Gender differences in symptom experiences of patients with acute coronary syndromes

Sex related inequalities in the management and prognosis of acute coronary syndrome in Switzerland: cross sectional study

Objectives

To assess the differences in the management and prognosis of acute coronary syndrome in men and women who were admitted to hospital for acute coronary syndrome.

Design

Cross sectional study.

Setting

Discharge data from Swiss hospitals linked at the hospital and patient levels.

Participants

224 249 adults (18 years and older) were admitted to hospital for acute coronary syndrome between 1 January 2009 and 31 December 2017 in any Swiss hospital, of which 72 947 (32.5%) were women. People who were discharged against medical advice were excluded.

Results

Women admitted to hospital with acute coronary syndrome were older than their male counterparts (mean age 74.9 years (standard deviation 12.4) v 67.0 years (13.2)). Irrespective of acute coronary syndrome type, women were less likely to undergo diagnostic procedures, such as coronary angiography (adjusted odds ratio 0.79 (95% confidence interval 0.77 to 0.82) for non-ST-segment elevation myocardial infarction v 0.87 (0.84 to 0.91) for ST-segment elevation myocardial infarction)) and ventriculography (0.84 (0.82 to 0.87) v 0.90 (0.87 to 0.91)). Women were also less likely to receive treatments, such as percutaneous coronary intervention (0.67 (0.65 to 0.69) v 0.76 (0.73 to 0.78)) and coronary artery bypass graft (0.57 (0.53 to 0.61) v 0.79 (0.72 to 0.87)). Women had a poorer prognosis than men, with a higher likelihood of healthcare related complications (1.10 (1.06 to 1.15) v 1.14 (1.09 to 1.21)) and of a longer hospital stay (1.24 (1.20 to 1.27) v 1.24 (1.20 to 1.29)). In non-adjusted models, the likelihood of death in hospital was higher among women (odds ratio 1.30 (95% confidence interval 1.24 to 1.37) for non-ST-segment elevation myocardial infarction v 1.75 (1.66 to 1.85) for ST-segment elevation myocardial infarction), but the association was reversed for ST-segment elevation myocardial infarction (adjusted odds ratio 0.87 (0.82 to 0.92)) or was non-significant for non-ST-segment elevation myocardial infarction (1.00 (0.94 to 1.06)) after adjustment for confounding variables. The main effect modifier was age: younger women were more likely to die than men of the same age and older women were less likely to die than men of the same age. For example, women who were younger than 50 years had a 38% increased likelihood of dying compared with men of the same age range (adjusted odds ratio 1.38 (1.04 to 1.83)).

Conclusions

Sex inequalities were reported in the management of heart disease in this population of patients from a high income country with good healthcare coverage. These differences affect mortality and morbidity, especially in younger women. Efforts are needed to overcome these inequalities, including educational programmes aimed at healthcare professionals.

Comparative study of acute coronary syndrome in postmenopausal women and age-matched men: A prospective cohort study in Southern India

Background:

Acute coronary syndrome (ACS) differs in women and men with respect to risk factors, clinical presentation, complications and outcome. The major reason for the differences has been the effect of estrogen which protects women from coronary artery disease (CAD) till menopause. Women develop CAD one decade later than men. Hence, we compared the profile of ACS in postmenopausal women with age-matched men to see, does the difference still exist.

Materials and Methods:

Comparative prospective study of 50 postmenopausal women as study group and fifty age-matched men as a control group diagnosed with ACS, who were admitted in a medical college hospital from December 2013 to September 2015. Chi-square test and Student's t-test have been used to find the significant association of study parameters between women and men.

Results:

Chest pain was the main complaint in the majority of the women (76%) and men (88%). Radiation of chest pain (60%) and sweating (72%) were significantly present in men compared to women (24% and 26%, respectively), whereas breathlessness was significantly present in women (40%) compared to men (16%). Women had later presentation to the hospital after symptom onset compared to men. Women had a higher respiratory rate (22.02 cycles/min) compared to men (20 cycles/min) and more crepitations compared to men. Men had more ventricular tachycardia (14%) and intracerebral hemorrhage (4%), whereas women had all other complications more than or same as men and higher in-hospital mortality (14%) compared to men (8%).

Conclusion:

Postmenopausal women with ACS had more atypical presentation of symptoms, later presentation to hospital, more tachypnea, more crepitations, more complications, and higher in-hospital mortality compared to men of the same age group. The difference in the profile of ACS continues to exist even after menopause and age matching.

Gender Disparities in Cardiac Catheterization Rates Among Emergency Department Patients With Chest Pain

BACKGROUND

Previous studies have noted differences in rates of cardiac testing based on gender of patients. We evaluated cardiac catheterization rates for men and women presenting to the emergency department (ED) with chest pain, particularly among patients without a history of myocardial infarction (MI) or recent positive stress test.

METHODS

We performed a prospective evaluation of patients presenting to an urban, academic medical center for assessment of chest pain. We recorded baseline information, testing, and outcomes related to ED, observation unit, and inpatient stay. Primary outcomes included gender differences in cardiac catheterization and stenting rates among patients without an MI or positive stress test.

RESULTS

Over the 5.5 year study period, 2242 ED patients with chest pain participated in the study (45% male). Men and women had similar rates of cardiac stress testing (16.7% vs. 15.2%, P = 0.317) as well as similar rates of positive cardiac stress testing (2.9% vs. 1.9%, P = 0.116). Men were more likely to undergo cardiac catheterization (10.4% vs. 4.9%, P < 0.001). Men who had neither MI nor positive stress test were more likely than women to undergo cardiac catheterization: 5.8% versus 3.3%, P = 0.010. Similarly, men in this group were more likely to experience stent placement: 2.1% versus 0.7%, P = 0.003.

CONCLUSIONS

Similar to previous studies, we noted disparities in cardiac testing by gender. Men were more likely to go to cardiac catheterization without an MI or a positive stress test. This disparity in a more aggressive strategy of cardiac catheterization in men may result in higher stenting rates in this group.

Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta-analysis

Background Timely recognition of patients with acute coronary syndromes (ACS) is important for successful treatment. Previous research has suggested that women with ACS present with different symptoms compared with men. This review assessed the extent of sex differences in symptom presentation in patients with confirmed ACS. Methods and Results A systematic literature search was conducted in PubMed, Embase, and Cochrane up to June 2019. Two reviewers independently screened title-abstracts and full-texts according to predefined inclusion and exclusion criteria. Methodological quality was assessed using the Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% CI of a symptom being present were calculated using aggregated and cumulative meta-analyses as well as sex-specific pooled prevalences for each symptom. Twenty-seven studies were included. Compared with men, women with ACS had higher odds of presenting with pain between the shoulder blades (OR 2.15; 95% CI, 1.95-2.37), nausea or vomiting (OR 1.64; 95% CI, 1.48-1.82) and shortness of breath (OR 1.34; 95% CI, 1.21-1.48). Women had lower odds of presenting with chest pain (OR 0.70; 95% CI, 0.63-0.78) and diaphoresis (OR 0.84; 95% CI, 0.76-0.94). Both sexes presented most often with chest pain (pooled prevalences, men 79%; 95% CI, 72-85, pooled prevalences, women 74%; 95% CI, 72-85). Other symptoms also showed substantial overlap in prevalence. The presence of sex differences has been established since the early 2000s. Newer studies did not materially change cumulative findings. Conclusions Women with ACS do have different symptoms at presentation than men with ACS, but there is also considerable overlap. Since these differences have been shown for years, symptoms should no longer be labeled as "atypical" or "typical."

Acute Myocardial Infarction Experience Among Mexican American Women

INTRODUCTION

Health disparities in cardiovascular disease risk factors affect a burgeoning segment of the U.S. population-Mexican American (MA) women. MAs experience disparities in the prevalence of heart disease risk factors. However, there are no studies describing acute myocardial infarction (AMI) symptoms unique to this Hispanic subgroup. The aim of the study was to describe MA women's AMI symptom experience.

METHODS

A qualitative descriptive design guided the study. Data were collected in semistructured interviews with eight MA women who reported having an AMI within the past 18 months. Data were analyzed using qualitative content analysis.

RESULTS

The overall theme was "The nature of my AMI experience." This theme, composed of four categories, described their prodromal and AMI symptom experience: my perception of AMI, having a heart attack, AMI symptoms, and actions taken. No participants recognized prodromal or symptoms of AMI. Asphyxiatia (asphyxiating) and menos fuerza (less strength) were commonly described symptoms.

CONCLUSION

Participants attributed both prodromal and AMI symptoms to noncardiac causes, self-managed symptoms, and delay in seeking health care. Findings suggest that community engagement through culturally tailored family-focused heart health education for MA women and their family members may improve recognition of prodromal symptoms.

Fatigue and acute coronary syndrome: a systematic review of contributing factors

Fatigue is a symptom of ACS, but it remains unclear who is at risk and what factors contribute to fatigue. The purpose of the systematic review was to identify factors that influence fatigue in patients with ACS. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature published from 1981 to 2017 was reviewed, and of 983 articles screened, 36 met inclusion criteria. Variables contributing to fatigue fell into 3 categories: demographic characteristics, clinical characteristics, and other factors. More fatigue was found in women than men, and significant differences in fatigue were identified by race. Additionally, sleep deprivation, depression, and anxiety were associated with higher levels of fatigue. The findings highlight the importance of demographic, clinical, and other factors' impact on fatigue in ACS patients. Fatigue is an important symptom in ACS and healthcare providers must recognize how patient variables affect symptom expression.

Comparison of Delay Times Between Symptom Onset of an Acute ST-elevation Myocardial Infarction and Hospital Arrival in Men and Women <65 Years Versus ≥65 Years of Age.: Findings From the Multicenter Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) Study

Early administration of reperfusion therapy in acute ST-elevation myocardial infarctions (STEMI) is crucial to reduce mortality. Although female sex and old age are key factors contributing to an inadequate long prehospital delay time, little is known whether women ≥65 years are a particular risk population. Hence, we studied the interaction of sex and age (<65 years or ≥65 years) and the contribution of chest pain to delay time during STEMI. Bedside interview data were collected in 619 STEMI patients from the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Sex and age group stratification disclosed an excess delay risk for women ≥65 years, accounting for a 2.39 (95% confidence interval (CI) 1.39 to 4.10)-fold higher odds to delay longer than 2 hours compared with all other patient groups including younger women (p ≤0.002). Median delay time was 266 minutes in women ≥65 years and 148 minutes in younger women (p <0.001). Chest pain during STEMI had the lowest frequency both in women (81%) and men ≥65 years (83%) and the highest frequency (95%) in younger women. Experiencing non-chest pain was 2.32-fold (95% CI, 1.20 to 4.46, p <0.05) higher in women ≥65 years than in all other patients. Mediation analysis disclosed that the effect accounted for only 9% of the variance. Age specific educational strategies targeting women ≥65 years at risk are urgently needed. To tailor adequate strategies, more research is required to understand age- and sex driven barriers to timely identification of ischemic symptoms.

Sex differences in long-term mortality among acute myocardial infarction patients: Results from the ISAR-RISK and ART studies

BACKGROUND

Mortality rates in females who survived acute myocardial infarction (AMI) exceed those in males. Differences between sexes in age, cardiovascular risk factors and revascularization therapy have been proposed as possible reasons.

OBJECTIVE

To select sets of female and male patients comparable in respect of relevant risk factors in order to compare the sex-specific risk in a systematic manner.

METHODS

Data of the ISAR-RISK and ART studies were investigated. Patients were enrolled between 1996 and 2005 and suffered from AMI within 4 weeks prior to enrolment. Patients of each sex were selected with 1:1 equivalent age, previous AMI history, sinus-rhythm presence, hypertension, diabetes mellitus, smoking status, left ventricular ejection fraction (LVEF), and revascularization therapy. Survival times were compared between sex groups in the whole study cohort and in the matched cohort.

RESULTS

Of 3840 consecutive AMI survivors, 994 (25.9%) were females and 2846 (74.1%) were males. Females were older and suffered more frequently from hypertension and diabetes mellitus. In the whole cohort, females showed an increased mortality with a hazard ratio (HR) of 1.54 compared to males (p<0.0001). The matched cohort comprised 802 patients of each sex and revealed a trend towards poorer survival in females (HR for female sex 1.14; p = 0.359). However, significant mortality differences with a higher risk in matched females was observed during the first year after AMI (HR = 1.61; p = 0.045) but not during the subsequent years.

CONCLUSION

Matched sub-groups of post-AMI patients showed a comparable long-term mortality. However, a female excess mortality remained during first year after AMI and cannot be explained by differences in age, cardiovascular risk factors, and modes of acute treatment. Other causal factors, including clinical as well as psychological and social aspects, need to be considered. Female post-AMI patients should be followed more actively particularly during the first year after AMI.

Long-term prognosis of unrecognized myocardial infarction detected with cardiovascular magnetic resonance in an elderly population

BACKGROUND

Individuals with unrecognized myocardial infarctions (UMIs) detected with cardiovascular magnetic resonance (CMR) constitute a recently defined group whose prognosis has not been fully evaluated. However, increasing evidence indicate that these individuals may be at considerable cardiovascular risk. The aim of the present study was to investigate the prognostic impact of CMR detected UMIs for major adverse cardiac events (MACE) in community living elderly individuals.

METHODS

Late gadolinium enhancement CMR was performed in 248 randomly chosen 70-year-olds. Individuals with myocardial infarction (MI) scars, with or without a hospital diagnosis of MI were classified as recognized MI (RMI) or UMI, respectively. Medical records and death certificates were scrutinized. MACE was defined as cardiac death, non-fatal MI, a new diagnosis of angina pectoris, or symptom-driven coronary artery revascularization.

RESULTS

During follow-up (mean 11 years) MACE occurred in 10 % (n = 18/182) of the individuals without MI scars, in 20 % (n = 11/55) of the individuals with UMI, and in 45 % (n = 5/11) of the individuals with RMI, with a significant difference between the UMI group and the group without MI scars (p = 0.045), and between the RMI group and the group without MI scars (p = 0.0004). Cardiac death and/or non-fatal MI occurred in 15, 5, and 3 of the individuals in the NoMI, UMI, and RMI group respectively. Hazards ratios for MACE adjusted for risk factors and sex were 2.55 (95 % CI 1.20-5.42; p = 0.015) for UMI and 3.28 (95 % CI1.16-9.22; p = 0.025) for RMI.

CONCLUSIONS

The presence of a CMR detected UMI entailed a more than double risk for MACE in community living 70-year-old individuals.

Sex Differences in the Treatment and Outcome of Korean Patients With Acute Myocardial Infarction Using the Korean National Health Insurance Claims Database

Evidence showing higher acute myocardial infarction (AMI) mortality rates among female compared with male inpatients has stimulated interest in whether this disparity is the result of biological factors or differences in the provision of healthcare services. We investigated the impact of sex on in-hospital mortality rates due to AMI, and evaluated the contribution of differences in the delivery of optimal medical services for AMI.We retrospectively constructed a dataset of 85,329 new patients admitted to Korean hospitals with AMI between 2003 and 2007 from the Korea National Health Insurance Claims Database. We used the claims database to provide information about treatment after admission or death for each patient.Proportionally more female than male patients aged 65 years or older had complications; however, proportionally fewer female patients underwent invasive procedures. Female patients had a higher in-hospital mortality rate than males (21.2% vs 14.6%, odds ratio [OR] 1.58, 95% confidence interval [CI] 1.52-1.64). The probability of death within 30 days after admission remained higher for females than males after adjusting for demographic characteristics and severity (OR 1.08, 95% CI 1.04-1.13). After additionally adjusting for invasive and medical management, the probability of death within 30 days did not differ between males and females (OR 1.04, 95% CI 0.99-1.08). A similar trend was revealed by an additional analysis of patients according to younger (<65 years) and older (≥65 years) age groups.The higher in-hospital mortality rates after AMI in Korean female patients was associated with a lower procedure rate. Evidence indicating that AMI symptoms differ according to sex highlights the need for health policies and public education programs that raise awareness of sex-related differences in early AMI symptoms to increase the incidence of appropriate early treatment in females.

Symptom recognition and healthcare experiences of young women with acute myocardial infarction

BACKGROUND

Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ≤55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population.

METHODS AND RESULTS

We conducted a qualitative study using in-depth interviews with 30 women (aged 30-55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease.

CONCLUSIONS

Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women's elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

The effects of topical heat therapy on chest pain in patients with acute coronary syndrome: a randomised double-blind placebo-controlled clinical trial

AIMS AND OBJECTIVES

To investigate the effects of local heat therapy on chest pain in patients with acute coronary syndrome.

BACKGROUND

Chest pain is a very common complaint in patients with acute coronary syndrome. It is managed both pharmacologically and nonpharmacologically. Pharmacological pain management is associated with different side effects.

DESIGN

This was a randomised double-blind placebo-controlled clinical trial conducted in 2013.

METHODS

A convenience sample of 66 patients with acute coronary syndrome was selected from a coronary care unit of a local teaching hospital affiliated to Gonabad University of Medical Sciences, Gonabad, Iran. Patients were randomly assigned to either the experimental or the placebo group. Patients in the experimental and the placebo groups received local heat therapy using a hot pack warmed to 50 and 37 °C, respectively. We assessed chest pain intensity, duration and frequency as well as the need for opioid analgesic therapy both before and after the study. The study instrument consisted of a demographic questionnaire, the McGill Pain Questionnaire, and a data sheet for documenting pain frequency and duration as well as the need for analgesic therapy.

FINDINGS

The placebo heat therapy did not significantly decrease the intensity, the duration and the frequency of pain episodes. However, pain intensity, duration and frequency in the experimental group decreased significantly after the study. Moreover, the groups differed significantly in terms of the need for opioid analgesic therapy neither before nor after the intervention.

CONCLUSION

Local heat therapy is an effective intervention for preventing and relieving chest pain in patients with acute coronary syndrome.

RELEVANCE TO CLINICAL PRACTICE

Effective pain management using local heat therapy could help nurses play an important role in providing effective care to patients with acute coronary syndrome and in minimising adverse effects associated with pain medications.

Cognitive representations of symptoms of acute coronary syndrome and coping responses to the symptoms as correlates to pre-hospital delay in Omani women and men patients

The major purpose of this study was to describe gender-related cognitive representations of symptoms of acute coronary syndrome and coping responses to the symptoms as correlates to pre-hospital delay. Data were collected from 131 hospitalised Omani patients for acute coronary syndrome (81 men and 50 women) using a structured interview. Statistical analyses indicated that women perceived themselves as less susceptible to acute coronary syndrome than men. They reported the symptoms, shortness of breath and nausea/vomiting, more frequently than did men. Men who reported shorter pre-hospital delay were more likely to be free from diabetes, report neck pain, not experience left arm pain, attribute the symptoms to cardiac origin and not use the coping responses, ‘wait and see’ and ‘attempted to relax’. Whereas, women with shorter pre-hospital delay were more likely to experience sweating, perceive greater overall intensity of the symptoms and not report fear of diagnostic procedures as a barrier to seek healthcare early. The findings of this study suggest that, in women, the emotional aspect of the symptoms dominates the cognitive appraisal process, whereas the pathological aspect of the symptoms dominates the appraisal process in men.

Reliability of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey among black and white women

BACKGROUND

Coronary heart disease (CHD) mortality rates are higher among women, particularly black, than men. Women's mortality rates may reflect difficulty in recognizing CHD prodromal symptoms (PS) but reliable screening instruments for women are scarce. The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) captures women's PS presentation, but has limited testing among black women.

AIM

To assess the test-retest reliability of the MAPMISS PS section for black and white women.

METHODS

The sample was recruited from women enrolled in a longitudinal study examining the predictive validity of the MAPMISS. The MAPMISS was re-administered to 42 women (22 white, 20 black) 3-5 days after baseline assessment.

RESULTS

Women endorsed an average of 7.5 PS (SD 4.8; range 0-20) initially and 7.6 (SD 4.7; range 0-20) at retest. Over half of the women (54.8%) of both races endorsed the same number of PS at test and retest; for 69%, the number endorsed at both testings differed by no more than one. Percentage agreement and kappa statistics on the number ofPS endorsed were excellent overall and by race. PS test and retest scores, reflecting PS intensity and frequency, were highly correlated overall (r = 0.92, p < 0.001) and separately for white (r = 0.93, p < 0.001) and black women (r = 0.91,p < 0.001). Racial differences were insignificant.

CONCLUSIONS

Findings indicate (i) the MAPMISS PS score has excellent test-retest reliability (r = 0.92) when administered to women without a history of CHD, and (ii) test-retest reliability is as strong for black (r = 0.91) as for white women (r = 0.93).

Gender differences in fatigue associated with acute myocardial infarction

INTRODUCTION

Fatigue is a symptom of acute myocardial infarction (AMI); however, few studies have characterized the fatigue associated with AMI in men and women.

METHODS

The convenience sample included 88 men and 28 women admitted with a diagnosis of AMI at 6 Midwestern facilities. Data were collected upon hospital admission and 30 days after discharge. A total of 37 men and 10 women responded to the 30-day questionnaires. The Profile of Mood States Fatigue (POMS-F) subscale was used to measure fatigue and the Depression-Dejection subscale to measure depressed mood.

RESULTS

At baseline, significant gender differences were found, with women more likely to have higher POMS-F scores (15.80, SD = 7.33) than men (11.19, SD = 7.04, P = .004). Significant gender differences were also found at 30 days (t = 2.40, df = 45, P = .02). POMS-F scores for women were higher at baseline, with decreased fatigue levels 30 days after discharge (t = 5.36, df = 9, P < or = .05). No differences were found in POMS-F scores for men (t = 1.26, df = 36, P = .213) between baseline and 30 days after discharge. Fatigue was associated with depressed mood and gender at baseline (R(2) = 0.48, P < .05) and 30 days after discharge (R(2) = 0.308, P < .05).

CONCLUSIONS

In this sample, fatigue at baseline and at 30 days after discharge was associated with gender and depressed mood. Women reported high levels of fatigue with AMI and lower fatigue after discharge. Men reported moderate to high fatigue levels, which did not change over time. Further research is needed to discern fatigue patterns before and after AMI.

Cluster analysis of women's prodromal and acute myocardial infarction symptoms by race and other characteristics

BACKGROUND AND OBJECTIVE

Although research has identified women's prodromal and acute myocardial infarction (MI) symptoms, diagnosing coronary heart disease in women remains challenging. Knowing how individual symptoms cluster by race and other characteristics would provide key diagnostic information. We performed a secondary analysis to: (a) generate naturally occurring symptom clusters based on prodromal and acute MI symptom scores separately, (b) examine the association between women's characteristics and symptom clusters, and (c) describe the percentage of women who reported experiencing the same symptoms in both prodromal and acute MI phases.

SUBJECT AND METHODS

The database contained retrospective self-reported data obtained by telephone survey from 1270 women (43% black, 42% white, 15% Hispanic) with a confirmed MI recruited from 15 geographically diverse sites. Data included frequency and severity of 33 prodromal symptoms, intensity of 37 acute MI symptoms, and comorbidities/risk factors. We used both bivariate and multivariate analyses to examine associations between cluster assignment and characteristics/risk factors. Because of the possibility of complex interactions, we explored nonlinear interactions with recursive partitioning.

RESULTS

Cluster analysis yielded 3 naturally occurring clusters for each of the prodromal and acute symptom sets. Each cluster contained women who reported increasing frequency and severity of symptoms. Six characteristics (age, race, body mass index, personal history of heart disease, diabetes, smoking status) were strongly associated with the clusters. Body mass index was the most important factor in classifying prodromal symptoms, whereas age was for acute symptoms.

CONCLUSIONS

Black women younger than 50 years were more likely to report frequent and intense prodromal symptoms, whereas older white women reported the least. Younger, obese, diabetic black women reported the most acute symptoms, whereas older nonobese, nondiabetic white women reported the fewest. Symptom clusters and characteristics of women in these clusters provide valuable diagnostic information. Further research with a control group is needed.

Predictors and use of nonpharmacologic interventions for procedural pain associated with turning among hospitalized adults

Many hospitalized adults cannot reposition themselves in their beds. Therefore, they are regularly turned by their nurses, primarily to prevent pressure ulcer formation. Earlier research indicates that turning is painful and that patients are rarely premedicated with analgesics. Nonpharmacologic interventions may be used to help with this painful procedure. However, no published research was found on the use of nonpharmacologic interventions for turning of hospitalized patients. The objectives of this study were: 1) to describe patient pain characteristics during turning and their association with patient demographic and clinical characteristics; 2) to determine the frequency of use of various nonpharmacologic interventions for hospitalized adult patients undergoing the painful procedure of turning; and 3) to identify factors that predict the use of specific nonpharmacologic interventions for pain associated with turning. Hospitalized adult patients who experienced turning, the nurses caring for them, and others who were present at the time of turning were asked if they used various nonpharmacologic interventions to manage pain during the turning. Out of 1,395 patients, 92.5% received at least one nonpharmacologic intervention. Most frequently used were calming voice (65.7%), information (60.6%), and deep breathing (37.9%). Critical-care patients were more likely to receive a calming voice (odds ratio [OR] 1.66, p < .01), receive information (OR 1.62, p < .001), and use deep breathing (OR= 1.36, p < .05) than those who were not critical-care patients. Those reporting higher pain were consistently more likely to receive each of the three interventions (OR 1.01, p < .05 for all 3). In conclusion, nonpharmacologic interventions are used frequently during a turning procedure. The specific interventions used most often are ones that can be initiated spontaneously. Our data suggest that patients, nurses, and family members respond to patients' turning-related pain by using nonpharmacologic interventions.

Physiological and anatomical bases for sex differences in pain and nausea as presenting symptoms of acute coronary syndromes

Acute coronary syndromes (ACS) are common in both men and women. Studies show that women have longer times before diagnosis and treatment in the Emergency Department and worse outcomes than men, which may be related to the differing symptom presentations of men and women. Men are more likely to have chest pain, whereas women are more likely to have dyspnea or nausea. However, women tend to be older and more likely to have diabetes mellitus, hypertension, and peripheral neuropathies. Men and women also exhibit differences in the neural receptors and pathways involved in pain and noxious-stimuli perception. Moreover, men and women may have subtle differences in the locations and sites of their atherosclerotic lesions, all of which may affect symptom presentation. The purposes of this review are to present: (1) the physiology of two common symptoms associated with ACS, ie, pain and nausea; (2) how these symptoms differ between men and women; and (3) how different comorbidities may affect the presentation of these symptoms.

Quality Difference in Craniofacial Pain of Cardiac vs. Dental Origin

Craniofacial pain, whether odontogenic or caused by cardiac ischemia, is commonly referred to the same locations, posing a diagnostic challenge. We hypothesized that the validity of pain characteristics would be high in assessment of differential diagnosis. Pain quality, intensity, and gender characteristics were assessed for referred craniofacial pain from dental (n = 359) vs. cardiac (n = 115) origin. The pain descriptors “pressure” and “burning” were statistically associated with pain from cardiac origin, while “throbbing” and “aching” indicated an odontogenic cause. No gender differences were found. These data should now be added to those craniofacial pain characteristics already known to point to acute cardiac disease rather than dental pathology, i.e., pain provocation/aggravation by physical activity, pain relief at rest, and bilateralism. To initiate prompt and appropriate treatment, dental and medical clinicians as well as the public should be alert to those clinical characteristics of craniofacial pain of cardiac origin.

Racial differences in women's prodromal and acute symptoms of myocardial infarction

BACKGROUND

Minority women, especially black and Hispanic women, have higher rates of coronary heart disease and resulting disability and death than do white women. A lack of knowledge of minority women's symptoms of coronary heart disease may contribute to these disparities.

OBJECTIVE

To compare black, Hispanic, and white women's prodromal and acute symptoms of myocardial infarction.

METHODS

In total, 545 black, 539 white, and 186 Hispanic women without cognitive impairment at 15 sites were retrospectively surveyed by telephone after myocardial infarction. With general linear models and controls for cardiovascular risk factors, symptom severity and frequency were compared among racial groups. Logistic regression models were used to examine individual prodromal or acute symptoms by race, with adjustments for cardiovascular risk factors.

RESULTS

Among the women, 96% reported prodromal symptoms. Unusual fatigue (73%) and sleep disturbance (50%) were the most frequent. Eighteen symptoms differed significantly by race (P<.01); blacks reported higher frequencies of 10 symptoms than did Hispanics or whites. Thirty-six percent reported prodromal chest discomfort; Hispanics reported more pain/discomfort symptoms than did black or white women. Minority women reported more acute symptoms (P < .01). The most frequent symptom, regardless of race, was shortness of breath (63%); 22 symptoms differed by race (P <.01). In total, 28% of Hispanic, 38% of black, and 42% of white women reported no chest pain/discomfort.

CONCLUSIONS

Prodromal and acute symptoms of myocardial infarction differed significantly according to race. Racial descriptions of women's prodromal and acute symptoms should assist providers in interpreting women's symptoms.

Patient perception of symptoms and quality of life following ablation in patients with supraventricular tachycardia

OBJECTIVES

It remains unclear which symptom experiences and aspects of quality of life (QOL) change after ablation in patients with supraventricular tachycardia (SVT). To determine how patient perceptions of symptoms and QOL change after ablation, we used a single group pretest-posttest design.

METHODS

Patients with SVT (n=52; mean age 41+/-17 years; 65% female) completed generic and disease-specific measures at baseline and 1 month after ablation.

RESULTS

Significant improvement after ablation was noted on virtually all measures (P <.05). Patients reported decreases from baseline regarding frequency and duration of episodes, number of symptoms, and impact of SVT on routine activities. All symptoms decreased in prevalence; however, no symptoms were completely eliminated at 1-month follow-up. Women, more so than men, reported larger changes in symptom and QOL scores after ablation.

CONCLUSIONS

Despite the small sample, statistically significant improvement was found after ablation in a variety of patients with different symptoms and QOL indices.

Diagnosis: a liminal state for women living with lupus

Women with systemic lupus erythematosus (SLE or lupus) often experience a protracted diagnostic period in which their symptoms are treated as medically unexplained. Although they know they are ill, their symptoms have not been validated as indicative of disease by a health care professional. Consequently, the diagnostic period can be viewed as liminal, the middle stage in the rites of passage and what Turner (1969/1997) has labeled "betwixt and between." Drawing on the analysis of narratives solicited from 23 women recruited from online lupus support groups, I explore the gendered nature of diagnosis for women with lupus using van Gennep's (1960) rites of passage as a conceptual framework.

Myocardial infarction in women: promoting symptom recognition, early diagnosis, and risk assessment

Even with national campaigns to help increase awareness, most people do not realize that heart disease is now the leading cause of death for women. Women experiencing an acute cardiac event often do not recognize the symptoms or are misdiagnosed by healthcare providers because of atypical symptom presentation. This can lead to a significant delay in treatment and a less desirable recovery outcome. To help promote early identification of cardiac risk and cardiac events, this article highlights the range of symptom presentation in women with myocardial infarction and focuses on how advanced clinical nurses can increase nurses' and the public's understanding of this disease in women.

Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested.

Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression.

Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient’s hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured.

Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01–0.49), palpitations (β = 0.31; CI = 0.06–0.56), nausea (β = 0.37; CI = 0.10–0.65), numbness in the hands (β = 0.29; CI = 0.02–0.57), and unusual fatigue (β = 0.60; CI = 0.27–0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women.

Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear.

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

BACKGROUND

Few studies have examined the time between onset of myocardial infarction (MI) symptoms and arrival at hospital (prehospital delay time) and symptoms in men vs. women.

AIMS

To describe prehospital delay time and symptoms in men vs. women with MI and to analyse trends over time and according to age.

METHODS

The Northern Sweden MONICA myocardial infarction registry, 1989-2003, included 5,072 men and 1,470 women with a confirmed MI.

RESULTS

Typical pain was present in 86% of the men and 81% of the women. The proportion with typical symptoms decreased over time for men and increased for women. Typical symptoms were more common among younger persons than older persons. Insufficiently reported symptoms was unchanged in men over time and decreased among women. Up to the age of 65, no gender differences were seen in the prehospital delay. In the oldest age group (65-74 years) time to hospital was longer than among the younger groups, especially among women.

CONCLUSION

There were no major gender differences in prehospital delay or type of symptoms. However, over time the proportion with typical symptoms decreased in men and increased in women. Older patients had longer prehospital delay and less typical symptoms.

Unexplained chest pain in relation to psychosocial factors and health-related quality of life in men and women

BACKGROUND

Unexplained chest pain is a frequent and increasingly common complaint among patients admitted to Emergency Departments. Previous studies have defined unexplained chest pain as non-cardiac or non-coronary artery disease, i.e. patients with other organic causes explaining the chest pain could be included. To increase the knowledge of unexplained chest pain, this study only includes patients without any known explanation for their chest pain.

AIM

To analyze gender differences regarding pain characteristics, psychosocial factors and health-related quality of life among patients diagnosed unexplained chest pain.

METHODS AND RESULTS

The results are based on 179 patients (101 men, 78 women) between 16 and 69 years old (mean age 45.3) consecutively admitted to Emergency Department. Pain characteristics were assessed by Pain-O-Meter. Social relationships, depression, anxiety, and health-related quality of life were measured by a self-administered questionnaire. There were no gender differences regarding chest pain intensity; however women described their pain as burning (p<0.01) and frightening (p<0.03) more often than men. Men reported less depression (p<0.01) and less trait anxiety (p=0.01) than women. Chest pain intensity did not significantly impact health-related quality of life except physical functioning in men (p=0.05).

CONCLUSION

Gender differences were few. Chest pain intensity did not significantly impact health-related quality of life.