Gender differences in symptom presentation of ST-elevation myocardial infarction – An observational multicenter survey study

doi:10.1016/j.ijcard.2018.03.084

International Journal of Cardiology

Volume 264, 1 August 2018, Pages 7-11

https://doi.org/10.1016/j.ijcard.2018.03.084 Get rights and content

Highlights

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Female sex was strongly predicting non-chest pain presentation in STEMI (OR 5.3, 95% CI 2.6–9.8).
•
In women shoulder (33 vs 15%), throat (34 vs 18%) and back pain (29 vs 12%) was twice as common as in men.
•
Nausea was prevalent in half of the women compared to less than a third of the men (49 vs 29%).
•
The total burden of both chief complaints and associated symptoms were higher in women than in men.
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Women less often interpreted their symptoms as of cardiac origin (60 vs 69%).

Abstract

Background

Symptom presentation has been sparsely studied from a gender perspective restricting the inclusion to ST elevation myocardial infarction (STEMI) patients. Correct symptom recognition is vital in order to promptly seek care in STEMI where fast reperfusion therapy is of utmost importance. Female gender has been found associated with atypical presentation in studies on mixed MI populations but it is unclear whether this is valid also in STEMI.

Objectives

We assessed whether there are gender differences in symptoms and interpretation of these in STEMI, and if this is attributable to sociodemographic and clinical factors.

Methods

SymTime was a multicenter observational study including a validated questionnaire and data from medical records. Eligible STEMI patients (n = 532) were enrolled within 24 h after admittance at five Swedish hospitals.

Results

Women were older, more often single and had lower educational level. Chest pain was less prevalent in women (74 vs 93%, p < 0.001), whereas shoulder (33 vs 15%, p < 0.001), throat/neck (34 vs 18%, p < 0.001), back pain (29 versus 12%, p < 0.001) and nausea (49 vs 29%, p < 0.001) were more prevalent. Women less often interpreted their symptoms as of cardiac origin (60 vs 69%, p = 0.04). Female gender was the strongest independent predictor of non-chest pain presentation, odds ratio 5.29, 95% confidence interval 2.85–9.80.

Conclusions

A striking gender difference in STEMI symptoms was found. As women significantly misinterpreted their symptoms more often, it is vital when informing about MI to the society or to high risk individuals, to highlight also other symptoms than just chest pain.

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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Among 585 patients with STEMI and COVID-19 infection, 154 (26.3%) were women. Compared to men, women were significantly older, had a higher prevalence of diabetes and stroke/transient ischemic attack, and were more likely to be on statins on presentation. Men more frequently presented with chest pain, whereas women presented with dyspnea. Women more often had STEMI without an identified culprit lesion than men (33% vs 18%, P < .001). The use of percutaneous coronary intervention was significantly higher in men, whereas medical therapy was higher in women. In-hospital mortality was 33% for women and 27% for men (P = .22).
In patients presenting with STEMI in the context of COVID-19, the in-hospital mortality rate was 30% and similar for men and women. Lack of an identifiable culprit lesion was common in the setting of COVID-19 for both sexes but more likely in women (1/3 of women vs 1/5 of men). Evaluation of specific underlying etiologies is underway to better define the full impact of COVID-19 on STEMI outcomes and better understand the observed sex differences.
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Citation Excerpt :
This is supported by our finding that readmission for heart failure and AMI were especially prominent among non-revascularized women. Women with acute coronary syndromes are less likely to present with chest pain [23], and instead may present with atypical symptoms such as nausea or abdominal pain [24]. Canto et al. noted that atypical presentations lead physicians to broaden their differential diagnosis and delay or defer cardiology referral and angiography [23,25,26].
Cardiovascular disease is the leading cause of death for women in the United States. Revascularization is considered the standard of care for treatment of ST-segment elevation myocardial infarction (STEMI) and is known to reduce readmission. However there is a paucity of data that examines the sex-dependent impact of revascularization on readmission. We aimed to investigate sex differences in revascularization rates, 30-day readmission rates, and primary cause of readmissions following STEMIs.
STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. Revascularization rates, 30-day readmission rates, and primary cause of readmission were examined. Interaction between sex and revascularization was assessed. Multivariable regression analysis was performed to identify predictors of 30-day readmission and revascularization for both sexes.
219,944 women and 489,605 men were admitted with STEMIs. Women were more likely to be older, and have more comorbidities. Women were less likely to undergo revascularization by percutaneous coronary intervention (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.66–0.70) or coronary artery bypass graft surgery (adjusted OR 0.40; CI 0.39–0.44). Women had higher 30-day readmission rates (15.7% vs. 10.8%, p < 0.001; OR 1.20, CI 1.17–1.23), and revascularization in women was not associated with a decreased likelihood of 30-day readmission. The primary cardiac cause of readmission in women was heart failure.
Compared to men, women with STEMIs had lower rates of revascularization and higher rates of 30-day readmission. When revascularized, women were still more likely to be readmitted as compared to non-revascularized women.
Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016
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From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P = .001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P = .001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95).
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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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¹: This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Gender differences in symptom presentation of ST-elevation myocardial infarction – An observational multicenter survey study

Highlights

Abstract

Background

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Strengths and limitations

Clinical implications

Funding

Disclosures

Contributors

Acknowledgements

Heart Lung

Int. J. Cardiol.

Am. Heart J.

Am. Heart J.

Gend. Med.

Am. J. Cardiol.

Am. J. Cardiol.

Prev. Med.

Am. J. Cardiol.

Am. Heart J.

Am. J. Cardiol.

Heart Lung

Intensiv Crit. Care Nurs.

Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain

JAMA

Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study

Eur. J. Cardiovasc. Nurs.

Sex differences in acute coronary syndrome symptom presentation in young patients

JAMA Intern. Med.