Sex Differences in Acute Coronary Symptoms
Abstract & Commentary
By Michael H. Crawford, MD, Professor of Medicine, and Chief of Clinical Cardiology, at the University of California, San Francisco. Dr. Crawford is on the speaker's bureau for Pfizer.
Synopsis: The same appearances in presentation of men and women with ACS can largely be explained by factors other than sex.
Source: Arslanian-Engoren C, et al. Symptoms of Men and Women Presenting with Acute Coronary Syndromes. Am J Cardiol. 2006;98:1177-1181.
It is well known that women with acute coronary syndromes (ACS) arrive later, get fewer evidence-based therapies, and have worse outcomes. Chest pain is the critical symptom that starts the ACS management cascade. It has been suggested that women with ACS present with different symptoms than men; thus, explaining their delayed and often inadequate therapy. The investigators analyzed 1941 patients in the Acute Coronary Syndrome Registry at the University of Michigan to see if any differences in the presenting symptoms of men and women were sex related or could be explain by other factors. Women represent 35% of the patients, 72% of whom had myocardial infarction and 28% unstable angina. Women were older than the men (67 vs 61 years, p < 0.01). As compared to men, women > 65 years were more likely to be obese; women < 65 were more often lean; women had systemic hypertension more often and were less likely to have had coronary revascularization in the past. Women delayed more than men before coming to the hospital (14.5 vs 12 hours, P < 0.01). Men were more likely to present with chest pain, but the difference was small (89% vs 82%, P < 0.01). Left arm radiation (30% vs 25%, P < 0.05) and diaphoresis (38% vs 29%, P < .01) were more common in men and nausea was more common in women (29% vs 25%, p < 0.05). Dyspnea was not different. Logistic regression analysis showed that only diaphoresis and nausea were predicted by sex, but the strongest predictor of nausea was inferior ST-segment elevation. The authors concluded that sex should be considered in the evaluation of ACS, but factors other than sex explained most of the small differences found between men and women.
Commentary
This study confirms my clinical impression that there is no major difference in the presenting symptoms of men and women with ACS. Most present with chest pain; > 80% in both sexes. The small differences in other symptoms largely disappear when other clinical factors are considered. For example, diabetes is more common in women < 65 years of age as compared to young men (34% vs 27%, p < 0.01). Only diaphoresis seemed to be explained mainly by sex, being more common in men, but this difference was driven by younger men (incidence 42%); older men had similar rates as women (33 vs 29%). Thus, most of the differences in the presentation of ACS in men and women can be explained by differences in age, comorbidities, and location of ischemia.
The major message of this paper is that in order to recognize ACS quickly, so that timely interventions can be undertaken to reduce the risk of arrhythmias, heart failure, cardiac arrest or a large infarction, presentations other than chest pain need to be considered indications for performing a STAT ECG. This may be more important in women who can present atypically because of other clinical factors, but it is imperative in both sexes to pay attention to more subtle presentations such as diaphoresis, nausea and dyspnea. More important than sex is the fact that older aged individuals of both sexes are less likely to present with chest pain. Finally, the sobering reminder in this study that patients delay 12 to 15 hours before seeking medical attention for their symptoms needs to be addressed. Clearly more public education is in order, especially for women who delay the longest.
The same appearances in presentation of men and women with ACS can largely be explained by factors other than sex.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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