Gender differences in symptom presentation of ST-elevation myocardial infarction – An observational multicenter survey study
Introduction
It is recognized that an atypical presentations of myocardial infarction (MI) can result in delay in seeking medical care, and thus a worse outcome [1]. Correct recognition of MI symptoms by the patient is vital in order to seek medical care promptly [2]. Female gender has been found associated with prehospital delay in several studies [2,3] possibly due to a higher risk of failure to recognize the symptoms as an evolving MI. If there are gender differences in symptoms in MI is debated. Studies on this topic have inconsistent findings, probably because mixed populations were included, i.e. STEMI, non ST-elevation MI (NSTEMI), unstable angina (UAP), and non-cardiac chest pain [[4], [5], [6], [7], [8], [9]]. Most studies relied on information from medical records, which may be associated with information bias [[6], [7], [8]] and almost no study have restricted the inclusion to STEMI where reducing delay times is most crucial. Greater understanding of gender differences in symptoms of STEMI is needed and prospective studies using self-reported data is lacking.
The aims of the current study were to 1) assess whether women and men experience different symptoms when suffering from STEMI, 2) if this is attributable to differences in sociodemographic and clinical factors and 3) whether there are gender differences in the interpretation of these symptoms.
Section snippets
Methods
This multicenter survey study “Symptoms and Delay Times of ST-elevation Myocardial Infarction from a Gender Perspective (SymTime)” had an observational design of self-reported data and is described in more detail in a previous publication [10]. A validated self-administered questionnaire developed and tested in a Swedish chest pain population was used [2]. In collaboration with the original developer a new literature research and an expert validation were conducted. In addition a small pilot
Results
The total study population consisted of 532 STEMI patients (24% women, n = 126) comprising 36% of all STEMI patients treated at the five hospitals during the study period (n = 1473) according to the Swedish quality register SWEDEHEART [13]. Women were older than men (69.7 vs 64.3 years, p < 0.001), had lower educational level and were more often living alone. They had higher prevalence of concomitant conditions such as hypertension (Table 1). There was no gender difference in culprit artery or
Discussion
The results of the present national multicenter survey show that female gender is a strong and independent predictor of presenting without chest pain (CP) (defined as chest or thoracic pain, pressure or discomfort) in STEMI. After controlling for other factors such as age, smoking, co-morbidities and culprit lesion [7,14], women had more than five times higher risk of presenting without CP where female gender was the only significant predictor. Women had 2–3 times higher risk of presenting with
Strengths and limitations
The main strength in the current study is the prospective gathering of self-reported data within 24 h restricting the selection to STEMI patients. The external validity is high in this multicenter study having wide inclusion criteria and approximately 1/10 of all hospitalized Swedish STEMI patients during the inclusion period was included.
As always in registry and survey studies one important limitation is that possible confounders could be missed. Moreover, patients having difficulties in
Clinical implications
In this multicenter trial, including >10% of all Swedish patients hospitalized with STEMI during 15 months, we found more similarities than differences. Anyhow, the most striking finding was the strong and independent association between female gender and non-chest pain presentation. Gender difference in age was of minor importance, as well as the difference in prevalence of diabetes and other concomitant factors. Our findings are important for the planning of educational campaigns/programs to
Funding
This work was supported by the Medical Research Council of Southeast Sweden (FORSS), the County Council of Östergötland and the County Council of Norrbotten.
Disclosures
None declared.
Contributors
SSL, IT and ES planned and designed the study, as well as the statistical analytic plan (SAP). KHÄ, ME, RMI and SSL contributed to the data collection. SSL performed the data analyses. All authors contributed to the manuscript preparation and approved the final version of the manuscript.
Acknowledgements
The authors hereby acknowledge all participating hospital departments and their staff who included patients on a daily bases. We especially acknowledge Elisabeth Logander, the highly skilled research nurse a Linköping University Hospital, who supported the study group throughout the project.
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2020, Emergency Medicine Clinics of North AmericaCitation Excerpt :When the Framingham researchers discovered that 25% of the MIs in their cohort of patients had been diagnosed by routine office electrocardiograms (ECGs) after the actual event had long been completed, they postulated that these MIs were missed as a result of being “silent” or atypical.19 Inconsistent methods of defining atypical presentations, however, have resulted in widely varying estimates of their incidence, ranging from 6% to 52%.20–26 Nevertheless, these studies have identified several populations that are consistently more likely to present in an atypical fashion: women, the elderly, and nonwhite minorities.4,20,27
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.