Women and coronary disease: relationship between descriptors of signs and symptoms and diagnostic and treatment course

Recognition and treatment of ischemic heart diseases in women

Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.

An integrative review of fatigue experienced by women before and during myocardial infarction

AIMS AND OBJECTIVES

To explore the extant literature for key features of prodromal and acute myocardial infarction fatigue experienced by women, including estimates of severity, narrative descriptors, impacts on activities of daily living and frequency, and to describe what is known from the current evidence base.

BACKGROUND

Several studies, conducted across the globe, have investigated prodromal and acute myocardial infarction symptoms experienced by women and suggested that fatigue is prevalent, and they have also sporadically described specific characteristics of fatigue, such as narrative descriptors and severity. However, no review specific to this acute and prodromal fatigue could be located in the literature.

DESIGN

Integrative review, guided by Whittemore and Knafl's approach and the Theory of Unpleasant Symptoms.

METHODS

We used a comprehensive, systematic approach to searching, screening, selecting, evaluating and analysing the records. Data were collected in February 2017.

RESULTS

Twenty-one articles were included in the review, including nine quantitative, six qualitative and six mixed-methods studies, with the majority (14) published in the USA. The average age of participants across the studies was the early 60s. Distress, quality, intensity and timing of prodromal myocardial infarction fatigue were more completely described in the literature than acute myocardial infarction fatigue.

CONCLUSIONS

Fatigue is the most common prodromal myocardial infarction symptom experienced by women and is also a common acute symptom. Additional research exploring prodromal and acute myocardial infarction fatigue is necessary.

RELEVANCE TO CLINICAL PRACTICE

As healthcare professionals work with women across the healthcare spectrum, recognising fatigue as an important potential myocardial infarction symptom is essential. Not only can women be educated about this symptom and other possible myocardial infarction symptoms, but clinicians can consider fatigue as an important symptom in a constellation of factors when evaluating women's health and the potential for coronary disease and myocardial infarction.

Symptom Interpretation in Women With Diabetes and Myocardial Infarction

Purpose

The purpose of this study was to describe the role of diabetes in acute myocardial infarction (MI) symptom interpretation.

Methods

This is a secondary data analysis of a study of treatment-seeking delay in women with acute MI (N = 52). This study included a subsample of those with diabetes (n = 16). Women were interviewed while hospitalized with MI about their actions, thoughts, and feelings from symptom onset to entry into the health care system. Qualitative description was the method of analysis.

Results

Three major themes were identified in the qualitative data: diabetes and decision making, presenting symptoms, and symptom attribution. Not all women included information about diabetes in their story, but those who checked blood sugars generally found it to be elevated. Diabetes was a factor in decision making for more than half of the sample. Presenting symptoms were variable but raised hypotheses about shortness of breath as a common presenting symptom for women with diabetes and MI. The third theme, symptom attribution, revealed confusion as to the cause of symptoms.

Conclusions

These results provide insight into symptom interpretation in women with diabetes and MI. Women with diabetes should consider atypical symptoms such as shortness of breath, gastrointestinal symptoms, and fluctuating blood sugars as reasons to seek care. Education for women with diabetes should include action plans for how to recognize and respond to symptoms. More research on the influence of diabetes on MI symptom attribution and decision making is needed.

To Be Stricken with Acute Myocardial Infarction: A Grounded Theory Study of Symptom Perception and Care-seeking Behaviour

The process of perceiving symptoms of illness is complex, and many patients delay seeking care when symptoms of acute myocardial infarction occur. However delayed treatment can have great consequences for the prognosis. This article reports on a grounded theory study, the aim of which was to increase our understanding of the individual’s thoughts, feelings and actions at the onset of an acute heart attack. Qualitative analysis of semi-structured interviews revealed four different ways of perceiving the onset of symptoms: understanding, misinterpretation, amazement and disregard. The symptom perception categories were related to two core categories labelled health beliefs and acute reactions. Some persons were aware of risks for coronary heart disease and were ready to seek care immediately. Several others had illusions of invulnerability. Such illusions caused people to delay seeking care at the onset of symptoms of myocardial infarction.

Acute chest pain in contingency operations at a Role 1 facility

Acute chest pain is a common medical presenting complaint which can be difficult to diagnose and treat outside of a fully equipped emergency department. In future contingency operations the number of personnel deployed is likely be smaller, with the medical cover appropriate for the population at risk, such that the deployed medical facilities will be smaller than the Role 3 unit with which we have become familiar over the last 10 years of operations in Afghanistan. Physician involvement in these smaller medical facilities is crucial to maintain clinical effect when dealing with patients presenting with disease and non-battle injury, which can often make up the majority of deployed healthcare work. Patients presenting with chest pain require rapid assessment and stabilisation prior to medical evacuation to a suitable definitive care unit. This article focuses on emergency acute chest pain presentations, non-cardiac causes of chest pain, risk reduction and how contingency will affect patient care.

Gender differences in symptom predictors associated with acute coronary syndrome: A prospective observational study

Signs and symptoms (typical and atypical symptoms) of acute coronary syndromes (ACS) differ between men and women. Identification of gender differences has implications for both health care providers and the general public. The aim of this study was to determine the symptom predictors of the acute coronary syndromes in men and women. In this prospective study, nurse data collectors directly observed 256 men and 182 women (N = 438) with symptoms suggestive of ACS in the Emergency Departments of eight hospitals in Tehran. ACS was eventually diagnosed in 183 (57.2%) men and 137 (42.8%) women on the basis of standard electrocardiogram and cardiac enzyme (CPK-MB) level. In men, chest symptoms (OR = 3.22, CI = 0.137-0.756, P = 0.009), dyspnea (OR = 2.65, CI = 1.78-4.123 P = 0.001) and diaphoresis (OR = 2.175, CI = 1.020-4.639, P = 0.044) were significantly associated with the diagnosis of ACS 3.78, 2.72 and 1.87 times more than in women having these symptoms, respectively. These results indicated that chest symptoms, diaphoresis and dyspnea were the more pronounced typical symptoms of ACS in men compared to women. Additionally, the numbers of typical symptoms can be considered as more predictive of ACS in men (OR = 1.673, CI = 1.211-2.224, P < 0.001) than women (OR = 1.271, CI = 1.157-2.331, P = 0.212). Therefore, clinicians need to take men showing typical symptoms into consideration carefully.

Prevalence and characteristics of anergia (lack of energy) in patients with acute coronary syndrome

Anergia, a commonly occurring syndrome in older adults and patients with cardiovascular diseases, is associated with functional and clinical limitations. To date, the prevalence and clinical-demographic characteristics of anergia in patients with acute coronary syndrome (ACS) have not been elucidated. We examined the prevalence and clinical-demographic characteristics of anergia in a multiethnic sample of patients with ACS. Hospitalized patients with ACS (n = 472), enrolled in the Prescription Usage, Lifestyle, and Stress Evaluation (PULSE) prospective cohort study, completed assessments of demographic, behavioral, and clinical characteristics within 7 days of hospitalization for an ACS event. Current depressive disorder was ascertained using a structured psychiatric interview 3 to 7 days after discharge. Anergia was assessed at baseline and defined using patients' binary responses (yes/no) to 7 items related to energy level. At least 1 complaint of anergia was reported by 79.9% of patients (n = 377) and 32% of patients (n = 153) met criteria for anergia. In a multivariable logistic regression model, anergia was independently associated with being a woman, being white (compared to black), having bodily pain, participating in exercise, having current depressive disorder, and having higher values on the Charlson Co-morbidity Index. In conclusion, anergia is a highly prevalent syndrome in patients with ACS. It is distinct from depression and is associated with modifiable clinical factors such as participation in exercise and bodily pain that may be appropriate targets for intervention.

Preparing nurses to initiate thrombolytic therapy for patients with an acute myocardial infarction - is there a consensus?

Within cardiac practice, one area that has seen much development involves the nurse assessing, diagnosing, and prescribing thrombolytic therapy for patients with a myocardial infarction. Alongside this, a variety of titles aimed at defining these new roles have emerged, but instead of clarifying the situation they have created more confusion about the actual characteristics and functions of nurses engaged in these innovative posts. In addition advice regarding the nature of preparation and training required to ensure the competency of nurses for these specific roles has been sparse and inconspicuous. As posts such as 'acute chest pain nurse', 'thrombolysis nurse', 'nurse-initiated thrombolysis' or 'nurse-led thrombolysis' increase and National Health Service targets tighten, it is timely to critically review the educational preparation for these roles for evidence of coherence. In particular, this paper analyses the literature in order to examine the content of educational programmes, teaching methods and assessment strategies in relation to preparing nurses to initiate thrombolytic therapy. The implications for those managing practice and the higher education sector are discussed. Finally, it is stressed that there is a need for national consultation relating to guidelines, standards and accreditation of practice schemes in this area of patient care.

Becoming a coronary artery bypass graft surgery patient: a grounded theory study of women's experiences

AIM

To explore women's experiences of becoming a coronary artery bypass graft surgery patient.

BACKGROUND

Coronary heart disease is a leading cause of morbidity and mortality for both sexes worldwide and is associated with significant human, fiscal and personal burden. There are growing numbers of women undergoing coronary artery bypass graft surgery; however, little is known about their experiences of being diagnosed, referred and waiting for surgery.

DESIGN

Grounded theory.

METHODS

A grounded theory study of 30 UK women with coronary heart disease waiting to undergo coronary artery bypass graft surgery. Data were collected using semi-structured interviews and were contextualised through informal observation of the main clinical areas.

RESULTS

Coronary heart disease and associated symptoms had extensive physical, social and emotional ramifications for the women. A substantive theory of the public-private dialogue around maintaining and renegotiating normality emerged and demonstrated that women faced significant disruption to their lives as they attempted to normalise and make sense of their illness experiences. Six categories emerged from the data: help seeking, diagnosis and referral, conceptualising surgery, living with coronary heart disease and waiting for surgery.

CONCLUSION

This study has uncovered women's experiences of becoming a coronary artery bypass graft patient. It has highlighted the extensive ramifications of heart disease and the need for more gender-sensitive information and support.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study provide health care professionals with a greater understanding of the experiences and needs of women through their journey to becoming a coronary artery bypass graft surgery. The study demonstrates that women need meaningful information particularly in relation to domestic and physical functioning. Nurses are in an important position to contribute to the care and support of women undergoing this process by providing appropriate and gender-sensitive information that can improve health outcomes and quality of life.

Gender differences on chest pain perception associated with acute myocardial infarction in Chinese patients: a questionnaire survey

AIMS

To investigate gender differences in chest pain perception among Chinese patients with acute myocardial infarction.

BACKGROUND

Thrombolytic therapy is beneficial to outcomes of acute myocardial infarction if administered within 12 hours from the onset of chest pain. However, cardiac symptom interpretation may impact time of presentation to hospital. Differences in cardiac symptom reports by gender partly explain misdiagnoses and delays in treatment, particularly among women. Whether, such trends apply to Chinese patients with myocardial infarction is unknown.

DESIGN

A descriptive prospective study.

METHODS

Using questionnaires, data on demographic variables, the number of patients reporting chest pain and other chest sensations at the onset of acute myocardial infarction and chest pain intensity, description, location and radiation across the chest were collected.

RESULTS

A total of 128 participants equally divided by gender were recruited. Chest pain was more prevalent among men than women (84.37% vs. 67.19%, p < 0.05). Although no statistical significance was found, Chinese men had higher mean chest pain intensity scores (7.54 SD 2.35 vs. 7.51 SD 2.25) and reported less atypical chest pain (0.00% vs. 9.3%) compared with women. Men had more upper right sided chest pain (40.74% vs. 20.93%, p = 0.038) whereas women experienced increased neck pain and pain to the upper central chest, middle central chest, upper central back, middle central back and middle right back regions.

CONCLUSIONS

Discreet gender differences in chest pain perceptions exist between Chinese men and women, with the latter group, who may be considered as a high-risk group for missed and delayed diagnosis from myocardial infarction, reporting more atypical presentations.

RELEVANCE TO CLINICAL PRACTICE

Irrespective of culture, women with myocardial infarction tend to present with atypical chest pain symptoms and therefore they should be aggressively investigated.

Community-based gender perspectives of triage and treatment in suspected myocardial infarction

BACKGROUND

The gender perspectives of the triage of acute coronary syndromes (ACS) in a community are insufficiently explored.

METHODS

Patients (n=3224) with symptoms of ACS, in whom ECG was sent by the ambulance crew to a coronary care unit (CCU)/ cath lab, were investigated in the municipality of Göteborg in 2004-2007. Background, triage priority, investigations and treatment were analysed (p-values age adjusted) in relation to gender. Data were compared with three published studies (1995-2002: Surveys 1-3).

RESULTS

Women were directly admitted to the CCU significantly less frequently than men (23 versus 35%, p<0.0001). Adjusted for ECG findings, age, symptoms and medical history, odds ratio and 95% confidence limits (for direct admission; men versus women) were 0.61; 0.46-0.82. SURVEY 1: Patients with ACS, aged <80, in CCU at a university hospital (n=1744). Only minor differences between women and men, with regard to investigations and treatment, were found. SURVEY 2: Patients discharged from hospital (dead or alive) with AMI, regardless of type of ward (n=1423). Fewer women than men were admitted to CCU and fewer women underwent coronary angiography (21% versus 40%; p=0.02) and coronary revascularisation (12% versus 27%; p=0.004). SURVEY 3: Patients with symptoms of AMI (n=930) and patients with a confirmed AMI (n=130) from a pre-hospital perspective. Women tended to be given lower priority than men both by the ambulance dispatchers and by the ambulance crew.

CONCLUSION

In our practice setting, men are given priority over women in admission to CCU, but no gender differences are seen thereafter.

Intimate partner violence and cardiovascular risk: is there a link?

AIM

This paper is a report of a study of the relationship between stress associated with intimate partner violence and smoking and cardiovascular risk.

BACKGROUND

Stress related to intimate partner violence persists after a woman leaves an abusive relationship. Persistent stress is associated with cardiovascular disease, the leading single cause of death among women. Smoking, an established risk factor for cardiovascular disease, is a coping mechanism commonly used to decrease the anxiety and stress of intimate partner violence. However, cardiovascular health is poorly understood in abused women.

METHOD

Secondary analysis of data collected between 2004 and 2005 with a community sample of 309 women who had separated from an abusive partner 3 months to 3 years previously was conducted to create a descriptive profile of cardiovascular risk. Bivariate tests of association and logistic regression analysis were used to test relationships among variables.

RESULTS

Of the women, 44.1% were smokers; 53.2% had body mass indices classified as overweight or obese; 54.7% had blood pressures above normal range; and 50.8% reported cardiovascular symptoms. Neither severity of intimate partner violence nor smoking behaviours were statistically significant in explaining the presence of cardiovascular symptoms.

CONCLUSION

The prevalence of hypertension, obesity and smoking suggests that survivors of intimate partner violence may be at heightened risk for cardiovascular disease and warrant clinical attention. Because cardiac symptoms develop as women get older, the mean age of 39 years in this sample may explain why intimate partner violence severity and smoking did not sufficiently explain the presence of cardiac symptoms.

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.

'It was not chest pain really, I can't explain it!' An exploratory study on the nature of symptoms experienced by women during their myocardial infarction

AIMS AND OBJECTIVES

This study sought to explore the presenting nature of cardiac symptoms as experienced by women diagnosed with a myocardial infarction. The objectives were to use the participants' own words to gain a detailed understanding of how they perceived their evolving symptoms.

BACKGROUND

Women with coronary heart disease tend to delay seeking help despite experiencing symptoms. The classic hallmarks used to diagnose a myocardial infarction have been based on research primarily involving white middle-aged men with a focus on specific descriptions of chest pain. Whether these hallmarks apply to women in the same way as they apply to men is an area of increasing contention.

DESIGN

Using a purposive sample, a qualitative design was used to investigate the nature of cardiac symptoms experienced by women prior to and at the time of their myocardial infarction.

METHOD

Twelve women participated in semi-structured in-depth tape-recorded interviews conducted while they were in hospital.

RESULTS

Three interlinking themes emerged, which reflect a changing dynamic status in health, mediated by the perceived threat of individual symptoms. These included gradual awareness, not having pain in the chest and reactions to symptoms.

CONCLUSIONS

It would appear that symptom presentation and distribution amongst women may not follow the pattern traditionally associated with current understanding of a 'typical' myocardial infarction. These differences together with perceptions about their cardiac symptoms may influence their health-seeking behaviours.

RELEVANCE TO CLINICAL PRACTICE

Women with a myocardial infarction may present with non-specific chest symptoms, which are difficult to interpret or recognize by patients and health professionals alike. Skill in recording history and in performing a comprehensive assessment of initial and current symptoms will enable nurses to identify women with a differential diagnosis of chest pain readily. Additionally, to increase awareness of coronary heart disease, nurses must use any opportunity to educate women of all age groups.

Symptom presentation and time to seek care in women and men with acute myocardial infarction

BACKGROUND

Leventhal's common sense model of illness representation was used to examine symptom presentation, time to seek care, and expectations about the experience of having an acute myocardial infarction (AMI).

HYPOTHESES

(1) Women with AMI will report a different symptom set than men, (2) women's expectations about AMI, for level of risk and symptoms, will be different than men's, (3) women will take longer to seek care than men, and (4) as suggested by the common sense model, a match between expected and actual symptoms will be related to shorter time to seek care.

METHOD

A descriptive, correlational design was used. Thirty woman and 30 men diagnosed with AMI or an evolving MI treated with thrombolytic therapy or primary percutaneous coronary intervention were interviewed using the Symptom Representation Questionnaire.

RESULTS

Gender differences in symptom presentation were limited. The majority of women and men reported that their symptoms were different from what they expected an AMI would be like. Most stated that their pain was less than expected, whereas some reported either the location of discomfort or associated symptoms as different then expected. There was no gender difference in time to seek care. Logistic regression and survival analysis demonstrated that participants who reported a match between symptoms expected and actual symptoms experienced arrived in the emergency department sooner than those whose symptoms did not match their expectations.

CONCLUSION

The findings provide support for the use of the common sense model to explain care-seeking behavior in AMI.

Differences in the Symptoms Associated With Unstable Angina and Myocardial Infarction

The purpose of this study was to examine whether the symptoms experienced by patients with unstable angina (UA) differed from the symptoms experienced by patients with myocardial infarction (MI). Data were obtained from two studies: one examining the symptoms of MI (n=238) and one examining the symptoms of UA (n=100). Interviews were conducted after hospital admission at three medical centers in the Midwest. There were no differences between patients with MI or UA in age, gender, or race. The patients experiencing MI reported significantly more nausea (46% vs. 32%), vomiting (19% vs. 2%), indigestion (42% vs. 16%), and fainting (9% vs. 2%). The patients experiencing UA reported significantly more chest discomfort (97% vs. 87%), lightheadedness (52% vs. 39%), numbness in the hands (43% vs. 28%), and neck discomfort (31% vs. 13%). Patients with MI rated the peak intensity of the chest discomfort higher than patients with UA (mean 8.4 vs. mean 7.7).

Are There Gender Differences Related to Symptoms of Acute Myocardial Infarction? A Norwegian Perspective

The purpose of this study was to compare symptom presentation and illness behavior among women and men with acute myocardial infarction and assess various aspects that influence prehospital delay. This is a cross-sectional, retrospective study using self-reported questionnaires. The sample consisted of 82 women and men in Norway, up to 65 years of age, with first-time acute myocardial infarction between March and October 1999. The findings demonstrated that the most commonly reported symptom in both genders was chest pain. More than 90% of women and men experienced chest pain, with no difference between the genders. More women than men had nausea as well as pain located in their arms, back, jaw, and throat. More men than women attributed their symptoms to be cardiac in origin. Experiencing pain in the shoulders, attributing symptoms to be noncardiac, consulting a family member, and contacting several medical practitioners increased prehospital delay. During the year before the event, women were more likely to experience fatigue than men. The conclusion of this study is that women experienced a greater diversity of symptoms than men. Acute symptoms, interpretation of symptoms, and illness behavior may influence prehospital delay.

Gender differences in signs and symptoms presentation and treatment of Jordanian myocardial infarction patients

Heart disease is the number one killer in the USA. In Jordan, cardiovascular disease is the leading cause of death, and about 34.5% of women die of cardiovascular disease as compared with 44.25% of men. The differences between men and women in heart disease, such as signs and symptoms presentation, diagnostic and therapeutic interventions, are becoming more apparent in the literature. There is a dearth of research regarding gender differences among Jordanian myocardial infarction (MI) patients. Therefore, the purpose of this study was to explore the differences between Jordanian men and women in signs and symptoms presentation of MI and follow-up care. A convenience sample of 83 patients (26 women and 57 men) who were diagnosed with MI, mentally competent and haemodynamically stable were used to explore the research questions. An interview guide and chart audit were used to elicit information about initial and associated signs and symptoms and treatment plan of MI patients. Chest pain was the most common initial symptom in both men and women. The four most common associated signs and symptoms reported by both men and women were general weakness, sweating, nausea and fatigue. However, women experienced more general weakness and sweating compared with men. Women were less likely to receive intravenous nitroglycerin, heparin and thrombolytic therapy for the treatment of MI. Chest pain was the initial symptom of MI reported by men and women. Although similarities exist in the associated sings and symptoms, women might experience different associated signs and symptoms from men. Despite these similarities, women are still less likely than men to receive the therapeutic regimen used for men.

Gender- and age-related differences in treatment and control of cardiovascular risk factors among high-risk patients with angina

Dyslipidemic, hypertensive patients (N = 48,863) were stratified by gender, age, and angina (n = 2502) vs. nonangina (n = 46,358) status. Comparing 95% confidence intervals yielded significant differences in treatment and cardiovascular risk factor control between subgroups. More men than women had low-density lipoprotein cholesterol (LDL-C) <100 mg/dL (angina, 43.94-43.96 vs. 34.42-34.50; nonangina, 32.43-32.43 vs. 17.25-17.25) and 100-129 mg/dL (angina, 32.12-32.14 vs. 35.10-35.18; nonangina, 53.86-53.86 vs. 32.44-32.44). More women than men had LDL-C > or = 130 mg/dL (angina, 27.68-27.72 vs. 23.91-23.93; nonangina, 38.70-38.70 vs. 35.38-35.39). Women were less likely than men to receive statins (angina, 69.95-69.99 vs. 82.11-82.13; nonangina, 59.80-59.80 vs. 63.72-63.72), any antilipidemic medication at all (angina, 25.93-25.97 vs. 13.48-13.48; nonangina, 36.73-36.73 vs. 30.73-30.73), or to have current cholesterol measurements (angina, 56.82-56.88 vs. 34.54-34.56; nonangina, 45.77-45.77 vs. 39.75-39.75). Primary care providers treat high-risk patients relatively aggressively; however, opportunities to forestall cardiovascular disease may be missed in hypertensive, dyslipidemic women whose LDL-C is often not measured and controlled.

Female sex: a protective role in suspected myocardial ischemia

OBJECTIVE

Women are felt to have poor outcomes in coronary artery disease, largely on the basis of secondary observations in acute coronary syndrome trials. We sought to examine the neglected topic of sex differences in workup and outcomes in the general population presenting with chest pain.

METHODS

We examined 439 consecutive patients admitted via the emergency department with ongoing chest pain. Cardiac testing was defined as any cardiac catheterization or stress test. Positive testing was defined as a 70% or greater stenosis in an epicardial coronary artery on catheterization, or a positive stress test result. Follow-up was obtained via telephone contact at 4 months following discharge.

RESULTS

Further cardiac testing was deemed necessary in 68% (164/241) of women and 77% (153/198) of men (P=0.038). Among women undergoing further testing, only 21% (35/164) had positive tests, whereas 41% (62/153) of men had positive tests (P=0.002). At 4 months, women were less likely to have suffered the combined endpoint of subsequent myocardial infarction, revascularization, or death, than men (15 vs. 23%, P=0.027). Events were more likely to occur in patients who had further testing, and especially in those who had positive testing.

CONCLUSIONS

These data suggest that women admitted with chest pain are less likely to have active coronary artery disease, and much less likely to have poor outcomes at 4 months than men. This apparent 'gender protection' effect warrants further study.

Gender differences in symptom experiences of patients with acute coronary syndromes

To compare the symptom experiences between men and women with acute coronary syndromes (ACS), we surveyed a convenience sample of 112 subjects with a final diagnosis of ACS in four hospitals. Our study found that after adjusting for cardiac diagnosis, diabetes, and age, women were more likely than men to experience chest discomfort rather than chest pain; pain/discomfort only in areas of the body other than the chest; pain/discomfort that started first either in the arm(s) or in areas of the body other than the chest; and unexplained anxiety. Women were less likely than men to experience chest pain/discomfort, pain/discomfort in the left side of the chest, and chest pain/discomfort as the most worrisome symptom. Significant gender differences were observed in the reports of several symptoms associated with ACS. This study is the first to identify different pain/discomfort referral patterns between men and women that require further validation.

Gender differences in symptoms associated with acute myocardial infarction: a review of the research

Recognizing similarities and differences in symptom experiences of acute myocardial infarction (AMI) between men and women has implications for both health care providers and the general public. Rapid accurate diagnosis is necessary to implement timely lifesaving treatment. The purpose of this article is to critically review and evaluate studies that have compared symptoms of AMI between men and women. Research to date has demonstrated that during AMI, women are more likely than men to report shortness of breath, nausea, vomiting, back pain, jaw pain, neck pain, cough, and fatigue, but less likely than men to report chest pain and sweating. However, the findings were inconsistent across studies. These inconsistent findings could be attributable to methodological issues such as collecting data from medical records, small sample sizes, and controversial eligibility criteria for studies. More studies are needed to confirm gender differences in symptom experiences of AMI.

Black, Hispanic, and White women's knowledge of the symptoms of acute myocardial infarction

OBJECTIVE

To examine Black, Hispanic, and White women's knowledge of the symptoms of acute myocardial infarction.

DESIGN

Descriptive, nonexperimental design.

SETTING

Detroit, Michigan, and San Antonio, Texas, metropolitan areas.

PARTICIPANTS

A convenience sample of 78 ethnically diverse women. Hispanics (n = 26) were recruited from San Antonio, Texas; Blacks (n = 26) were recruited from Detroit, Michigan; and Whites were recruited from San Antonio, Texas (n = 13), and Detroit, Michigan (n = 13).

MAIN OUTCOME MEASURES

Participants ranked 10 acute symptoms they believed represented a myocardial infarction: anxiety, arms ache, change in thinking, chest pain, cough, fatigue, decreased appetite, headache, indigestion, and shortness of breath. Next, participants assigned a likelihood score for each acute symptom as representing a myocardial infarction.

RESULTS

Hispanic women were more likely than Black women to perceive the symptom of headache as indicative of a myocardial infarction. Women older than age 45 were more likely to assign a higher likelihood score to the symptom of shortness of breath than were women age 45 or younger.

CONCLUSIONS

Age and ethnic differences were noted in women's perception of the signs and symptoms indicative of a myocardial infarction.

Chest pain and associated symptoms of acute coronary syndromes

Coronary heart disease is the primary health risk for all Americans. Acute coronary syndromes (ACS) is the term used to denote any 1 of 3 clinical manifestations of coronary heart disease: unstable angina, non-ST elevation myocardial infarction, and ST-elevation MI. The major challenge to healthcare providers is the rapid and accurate identification of patients with ACS who would benefit from immediate thrombolysis or percutaneous coronary interventions. The purpose of this article is to describe the incidence, causes, risk factors, assessment, and diagnosis of patients presenting with ACS as well as current recommendations for nurses who treat patients with ACS.

Knowledge of heart attack symptoms in older men and women at risk for acute myocardial infarction

PURPOSE

Coronary heart disease is the number one cause of death for both men and women. While adults 65 years of age and older comprise the largest percentage of those who experience an acute myocardial infarction (AMI), investigators to date have failed to examine the knowledge of this population about AMI symptoms. The purpose of this study was to document knowledge about cardiovascular disease and AMI symptoms in older individuals with coronary heart disease to identify the characteristics associated with increased knowledge of cardiovascular disease.

METHODS

A descriptive design was used with a convenience sample of (N = 115) older adults at risk for AMI. Data were collected during face-to-face interviews in the participants' homes and analyzed using frequencies, percentages, chi, and multiple regression analysis.

RESULTS

Men and women were not significantly different in their knowledge of AMI symptoms except for jaw pain. More than 95% of the both men and women knew typical symptoms of AMI, such as chest pain, pressure, shortness of breath, arm or shoulder pain, and sweating. Less than 75% of both men and women knew that symptoms such as neck pain, nausea or vomiting, back pain, heartburn, and jaw pain could be symptoms of AMI. Thirty-one percent did not know about reperfusion therapies in the treatment of AMI. Having a cardiologist involved in care was weakly predictive of less knowledge.

CONCLUSIONS

Education and counseling of older patients at high risk for heart disease is complex, but should emphasize atypical symptoms and treatment options.

Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms

Patients (n = 194) with confirmed acute myocardial infarction (AMI) were interviewed to determine sociodemographic, clinical, social, behavioral, cognitive and emotional factors that contribute to delay in seeking treatment for their symptoms. Initial symptom experience was similar for men and women: both were most commonly at home when symptoms began; both were most commonly in the presence of their spouse or other family member; few patients (<10%) called the emergency medical system as their first reaction. Several factors contributed similarly to delay in men and women. Factors that exerted a differential effect on delay between men and women were age, history of AMI, type of AMI (Q-wave and non-Q-wave), concerns about not wanting to trouble others, and prior knowledge of thrombolytics. There was no difference in delay between men and women (median 3.08 versus 3.10 h), but there are important gender differences in the reasons patients delay and in their patterns of decision-making that may assist clinicians trying to tailor interventions.

Gender and age inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better?

Although the mortality and incidence of coronary heart disease (CHD) in England and Wales has declined in recent years, an ageing population has contributed to keeping the prevalence of CHD largely unchanged. Evidence suggests that revascularisation procedures have contributed not only to this decline in mortality, but also to the decline in morbidity from heart disease, and to improvements in quality of life, even in old age. Despite clinical evidence of benefit, revascularisation is less often provided for older people and for women. This paper considers the equity of the provision of revascularisation according to need by gender and age using the Hospital Episodes Statistics (HES) database which includes all NHS hospital admissions in England. Trends from 1991 to 1999 were examined comparing admissions for acute myocardial infarction (as a proxy indicator of need in the absence of direct measures) and the procedures coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). The rates of CABG and PTCA have increased dramatically by 72% and 48%, respectively, between 1991/3 and 1997/9. Making allowance for differences in need, to achieve equitable provision with men, over 12,000 extra CABG and over 5000 PTCA procedures would be required for women, amounting to 19% and 10% increases in the total volume of each procedure, respectively. Similarly, attempting to meet need up to the age of 79 years would require over 13,000 extra CABG and over 13,000 PTCA procedures for men, and an additional 14,300 CABG and almost 10,000 extra PTCA procedures for women, representing 42% and 40% increases in CABG and PTCA, respectively. As women tend to present with CHD at older ages this indicates that they may be the victims of a 'double whammy' of inequity. Moreover, these inequities have remained constant through the study period. Possible explanations for this shortfall of provision are proposed.

Does hormonal status influence the clinical presentation of acute coronary syndromes in women?

BACKGROUND

Previous studies suggest that the clinical presentation of acute coronary syndromes (ACS) may differ between women and men. It is not known if different clinical presentations may be explained by hormonal status in women with ACS. Our objective was to compare the clinical presentation of ACS between premenopausal (PRE) women and post-menopausal women with hormone replacement therapy (HRT) and without (POST).

METHODS

This was a prospective study of consecutive women admitted with a diagnosis of ACS (myocardial infarction [MI] or unstable angina). All women answered a detailed questionnaire that included a list of 27 clinical symptoms. Symptom results were adjusted for age and current coronary event diagnosis.

RESULTS

Seventy-three Caucasian women were studied. No differences were found in terms of the frequency of reported typical symptoms of ACS between PRE (n = 23), HRT (n = 32), and POST (n = 18). However, PRE more often reported atypical chest symptoms than HRT and POST women (57% vs. 31% vs. 22%, PRE vs. HRT vs. POST, respectively, p = 0.05). HRT and POST women experienced substernal chest pain more frequently than PRE (44% vs. 78% vs. 83%, p = 0.03). In contrast, PRE more frequently tended to experience chest pressure (57% vs. 31% vs. 39%, p = 0.2) or chest pain in other locations (22% vs. 3% vs. 6%, p = 0.06). HRT and POST groups reported more frequent indigestion-like pain/discomfort (22% vs. 50% vs. 56%, p = 0.04) and midback pain (35% vs. 63% vs. 72%, p = 0.04) during ACS compared with PRE women. POST experienced sudden fatigue more frequently than PRE and HRT (61% vs. 53% vs. 89%, p = 0.03).

CONCLUSIONS

Our results suggest that almost all women admitted with ACS experienced typical chest symptoms but frequently reported both typical and atypical symptoms. Independently of age, atypical chest symptoms occurred more frequently in premenopausal women than in postmenopausal women with or without HRT.

Symptoms in acute coronary syndromes: does sex make a difference?

BACKGROUND

Coronary heart disease is a major problem in both men and women, but several studies have shown sex differences in symptoms of acute coronary syndromes (ACS). Some findings, however, have been disparate and inadequate, and thus a comprehensive overview of this literature would be of value.

METHOD

Fifteen studies that identified symptoms of ACS for both women and men were examined through a review of the literature from 1989 to 2002. Terms used for the search included "myocardial infarction," "symptoms," "gender differences," and "acute coronary syndromes."

RESULTS

Although chest pain was the most common symptom in both men and women, several differences were also noted. In all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain and nausea and/or vomiting, dyspnea, palpitations, indigestion, dizziness, fatigue, loss of appetite, and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. The designs and methodologies of the studies varied considerably.

CONCLUSION

In addition to the typical symptom of chest pain in ACS, women experience other atypical symptoms more frequently than men. Thus, there may be sex differences in the symptoms of ACS, differences that have a bearing not only on clinical practice, but also on the interpretation of available clinical studies and the design of future investigations.

Do Emergency Nursesʼ Triage Decisions Predict Differences in Admission or Discharge Diagnoses for Acute Coronary Syndromes?

Coronary heart disease is the number 1 killer of adults in the United States, affecting 1 in 5 men and women. However, women are more likely than men to die after an acute coronary event and are less likely to receive prompt or aggressive treatment. Few studies have examined the role of emergency nurses' triage decisions in these disparities, even though nurses often determine initial patient priority and urgency status for emergency cardiac evaluation and treatment. The purpose of this prospective study was to examine if nurses' initial triage decisions could predict admission or discharge diagnoses for acute coronary syndromes (ACS). A total of 108 nurses' triage decisions made by 13 nurses were examined. There were no differences in nurses' triage decisions based on patient gender, race, or age. By multivariate analysis, chest pain, history of coronary heart disease, history of myocardial infarction, and smoking were predictive of an ACS decision. Overall, accuracy for predicting admission diagnosis was poor. Sensitivity and specificity were 57% and 59%, respectively, with a positive predictive value of 68% and a negative predictive value of 56%. It was similarly poor for predicting discharge diagnosis. Sensitivity and specificity for discharge diagnosis were 55% and 69%, respectively, with a positive predictive value of 17% and a negative predictive value of 93%. Findings indicate limitations in the ability of nurses' triage decisions to predict admission and discharge diagnoses for ACS.

Womenʼs Delay in Seeking Treatment With Myocardial Infarction

Women, especially those older than 65 years, delay longer than do men before seeking medical treatment for symptoms of an acute myocardial infarction (AMI). The majority of delay time results from the patient's lengthy decision-making processes after symptoms begin and before seeking medical treatment. Effective treatment is time dependent as mortality and morbidity rise with each hour of delay. Therefore, the purpose of this research was 2-fold: (1) to synthesize reported research findings concerning women's reasons for delay in seeking treatment for symptoms of an AMI and (2) to identify areas for further research. Using Cooper's (Synthesizing Research. 3rd ed. London: Sage; 1998) framework for integrative review, this manuscript synthesized the literature from 48 reports published from 1995 to 2003 to describe the primary reason(s) for women's prehospital delay. Three categories emerged to explain why women delay in seeking treatment: (1) clinical, (2) sociodemographic, and (3) psychosocial factors. These factors are found to be multifaceted and complex. The most significant reasons for delay in seeking treatment for symptoms of AMI are the following: atypical presentation of symptoms, severity of presenting symptoms, presence of other chronic illnesses that confused acute symptoms, correct attribution or labeling of symptoms to the heart, perceived seriousness of the symptoms, beliefs of low self-perceived vulnerability to heart attack, and engagement in various other coping mechanisms. This synthesis identified and clarified the current state of science regarding women's prehospital delay in seeking treatment for symptoms of an AMI. Areas for future research are also discussed.

Epidemiology of coronary heart disease in women

Cardiovascular disease (CVD) is the leading cause of mortality in women and a major cause of morbidity. Coronary heart disease (CHD) accounts for nearly half of all CVD deaths. Gender differences in CHD include a later age of onset for women, a greater prevalence of comorbid diseases, and differences in the initial manifestations of the disease. Traditional risk factors for CHD include tobacco use, hypertension, diabetes mellitus, dyslipidemia, obesity, sedentary lifestyle, and atherogenic diet. More recently identified risk factors in women include high sensitivity C-reactive protein (hsCRP), homocysteine, and lipoprotein (a). Appropriate management of risk factors is associated with a reduced incidence of CHD, yet poor implementation in women is widely documented. Barriers to optimal risk factor management in women should be identified and overcome in an effort to maximize the cardiovascular health of women.

Development of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey

BACKGROUND/OBJECTIVES

Coronary heart disease (CHD) is the number one cause of death in women, yet, little is known about women's symptoms. Early symptom recognition of CHD in women is essential but most instruments do not assess both prodromal and acute CHD symptoms. Our aims were to develop an instrument validly describing women's prodromal and acute symptoms of myocardial infarction and to establish reliability of the instrument, the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS).

METHODS

Four studies contributed to the content validity and reliability of this instrument. Two qualitative studies provided the list of symptoms that were confirmed in study 3. The resulting instrument assesses 37 acute and 33 prodromal symptoms. In study 4, 90 women were retested 7 to 14 days after their initial survey. We used the kappa statistic to assess agreement across administrations.

RESULTS

The women added no new symptoms to the MAPMISS. The average kappa of acute symptoms was 0.52 and 0.49 for prodromal. Next we calculated a weighted score. The mean acute score for time 1 was 19.4 (SD = 14.43); time 2 was 12.4 (SD= 8.79) with Pearson correlation indicating stability (r = .84; P < .01). The mean prodromal score at time 1 was 23.80 (SD= 24.24); time 2 was 26.79 (SD = 30.52) with a Pearson correlation of r = .72; P < .01.

CONCLUSIONS

The tool is comprehensive, has high content validity, and acceptable test-retest reliability. Low kappas were related to few women having those symptoms. The symptom scores remained stable across administrations.

Gender Disparities in Common Sense Models of Illness Among Myocardial Infarction Victims

Symptom attributions were contrasted between male and female myocardial infarction victims (N = 157) who were comparable on age, cardiac risk status, medical history, symptom presentation, and other variables. Women were less likely than men to attribute their prehospital symptoms to cardiac causes. In the context of hearing symptom attributions or advice from support persons, women were less likely than men to report receiving a cardiac attribution or advice to seek medical attention. Results have implications for how victim gender influences the lay interpretation of cardiac symptoms.

Women's early warning symptoms of acute myocardial infarction

BACKGROUND

Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women.

METHODS AND RESULTS

Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology.

CONCLUSIONS

Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events.

Symptom reflections of women with cardiac disease and advanced practice nurses: a descriptive study

The purpose of this descriptive study was to explore the experiences of women with cardiac disease in regard to cardiac risk factors, symptoms, and symptom interpretation. Interviews with a convenience sample of 21 African American and Caucasian female patients, aged 40-81 years with cardiac diagnoses, were taped and transcribed. Three advanced practice nurses with experience in cardiovascular nursing were interviewed individually for background. Analyses of symptoms indicated that women experienced a range of prodromal symptoms other than chest pain prior to hospitalization such as: edema, shortness of breath, lightheadedness, dry cough, and exhaustion. Atypical symptoms delayed recognition of a cardiac problem for some women. The lack of symptom consistency underscores the need for thorough assessment and screening of women at risk for cardiac problems. Advanced practice nurses are aware of current cardiac disease research in women but they must continue to be vigilant for atypical symptoms.

Gender-related differences in intensive care: a multiple-center cohort study of therapeutic interventions and outcome in critically ill patients

OBJECTIVE

To determine whether gender-related differences exist in the provided level of care and outcome in a large cohort of critically ill patients.

DESIGN

Prospective, observational cohort study with data collection from January 1, 1998, to December 31, 2000.

SETTING

Thirty-one intensive care units in Austria.

PATIENTS

A total of 25,998 adult patients, consecutively admitted to 31 intensive care units in Austria.

INTERVENTIONS

We assessed severity of illness, level of provided care, and vital status at hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Of 25,998 patients, 58.3% were male and 41.7% were female. Hospital mortality rate was slightly higher in women (18.1%) than in men (17.2%), but severity of illness-adjusted mortality rate was not different. Men received an overall increased level of care and had a significantly higher probability of receiving invasive procedures, such as mechanical ventilation (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.16-1.28), single vasoactive medication (OR, 1.18; 95% CI, 1.12-1.24), multiple vasoactive medication (OR, 1.21; 95% CI, 1.15-1.28), intravenous replacement of large fluid losses (OR, 1.14; 95% CI, 1.08-1.20), central venous catheter (OR, 1.06; 95% CI, 1.01-1.12), peripheral arterial catheter (OR, 1.15; 95% CI, 1.10-1.22), pulmonary artery catheter (OR, 1.48; 95% CI, 1.34-1.62), renal replacement therapy (OR, 1.28; 95% CI, 1.16-1.42), and intracranial pressure measurement (OR, 1.34; 95% CI, 1.18-1.53).

CONCLUSIONS

In a large cohort of critically ill patients, no differences in severity of illness-adjusted mortality rate between men and women were found. Despite a higher severity of illness in women, men received an increased level of care and underwent more invasive procedures. This different therapeutic approach in men did not translate into a better outcome.

Primary prevention programs to reduce heart disease risk in women

Cardiovascular disease is the number one killer of women. Despite this statistic, many women do not perceive heart disease as a priority health concern. Recognizing that prevention begins in the community, the American Hospital Association launched a national fellowship program in 1998 to improve cardiovascular health. This article describes a practice innovation designed by a clinical nurse specialist who participated as a 1999-2000 cardiovascular fellow. The Women's Prevention Center, a community-based clinic within the walls of a heart hospital, provides a personalized cardiovascular assessment for women, including both heart history and assessment of physical parameters (eg, blood pressure, fasting glucose, lipid panel, waist-hip ratio). From this assessment, women are counseled on strategies to modify their individual risk factors, such as smoking cessation, heart-healthy nutrition and exercise, and are assisted in developing realistic lifestyle or medical management goals. After the initial assessment, outcomes are measured at 3-, 6-, and 12-month follow-ups to determine both individual success with behavior changes and program effectiveness.