Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study

Sex Differences in Coronary Artery Disease: Insights From the KoRean wOmen'S chest pain rEgistry (KoROSE)

Interest in sex differences in coronary artery disease (CAD) has been steadily increasing. Concurrently, most of the data on these differences have primarily been Western-oriented. The KoRean wOmen'S chest pain rEgistry (KoROSE), started in 2011, has since published numerous research findings. This review aims to summarize the reported differences between men and women in CAD, integrating data from KoROSE. Cardiovascular risk in postmenopausal women escalates dramatically due to the decrease in estrogen levels, which normally offer cardiovascular protective effects. Lower estrogen levels can lead to abdominal obesity, insulin resistance, increased blood pressure, and endothelial dysfunction in older women. Upon analyzing patients with CAD, women are typically older and exhibit more cardiovascular risk factors than men. Diagnosing CAD in women tends to be delayed due to their symptoms being more atypical than men's. While in-hospital outcome was similar between sexes, bleeding complications after percutaneous coronary intervention occur more frequently in women. The differences in long-term prognosis for CAD patients between men and women are still a subject of ongoing debate. Pregnancy and reproductive factors also play a significant role as risk factors for cardiovascular disease in women. A notable sex disparity exists, with women found to use fewer cardiovascular protective drugs and undergo fewer interventional or surgical procedures than men. Additionally, women participate less frequently than men in clinical research. Through concerted efforts to increase awareness of sex differences and mitigate sex disparity, personalized treatment can be provided. This approach can ultimately improve patient prognosis.

Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States

BACKGROUND

The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States.

METHODS

Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model.

RESULTS

Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003).

CONCLUSIONS

The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

Time to make some noise about a quiet revolution

'Tomorrow belongs to those who can hear it coming' David Bowie. Language is a living entity that moves and changes. Use of gender-neutral language in medical literature is increasingly common. It is time for obstetricians and gynaecologists in Australia and New Zealand to interrogate their own bias and desire to maintain the status quo, and to consider reasons for change.

Patient and clinician experiences of uncertainty in the diagnostic process: Current understanding and future directions

OBJECTIVE

Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate and timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing (1) where patients and clinicians experience uncertainty within the diagnostic process, (2) how uncertainty affects the diagnostic process, (3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and (4) strategies to manage uncertainty.

DISCUSSION

Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined.

CONCLUSION

Scientific knowledge on diagnostic uncertainty, while previously elusive, is now becoming more clearly defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women's Chest Pain Registry

BACKGROUND/AIMS

Chest pain in patients with obstructive coronary artery disease (OCAD) is affected by several social factors. The gender-based differences in chest pain among Koreans have yet to be investigated.

METHODS

The study consecutively enrolled 1,549 patients (male/female, 514/1,035; 61 ± 11 years old) with suspected angina. The predictive factors for OCAD based on gender were evaluated.

RESULTS

Men experienced more squeezing type pain on the left side of chest, while women demonstrated more dull quality pain in the retrosternal and epigastric area. After adjustment for risk factors, pain in the retrosternal area (odds ratio [OR], 1.491; 95% confidence interval [CI], 1.178 to 1.887) and aggravation by exercise (OR, 2.235; 95% CI, 1.745 to 2.861) were positively associated with OCAD. In men, shorter duration (OR, 1.581; 95% CI, 1.086 to 2.303) and dyspnea (OR, 1.610; 95% CI, 1.040 to 2.490) increased the probability for OCAD, while left-sided chest pain suggested a low probability for OCAD (OR, 0.590; 95% CI, 0.388 to 0.897). In women, aggravation by emotional stress (OR, 0.348; 95% CI, 0.162 to 0.746) and dizziness (OR, 0.457; 95% CI, 0.246 to 0.849) decreased the probability for OCAD.

CONCLUSION

This is the first study to focus on gender differences in chest pain among Koreans with angina. Symptoms with high probability for OCAD were different between sexes. Our findings suggest that patient's medical history in pretest assessment for OCAD should be individualized considering gender.

Ranolazine Reduces Angina in Women with Ischemic Heart Disease: Results of an Open-Label, Multicenter Trial

Background: Persistent angina is prevalent in women, who more often present with atypical angina, and experience less relief from antianginal therapies. The impact of ranolazine on female-specific angina is unclear. A single-arm, open-label trial was conducted to quantify the impact of ranolazine on angina in women with ischemic heart disease (IHD). Materials and Methods: Women with IHD and ≥2 angina episodes/week were recruited from 30 U.S. sites. Angina and nitroglycerin (NTG) consumption were assessed using patient-reported diaries, Seattle Angina Questionnaire (SAQ), Duke Activity Score Index (DASI), and Women's Ischemia Symptom Questionnaire (WISQ) at baseline and at 4 weeks of treatment with ranolazine 500 mg twice/day. A modified intent-to-treat analysis and parametric or nonparametric methods were used as appropriate to analyze changes. Results: Of 171 women enrolled, mean age was 65 ± 12 years. Of the 159 women included in the analysis, at week 4 compared to baseline, median angina frequency decreased with ranolazine treatment from 5.0 to 1.5 attacks/week and median change from baseline was -3.3 (95% confidence interval [CI]: -4.0 to -2.5; p ≤ 0.0001). Median NTG consumption decreased from 2.0 to 0.0 per week over the 4 weeks and median change was -1.0 (95% CI: -2.0 to -0.5; p < 0.0001). All five SAQ subscales showed mean improvements: physical limitation 9.2 (standard error [SE] 1.5; p < 0.0001), angina stability 31.8 (SE 2.7; p < 0.0001), angina frequency 17.7 (SE 1.6; p < 0.0001), treatment satisfaction 9.3 (SE 1.6; p < 0.0001), and disease perception 2.9 (SE 0.8; p < 0.0001). DASI score also improved 2.9 (SE 0.8; p = 0.0014). WISQ subscales also showed significant improvements (all p < 0.0001). Thirty-one women reported drug-related adverse events (AEs), predominantly mild to moderate gastrointestinal symptoms. Conclusions: Women with IHD treated with ranolazine for 4 weeks experienced less angina measured by SAQ and WISQ. NTG use decreased, physical activity improved, and treatment satisfaction improved. AEs were consistent with prior reports.

Illness Perceptions in Patients with Premature Coronary Artery Disease: A Sex-Based Analysis 8 Years After the Diagnosis

To assess illness perceptions in patients with premature atherosclerotic coronary artery disease (CAD), 717 adults with premature CAD (diagnosis of CAD in men age < 45 years and women age < 55 years) completed sociodemographic indices, the Beck's Depression Inventory-II, Beck Anxiety Inventory and the Brief Illness Perceptions 8 years after the diagnosis. Mean age was 49.59 ± 3.57 years for men and 57.72 ± 4.90 years for women at the time of study. Both sexes were treated through coronary artery bypass graft surgery, percutaneous coronary intervention, or medical treatment. Depressive and anxiety symptoms were significantly more prevalent among women. Generally, the patients believed that their disease was chronic and well controlled and that it had no considerable negative impact on their routine life. Overall, patients had a low concern about their illness. Women had a more negative perception of their disease than did men which may indicate their need for higher psychological support.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

BACKGROUND

Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences.

OBJECTIVE

The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS.

METHODS

A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured.

RESULTS

The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00-2.42), shoulder pain (OR, 1.76; CI, 1.13-2.73), and upper back pain (OR, 2.92; CI, 1.81-4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women.

CONCLUSIONS

Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

"Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain

Background

Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.

Methods

A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.

Results

The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.

Conclusions

Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

Frequency of craniofacial pain in patients with ischemic heart disease

Background

Referred craniofacial pain of cardiac origin might be the only symptom of ischemic heart accidents. This study aimed to determine the frequency of craniofacial pain in patients with ischemic heart disease.

Material and Methods

This cross-sectional study was accomplished on 296 patients who met the criteria of having ischemic heart disease. Data regarding demographics, medical history and referred craniofacial pain were recorded in data forms. In addition, patients underwent oral examination to preclude any source of dental origin. Chi-square test, Student’s t-test and backward regression model were used to analyze the data by means of SPSS software version 21. P<0.05 was considered significant.

Results

A total of 296 patients were studied comprising of 211 men (71%) and 85 women (29%) with the mean age of 55.8. Craniofacial pain was experienced by 53 patients out of 296, 35 (66%) of whom were male and 18 (34%) were female. None of the patients experienced craniofacial pain solely. The most common sites of craniofacial pain were occipital and posterior neck (52.8%), head (43.3%), throat and anterior neck (41.5%) respectively. We found no relationship between craniofacial pain of cardiac origin with age, diabetes, hypertension, and family history. On the other hand, there was a significant relationship between hyperlipidemia and smoking with craniofacial pain of cardiac origin.

Conclusions

Radiating pain to face and head can be expected quite commonly during a cardiac ischemic event. Dental practitioners should be thoroughly aware of this symptomatology to prevent misdirected dental treatment and delay of medical care.

Key words:Craniofacial pain, ischemic heart disease, myocardial infarction, angina pectoris, referred pain.

Craniofacial Pain as the Sole Sign of Prodromal Angina and Acute Coronary Syndrome: A Review and Report of a Rare Case

Orofacial pain can arise from different regions and etiologies. Some of the most debilitating pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). The problem with referred pain is the misdiagnosis and unnecessary therapy directed to the pain location instead of its origin. When craniofacial pain is the sole sign of myocardial ischemia, failure to recognize its cardiac source can endanger the patient. In particular, apart from unnecessary dental treatments, patients with acute myocardial infarction who do not experience chest pain run a very high risk of misdiagnosis and death. As endodontists, each of us may face many patients complaining of pain sensation in the teeth with the main source being other craniofacial/visceral organs. This review plots a diagnostically challenging case paving the way for further literature presentation in this regard. The aim of this compendious review was to gain knowledge about the prevalence, clinical characteristics and possible mechanisms of craniofacial pain of cardiac origin, in order to improve the clinician’s ability to make a correct diagnosis.

Gender differences in symptoms during 60-second balloon occlusion of the coronary artery

Previous investigations have demonstrated the presence of gender differences in the symptoms of angina pectoris and acute coronary syndrome. However, most of these investigations have had certain limitations, including being retrospective, an interview-related bias, a various duration of myocardial ischemia, and a lack of multivariate analysis, all of which would have affected the results. Accordingly, we prospectively examined the presence or absence of chest pain and non-chest pain symptoms during a 60-second balloon inflation in the setting of percutaneous coronary intervention, which provides a unique model of transient myocardial ischemia, in 110 men and 80 women with coronary artery disease. Chest pain and/or non-chest pain symptoms (occipital pain, jaw pain, neck/throat pain, shoulder pain, upper arm pain, back pain, and nausea) were observed during the balloon inflation in 72 men and 52 women. In the 124 patients with any symptoms during the balloon inflation, non-chest pain symptoms were more common in women than in men (31% vs 14%, p = 0.02); however, the incidence of chest pain did not differ between the men and women. After adjustment for covariables, including age, body mass index, hypertension, diabetes mellitus, current smoking, previous myocardial infarction, target vessels, β-blocker use, and calcium antagonist use, female gender remained significantly associated with non-chest pain symptoms (odds ratio 3.3, 95% confidence interval 1.2 to 9.9, p = 0.02). In conclusion, non-chest pain symptoms during the 60-second balloon occlusion of the coronary artery were more common in women than in men, supporting the presence of the gender difference in myocardial ischemic symptoms.

The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease

BACKGROUND

Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina.

METHODS AND RESULTS

This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina.

CONCLUSIONS

Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Low education as a risk factor for undiagnosed angina

BACKGROUND

Early awareness, recognition, and treatment of angina can help prevent or delay an acute myocardial infarction and potentially delay death. A patient's educational level may affect a physician's diagnosis of angina and/or a patient's symptom recognition. The objective of this study was to determine whether low education is a risk factor for undiagnosed angina.

METHODS

This was a cross-sectional observational study based on data from the National Health and Nutrition Examination Survey 2001 to 2008, providing a nationally representative sample of adults ≥40 years of age with angina based on physician diagnosis, presence of angina symptoms based on the Rose Questionnaire, or both. Educational attainment (high school or less vs more than high school) was the independent variable of interest. Undiagnosed angina (angina symptoms in the absence of angina diagnosis) was the dependent variable. We used logistic regression to control for age, sex, race/ethnicity, income, and health care visit during the past year.

RESULTS

Low education was associated with undiagnosed angina (odds ratio: 1.43; 95% confidence interval: 1.01-2.03). Other undiagnosed angina predictors included being female, being black, and having no health care visit during the past year.

CONCLUSIONS

Low education is associated with undiagnosed angina. These results underscore the need for providers to ask about angina symptoms and confirm patients' understanding of their angina diagnosis among those with low education.

Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain

OBJECTIVE

To examine functions of the exercise ECG in the light of the recent National Institute for Health and Clinical Excellence guidelines recommending that it should not be used for the diagnosis or exclusion of stable angina.

DESIGN

Qualitative ethnographic study based on interviews and observations of clinical practice.

SETTING

3 rapid access chest pain clinics in England.

PARTICIPANTS

Observation of 89 consultations in chest pain clinics, 18 patient interviews and 12 clinician interviews.

MAIN OUTCOME MEASURE

Accounts and observations of consultations in chest pain clinics.

RESULTS

The exercise ECG was observed to have functions that extended beyond diagnosis. It was used to clarify a patient's story and revise the initial account. The act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation of symptoms and further elaboration of symptoms. The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician.

CONCLUSIONS

Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of services without that test. Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.

Clinical characteristics and outcomes of Japanese women undergoing coronary revascularization therapy

BACKGROUND

Limited data are available for gender-based differences in patients undergoing coronary revascularization. This study aimed to identify gender-based differences in risk factor profiles and outcomes among Japanese patients undergoing coronary revascularization.

METHODS AND RESULTS

The subjects consisted of 2,845 women and 6,843 men who underwent first percutaneous coronary intervention or coronary artery bypass grafting in 2000-2002. The outcome measures were all-cause death, major adverse cardiovascular events (MACE) as the composite of cardiovascular death, myocardial infarction and stroke, and any coronary revascularization. The females were older than the males and more frequently had histories of heart failure, diabetes, hypertension, chronic kidney disease, anemia, and dyslipidemia. Unadjusted survival analysis revealed a significantly lower incidence of any revascularization in women (at 3 years: 28.2% vs. 31.2%, P = 0.0037), although no significant gender-based differences were shown in the incidence of all-cause death (at 3 years: 8.8% vs. 8.5%, P = 0.37) or MACE (at 3 years: 12.0% vs. 11.5%, P = 0.61). Multivariate analysis revealed that female gender was associated with significantly lower risks of any revascularization (relative risk = 0.93, 95% confidence interval [CI] = 0.88-0.99, P = 0.014) and all-cause death (relative risk = 0.86, 95%CI = 0.77-0.96, P = 0.005).

CONCLUSIONS

In Japanese patients undergoing first coronary revascularization, the coronary risk factor burden appeared greater in women than in men. Despite the greater modifiable risk factor accumulation, female gender was associated with a lower incidence of repeated revascularization relative to male gender.

Patients' descriptions of angina symptoms: a qualitative study of primary care patients

BACKGROUND

Initial diagnosis of angina in primary care is based on the history of symptoms as described by the patient in consultation with their GP. Deciphering and categorising often complex symptom narratives, therefore, represents an ongoing challenge in the early diagnosis of angina in primary care.

AIM

To explore how patients with a preexisting angina diagnosis describe their symptoms.

METHOD

Semi-structured interviews were conducted with 64 males and females, identified from general practice records as having received a diagnosis of angina within the previous 5 years.

RESULTS

While some patients described their angina symptoms in narratives consistent with typical anginal symptoms, others offered more complex descriptions of their angina experiences, which were less easy to classify. The latter was particularly the case for severe coronary artery disease, where some patients tended to downplay chest pain or attribute their experience to other causes.

CONCLUSION

Patients with a known diagnosis of angina do not always describe their symptoms in a way that is consistent with Diamond and Forrester's diagnostic framework for typicality of angina. Early diagnosis of angina in primary care requires that GPs operate with a broad level of awareness of the various ways in which their patients describe their 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.

Gender equity in treatment for cardiac heart disease in Portugal

Equity in health care delivery is one of the objectives of the Portuguese health care system. To date, research on this issue has mainly focused on income-related equity. This is the first study to shed light on gender equity, using a large data base that includes all patients admitted with cardiac heart disease at Portuguese NHS hospitals over the 2000-2006 period (259,519 discharges from 57 hospitals). In this paper we compare the use of catheterization and revascularization between men and women, controlling for age, comorbidities and hospital characteristics. Our findings show that women receive notably less catheterization and revascularization, with no significant change in this pattern over the 2000-2006 period. In addition, we observe that (i) gender differences disfavouring women are higher prior to detection of acute disease than after; (ii) women are significantly more likely to die during hospitalization despite equal treatment; (iii) gender differences against women are higher for non-elective admissions, and women are more often admitted through emergency units. These additional findings suggest that gender differences in detection, referral and treatment at early stages of the disease are likely to play a crucial role. They could possibly explain part of the higher gender differences before acute disease has been detected; they also lead women to be treated later, to be more frequently admitted through emergency units and to experience worse outcomes. However, alternative explanations cannot be discarded. The higher women's in-patient mortality may also signal gender differences in recovery from treatment, and the higher gap among emergency admissions could point to women's lower willingness to be treated. Further investigation should help to disentangle the precise role of each of these causal factors.

Gender specific variations in the description, intensity and location of angina pectoris: a cross-sectional study

BACKGROUND

Some research suggests that men and women may experience Angina Pectoris (AP) differently. More research is needed to characterize AP symptoms by gender and to familiarize health care providers with them, to enable proper education, diagnostic evaluation and timely management.

OBJECTIVE

This study examines gender differences in the description, intensity and location of AP in patients with CHD.

DESIGN

A cross-sectional study was performed to compare AP patients according to gender.

SETTINGS

This study was performed on patients residing in Tehran, who were being treated in a hospital and were admitted to cardiac units.

PARTICIPANTS

Five hundred patients with AP were selected. The participants were patients with AP who were diagnosed with CHD based on documented results from an angiography.

METHOD

Outpatients who were admitted to the cardiac units were screened. Informed consent was obtained from all study participants, who then completed the Iranian version of the AP characteristics questionnaire.

RESULTS

Women were significantly more likely to feel pain in the left arm and hand, odds ratio 1.5 (95% CI=1.0-2.1, P=0.04), left scapula, odds ratio 2.3 (95% CI=1.6-3.5, P<0.001), and neck, odds ratio 2.8 (95% CI=1.9-4.1, P<0.0001), while controlling for demographic and clinical factors. Women were significantly more likely to choose the possible pain descriptors for describing their AP and reported significantly greater intensity than men for all the pain descriptors. Significantly higher scores for sensory, affective, total and NRS (Numeric Rating Scale) scores were observed in women (P<0.001). Multiple linear regression analyses revealed that gender remained a statistically significant predictor of pain scores and NRS, while controlling for demographic and clinical factors.

CONCLUSION

Women and men differ with respect to description, intensity and location of AP. Educating the general public and informing health care providers about gender variation in AP may help to decrease delays in seeking medical care.

Influence of Assessment Methods on Reports of Gender Differences in AMI Symptoms

The purpose of this secondary analysis was to compare gender differences in retrospective reports of acute myocardial infarction (AMI) symptoms resulting from two different assessment methods: the open-ended inquiry and the combined assessment approach. Women reported more atypical symptoms in their responses to the open-ended inquiry and a greater number of typical, atypical, and total symptoms in the combined assessment approach in which the open-ended inquiry was followed by a series of closed-ended questions. Women reported more jaw/neck pain, dyspnea, and palpitations in response to the open-ended inquiry. In the combined assessment, men reported more chest pain/discomfort than women, whereas women were more likely to report jaw/neck pain, dyspnea, back pain, fatigue, paroxysmal nocturnal dyspnea, and palpitations. The data suggest that careful attention to the type of questions used to assess AMI symptoms could lead to more definitive conclusions regarding gender differences in AMI symptoms.

Acute stroke symptoms: comparing women and men

BACKGROUND AND PURPOSE

In a recent meta-analysis, women with stroke had 30% lower odds of receiving tissue plasminogen activator than did men, and some studies have reported greater in-hospital delays in women with stroke. Causes of these disparities are unclear but could result from a different symptom presentation in women. Our objective was to prospectively investigate gender differences in acute stroke symptoms.

METHODS

Ischemic stroke/TIA cases presenting to the University of Michigan Hospital (January 2005 to December 2007) were identified. Stroke/TIA symptoms, ascertained by patient interview, were classified as traditional or nontraditional (pain, mental status change, lightheadedness, headache, other neurological, nonneurological). Prevalence of any nontraditional symptom and of each symptom were calculated by gender. Logistic regression was used to compare nontraditional symptoms by gender adjusted for stroke vs TIA, proxy use, age, and discharge disposition (home vs other).

RESULTS

Included were 461 cases (48.6% women; median age, 67). Among women, 51.8% reported >or=1 nontraditional stroke/TIA symptom compared to 43.9% of men (P=0.09). The most prevalent nontraditional symptom was mental status change (women, 23.2%; men, 15.2%; P=0.03). The odds of reporting at least 1 nontraditional stroke/TIA symptom were 1.42 times (95% CI, 0.97-2.06) greater in women than in men.

CONCLUSIONS

A high prevalence of nontraditional symptoms among both genders was found, with women more likely to report nontraditional symptoms and, in particular, altered mental status, compared with men. Larger-scale studies focusing on stroke in women are warranted and could confirm gender differences in symptoms in a larger, more representative stroke population and address the clinical consequences.

Patient preferences for treatment for angina: an overview of findings from three studies

BACKGROUND

Access to cardiac treatments has been documented to vary with patients' age. It is unknown whether these variations reflect patients' treatment preferences. We aimed to investigate patients' preferences for cardiology treatments and develop a Patients' Preferences Questionnaire.

METHODS

Semi-structured interviews with primary care patients with diagnosed angina with postal follow-up. The resulting Patients' Preferences Questionnaire was tested with newly admitted inpatients with acute coronary syndrome and with patients in primary care.

RESULTS

The Patients' Preferences Questionnaire was psychometrically sound. Analyses of preference subscale scores showed that the most positive preference scores were for medication. Angioplasty scored highest at the negative end of the scale. Detailed analyses showed that older people and women were less likely to prefer coronary artery bypass surgery (CABG), reflecting its greater level of invasiveness. Older people (aged over 75 years, compared to people aged under 75 years), but not women, were also more cautious in their strength of preference for angioplasty. More positive attitudes towards CABG surgery, and more negative attitudes towards medication, were associated with greater impact of the condition on life.

CONCLUSIONS

The research resulted in a psychometrically sound Patients' Preferences Questionnaire. There was some evidence to support the view that older people's weaker preferences for CABG may contribute slightly to variations in the provision of re-vascularization. There was also variation in preferences within age groups, cautioning against the assumption that all or most older people are more reluctant than younger people to undergo invasive procedures.

Sex differences in use of interventional cardiology persist after risk adjustment

Background:

Studies from several countries have documented gender disparities in the management of coronary artery disease. Whether such gender disparities are seen in Italy and, if so, whether they can be explained by factors such as age and severity of illness were investigated.

Methods:

77 974 Piedmontese patients, admitted between 1999 and 2002, with a primary diagnosis of myocardial infarction (ICD 410), angina (ICD 413), chronic ischaemia (ICD 414) and chest pain (ICD 786.5) were studied. The number of men and women undergoing surgical treatment was extracted and the male–female odds ratios calculated. Several risk factors and a risk adjustment technique (APR-DRG) were used to control for possible confounders. Backward stepwise multiple logistic regression was used to adjust for significant covariates.

Results:

Crude analysis demonstrated that gender is a discriminating factor in the probability of surgery (OR 2.11, 95% CI 2.04 to 2.19), with similar findings among those with each main diagnosis. The odds ratios decreased after adjustment for age, co-morbidity and disease severity but remained significant.

Conclusions:

Men and women admitted to hospitals in a region of northern Italy with a diagnosis of cardiovascular disease are treated differently and this cannot be explained by age or severity of disease.

Presentation of stable angina pectoris among women and South Asian people

BACKGROUND

There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management.

METHODS

We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures.

RESULTS

Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p < 0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p < 0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio [HR] 2.30, 95% CI 1.70-3.11, p < 0.001) but not among men (HR 1.23, 95% CI 0.96-1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63-0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41-0.67, p < 0.001) were less likely than men and white patients to receive angiography.

INTERPRETATION

Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.

What do patients really want? Patients' preferences for treatment for angina

OBJECTIVE

To measure preferences for angina treatments among patients admitted from accident and emergency with acute coronary syndrome.

BACKGROUND

Evidence suggests variability in treatment allocations amongst certain socio-demographic groups (e.g. related to age and sex), although it is unclear whether this reflects patient choice, as research on patients' treatment preferences is sparse. Given current policy emphasis on 'patient choice', providers need to anticipate patients' preferences to plan appropriate and acceptable health services.

DESIGN

Self-administered questionnaire survey.

SETTING

In-patients in a UK hospital.

PARTICIPANTS

A convenience sample of 53 newly admitted patients with acute coronary syndrome. Exclusion criteria were: a previous cardiologist consultation (including previous revascularization); a clinical judgement of too ill to participate; post-admission death; non-cardiac reasons for chest pain.

MAIN OUTCOME MEASURES

Patients' preferences for coronary artery bypass graft (CABG); angioplasty; and two medication alternatives.

RESULTS

Angioplasty was the preferred treatment (for 80% of respondents), and CABG was second (most preferred by 19%, but second most preferred for 60%). The two least preferred (and least acceptable) treatments were medications. The majority of patients (83%) would 'choose treatment based on the extent of benefits' and 'accept any treatment, no matter how extreme, to return to health'. There were some differences in preference related to age (>70 years preferred medication to a greater degree than <70 years) and sex (males preferred CABG surgery more than females).

CONCLUSIONS

There was general preference for procedural interventions over medication, but most patients would accept any treatment, however extreme, to return to former health. There was some evidence of differences in preferences related to age and sex. Furthermore, most patients preferred to have some input into treatment choice (e.g. nearly half wanted to share decision responsibility with their doctor), with only 4% preferring to leave the decision entirely to their doctor. Given these findings, and past findings that suggest there may be variability in treatment allocation according to certain socio-demographic factors, this study suggests a need to develop and use preference measures, and makes a step towards this.

Differences according to gender in reporting physical symptoms during echocardiographic screening in healthy teenage athletes

BACKGROUND

Many studies have suggested that more women then men present with physical symptoms. There is no data available, however, on the differences in reporting of physical symptoms between teenage male and female athletes. Our objective was to evaluate the differences according to gender in physical symptoms in healthy teenage athletes.

METHODS

A total of 1,465 high school athletes, between the ages of 13 and 19 years participated in a mass echocardiographic screening programme for detection of cardiac abnormalities. Screening was conducted using a hand-carried cardiac ultrasound device (OptiGo, Philips). All participants were actively involved in a high school sport programme. Each athlete was required to fill out a questionnaire before the screening. The athletes were asked to report the occurrence of physical symptoms with activity or exercise. A physical examination was not performed during screening.

RESULTS

There were 1,031 (70.4%) male and 434 (29.6%) female participants. Significantly more female teenage athletes reported physical symptoms (190/434, 43.8% versus 267/1,031, 25.9%, odds ratio: 2.28, confidence interval: 1.76-2.81, p less than 0.001). Symptoms did not correlate with any echocardiographically identified cardiac abnormalities in either gender. The differences in the reporting of symptoms were significant for all physical symptoms addressed by the questionnaire.

CONCLUSION

There is a high prevalence of reporting physical symptoms in young healthy athletes without any relation to cardiac abnormalities. Young female athletes report physical symptoms nearly twice as often as their male counterparts.

Prevalence of Angina in Women Versus Men

Background— In the absence of previous international comparisons, we sought to systematically evaluate, across time and participant age, the sex ratio in angina prevalence in countries that differ widely in the rate of mortality due to myocardial infarction.

Methods and Results— We searched MEDLINE and EMBASE until February 2006 for healthy population studies published in any language that reported the prevalence of angina (Rose questionnaire) in women and men. We obtained myocardial infarction mortality rates from the World Health Organization. A total of 74 reports of 13 331 angina cases in women and 11 511 cases in men from 31 countries were included. Angina prevalence varied widely across populations, from 0.73% to 14.4% (population weighted mean 6.7%) in women and from 0.76% to 15.1% (population weighted mean 5.7%) in men, and was strongly correlated within populations between the sexes ( r =0.80, P <0.0001). Angina prevalence showed a small female excess with a pooled random-effects sex ratio of 1.20 (95% CI 1.14 to 1.28, P <0.0001). This female excess was found across countries with widely differing myocardial infarction mortality rates in women (interquartile range 12.7 to 126.5 per 100 000), was particularly high in the American studies (1.40, 95% CI 1.28 to 1.52), and was higher among nonwhite ethnic groups than among whites. This sex ratio did not differ significantly by participant’s age, the year the survey began, or the sex ratio for mortality due to myocardial infarction.

Conclusions— Over time and at different ages, independent of diagnostic and treatment practices, women have a similar or slightly higher prevalence of angina than men across countries with widely differing myocardial infarction mortality rates.

Performing stable angina pectoris: an ethnographic study

Symptoms play a crucial part in the formulation of medical diagnoses, yet the construction and interpretation of symptom narratives is not well understood. The diagnosis of angina is largely based on symptoms, but a substantial minority of patients diagnosed with "non-cardiac" chest pain go on to have a heart attack. In this ethnographic study our aims were to understand: (1) how the patients' accounts are performed or enacted in consultations with doctors; (2) the ways in which ambiguity in the symptom narrative is managed by doctors; and (3) how doctors reach or do not reach a diagnostic decision. We observed 59 consultations of patients in a UK teaching hospital with new onset chest pain who had been referred for a specialist opinion in ambulatory care. We found that patients rarely gave a history that, without further interrogation, satisfied the doctors, who actively restructured the complex narrative until it fitted a diagnostic canon, detaching it from the patient's interpretation and explanation. A minority of doctors asked about chest pain symptoms outside the canon. Re-structuring into the canonical classification was sometimes resisted by patients who contested key concepts, like exertion. Symptom narratives were sometimes unstable, with central features changing on interrogation and re-telling. When translation was required for South Asian patients, doctors considered the history less relevant to the diagnosis. Diagnosis and effective treatment could be enhanced by research on the diagnostic and prognostic value of the terms patients use to describe their symptoms.

The influence of patient and doctor gender on diagnosing coronary heart disease

Using novel methods, this paper explores sources of uncertainty and gender bias in primary care doctors' diagnostic decision-making about coronary heart disease (CHD). Claims about gendered consultation styles and quality of care are re-examined, along with the adequacy of CHD models for women. Randomly selected doctors in the UK and the US (n=112, 56 per country, stratified by gender) were shown standardised videotaped vignettes of actors portraying patients with CHD. Patients' age, gender, ethnicity and social class were varied systematically. During interviews, doctors gave free-recall accounts of their decision-making, which were analysed to determine patient and doctor gender effects. We found differences in male and female doctors' responses to different types of patient information. Female doctors recall more patient cues overall, particularly about history presentation, and particularly amongst women. Male doctors appear less affected by patient gender but both male and especially female doctors take more account of male patients' age, and consider more age-related disease possibilities for men than women. Findings highlight the need for better integration of knowledge about female presentations within accepted CHD risk models, and do not support the contention that women receive better-quality care from female doctors.

Epidemiology of angina pectoris: role of natural language processing of the medical record

BACKGROUND

The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding.

OBJECTIVE

To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes.

METHODS

Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.

RESULTS

Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up.

CONCLUSION

EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

Craniofacial pain as the sole symptom of cardiac ischemia

BACKGROUND

Craniofacial pain can be the only symptom of cardiac ischemia. Failure to recognize its cardiac source can put the patient's life at risk. The authors conducted a study to reveal the prevalence of, the distribution of and sex differences regarding craniofacial pain of cardiac origin.

METHODS

The authors prospectively selected consecutive patients (N = 186) who had had a verified cardiac ischemic episode. They studied the location and distribution of craniofacial and intraoral pain in detail.

RESULTS

Craniofacial pain was the only complaint during the ischemic episode in 11 patients (6 percent), three of them who had acute myocardial infarction (AMI). Another 60 patients (32 percent) reported craniofacial pain concomitant with pain in other regions. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region and teeth. Craniofacial pain was pre-ponderantly manifested in female subjects (P = .031) and was the dominating symptom in both sexes in the absence of chest pain.

CONCLUSIONS

Craniofacial pain commonly is induced by cardiac ischemia. This must be considered in differential diagnosis of toothache and orofacial pain.

CLINICAL IMPLICATIONS

Because patients who have AMI without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist's awareness of this symptomatology can be crucial for early diagnosis and timely treatment.

Prognosis research: why is Dr. Lydgate still waiting?

BACKGROUND

Understanding prognosis--the future risk of adverse outcomes among people with existing disease--plays third fiddle behind clinical research into therapeutic interventions and novel diagnostic technologies.

METHODS AND RESULTS

Diseases show marked variations in a wide range of prognostic outcomes, yet these variations have seldom been the subject of systematic and sustained epidemiologic and multidisciplinary research. This is important to prioritize hypotheses for testing in intervention studies in groups, and to refine tools for prognostication in individuals. Methodologic standards for the design, conduct, analysis and reporting of prognosis research are required. Training is needed for the clinicians, policymakers, and payers who use prognostic information.

CONCLUSION

Here, arguments detracting from the potential scope of prognosis research are rebutted and misconceptions addressed with the aim of stimulating debate on the evolving role of prognosis research.

Genetic testing for hereditary cancers: the impact of gender on interest, uptake and ethical considerations

Genetic testing promises earlier intervention and more successful outcomes for individuals at risk for hereditary breast/ovarian and colorectal cancer. Research shows that gender influences health and access to health care services. In this paper, we review theoretical issues of gender, and research outcomes, in relation to genetic testing for hereditary cancers. We argue that integrating a gender analysis into assessment of new technologies and health programs is necessary to improve appropriateness, accessibility and effectiveness. Attention to gender is also critical to developing a deeper understanding of the ethical issues (both benefits and harms) raised by new genetic technologies.

Gender effect on clinical features of achalasia: a prospective study

Background

Achalasia is a well-characterized esophageal motor disorder but the rarity of the disease limits performing large studies on its demographic and clinical features.

Methods

Prospectively, 213 achalasia patients (110 men and 103 women) were enrolled in the study. The diagnosis established by clinical, radiographic, and endoscopic as well as manometry criteria. All patients underwent a pre-designed clinical evaluation before and within 6 months after the treatment.

Results

Solid dysphagia was the most common clinical symptom in men and women. Chest pain was the only symptom which was significantly different between two groups and was more complained by women than men (70.9% vs. 54.5% P value= 0.03). Although the occurrence of chest pain significantly reduced after treatment in both groups (P < 0.001), it was still higher among women (32% vs. 20.9% P value= 0.04). In both sexes, chest pain did not relate to the symptom duration, LES pressure and type of treatment patients received. Also no significant relation was found between chest pain and other symptoms expressed by men and women before and after treatment. Chest pain was less frequently reported by patients over 56 yrs of age in comparison to those less than 56 yrs (p < 0.05).

Conclusion

It seems that chest pain is the distinct symptom of achalasia which is affected by sex as well as age and does not relate to the duration of illness, LESP and the type of treatment achalasia patients receive.

Angina symptoms in men and women with stable coronary artery disease and evidence of exercise-induced myocardial perfusion defects

BACKGROUND

To examine sex differences in pain and associated symptoms in patients with exercise-related ischemia, as well as the independence of these findings from other clinical factors.

METHODS

Prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging (MPI). Analyses were performed on 38 women and 94 men with both angina and MPI evidence of ischemia during exercise.

MEASURES

Chest pain localization, extension, intensity, quality, and presence of various non-pain-related symptoms.

RESULTS

Women rated their pain as more intense, used different words to describe it, and reported more non-pain-related symptoms than men (P < .05). They experienced pain and other sensations in the neck area more frequently (P < .05). Most of these differences remained after controlling for clinical or psychological variables, with the exception of pain intensity measures.

CONCLUSIONS

Sex differences in the experience of symptoms associated with MPI evidence of myocardial ischemia may complicate timely and accurate diagnosis of ischemia in women.

Relationship between provider-based measures of physical function and self-reported health-related quality of life in patients admitted for elective coronary angiography

BACKGROUND

Improving health-related quality of life (HRQOL) is important for patients with coronary artery disease (CAD). However, few clinicians measure HRQOL in clinical practice. More commonly used are two provider-based measures of CAD, the Canadian Cardiovascular Society (CCS) and the New York Heart Association (NYHA). We explored the relationship of these two provider-based measures with two self-reported HRQOL questionnaires, the Seattle Angina Questionnaire (SAQ) and the Short Form 36 (SF-36).

METHODS

Included were 753 outpatients (74% were men) admitted for elective cardiac catheterization. HRQOL, CCS class, and NYHA status were measured.

RESULTS

We found significant associations of CCS and NYHA with HRQOL concerning physical dimensions, but weaker associations for other important dimensions. We also observed weaker associations in women than men, not being previously reported.

CONCLUSIONS

HRQOL instruments add broader information in patients with CAD and should supplement provider-based measures. Further research is needed on possible implications of the observed sex differences.