-NR07088).

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Issues in cardiovascular nursingGender differences in symptoms associated with acute myocardial infarction: A review of the research

Section snippets

Data source: Chart reviews

Summary

Ann Emerg Med

Am J Cardiol

Ann Emerg Med

Am J Cardiol

Heart Lung

Am J Emerg Med

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

Ann Cardiol Angeiol (Paris)

Am J Cardiol

Heart Lung

Am J Cardiol

Duration of, and temporal trends (1994–1997) in, prehospital delay in patients with acute myocardial infarctionthe second National Registry of Myocardial Infarction

Arch Intern Med

Pre-hospital and hospital time delays in thrombolytic treatment in patients with suspected acute myocardial infarction. Analysis of data from the EMIP study. European Myocardial Infarction Project

Eur Heart J

Influence of sex on the use of cardiac procedures in patients presenting to the emergency department. A prospective multicenter study

Circulation

Time to presentation with acute myocardial infarction in the elderly associations with race, sex, and socioeconomic characteristics

Circulation

Gender differences in treatment-seeking delay in acute myocardial infarction

Prog Cardiovasc Nurs

Issues in cardiovascular nursing
Gender differences in symptoms associated with acute myocardial infarction: A review of the research