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

Prodromal Symptoms of Acute Myocardial Infarction in Women: A Systematic Review of Current Evidence

AIM

To synthezise quantitative current evidence on the prodromal symptoms experienced by women before the onset of acute coronary syndrome (ACS), focusing on the prevalence, nature and clinical implications of these symptoms.

DESIGN

A systematic review.

METHODS

The review adhered to Synthesis without meta-analysis guidelines and was registered with the PROSPERO database (ID: CRD42024541840). Systematic searches were conducted in PubMed, CINAHL, APA PsycArticles, APA PsycInfo and EMBASE. Included studies were quantitative, focused on women aged ≥ 18 years with confirmed acute coronary syndrome and reported prodromal symptoms. The Quality Assessment with Diverse Studies and the Cochrane Risk of Bias in non-randomized studies of Interventions tools were used for critical appraisal.

RESULTS

Of 2170 identified records, 11 full-text studies were reviewed. The most frequently reported prodromal symptom was unusual fatigue, followed by sleep disturbances and anxiety. Prodromal symptoms often occurred well before the acute event but were frequently misattributed to non-cardiac causes. Chest pain, typically associated with acute coronary syndrome, was less commonly reported as a prodromal symptom in women, complicating timely diagnosis and treatment.

CONCLUSIONS

The results highlight the need for increased awareness of these early warning signs among healthcare providers and women themselves. Enhanced recognition and understanding of these symptoms could lead to more timely and accurate diagnosis, ultimately improving outcomes for women at risk of acute myocardial infarction.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

To educate both health professionals and patients about the variability and significance of prodromal symptoms in women is essential to improve outcomes.

IMPACT

This study is the first to systematically review and synthesize the existing literature on prodromal symptoms of acute coronary syndrome specifically in women. The results show l that women are more likely to experience a broader and more complex range of prodromal symptoms, including fatigue, sleep disturbances and anticipatory anxiety, which often precede the acute event. The insights provided by our review could lead to significant improvements in the early diagnosis and treatment of AMI in women, ultimately reducing morbidity and mortality rates associated with cardiovascular diseases.

REPORTING METHOD

The review has adhered to relevant EQUATOR guidelines and has followed Synthesis without meta-analysis guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Trends and determinants of clustering for non-communicable disease risk factors in women of reproductive age in Nepal

BACKGROUND

Understanding the clustering of two or more risk factors of non-communicable disease, such as smoking, overweight/obesity, and hypertension, among women of reproductive age could facilitate the design and implementation of strategies for prevention and control measures. This study examined the factors associated with smoking, overweight/obesity, and hypertension among Nepalese women of reproductive age (15-49 years).

METHODS

This study used the Nepal Demographic and Health Surveys (NDHS) 2016 (6,079 women for smoking and overweight/obesity, 6076 for hypertension) and 2022 (6,957 women for overweight/obesity and smoking status and 3,749 women for hypertension) for comparison of trends of NCD risk factors among women aged 15-49 years. Additionally, for each participant, risk factors score (range of 0 to 3) was created by summing individual risk factors. We assessed the determinants of risk factor clustering using multivariable Poisson regression models with robust sandwich variance estimator to calculate adjusted prevalence ratios using NDHS 2022.

RESULTS

The national prevalence of overweight/obesity increased from 22.2% in 2016 to 29.2% in 2022 among women of reproductive age. In 2022, the prevalence for smoking, overweight/obesity, and hypertension were 3.8%, 29.2%, and 9.6%, respectively. More than one in four women (28.7%) had one NCD risk factor, while 6.5% had two such risk factors. Higher aged women (40-49 years) were more likely to have multiple NCD risk factors than those aged 15-29 years (APR: 3.19; 95% CI: 2.68-3.80). Those in the richest wealth quintile (APR: 1.52; 95% CI: 1.24-1.85), as well as married (APR: 3.02; 95% CI: 2.43-3.76) and widowed/divorced (APR: 2.85; 95% CI: 2.14-3.80) were more likely to have multiple NCD risk factors. Women from Koshi province (APR: 1.74; 95% CI: 1.41-2.15) had more NCD risk factors than those from the Sudurpaschim province. Working women also had a higher prevalence of NCD risk factors compared to non-working women (APR: 1.23; 95% CI: 1.06-1.43). Additionally, Hill Janajatis (APR: 1.44; 95% CI: 1.21-1.72) and Dalits (APR: 1.42; 95% CI: 1.15-1.75) women were more likely to have NCD risk factors compared to women of Brahmin hill origin.

CONCLUSIONS

Clustering of two or more NCD risk factors was higher among women aged ≥30 years, those who are currently married or widowed/divorced/separated, working women, and individuals from the wealthiest socioeconomic groups. A higher burden of risk factors underscores the importance of targeted public health interventions, particularly among women from advantaged socio-economic groups, those of affluent regions, and in the workplace.

Burden of non-communicable diseases among women of reproductive age in Kenya: a cross-sectional study

OBJECTIVE

To examine the burden of non-communicable diseases (NCDs) among women of reproductive age in Kenya, highlighting the prevalence and risk factors.

DESIGN

Cross-sectional design based on the 2022 Kenya Demographic and Health Survey.

SETTING

Kenya.

PRIMARY OUTCOMES

Predict the burden of hypertension, diabetes, heart disease, lung disease, arthritis, depression, anxiety, breast and cervical cancer.

RESULTS

Overall, 15.9% of Kenyan women aged 15-49 years were living with at least one NCD. The most prevalent NCD among this cohort was hypertension (8.7%) followed by arthritis (2.9%) and depression (2.8%). Our findings revealed that increasing age, increasing wealth, being married or formerly married, being overweight or obese, consuming alcohol and some occupations were risk factors of NCDs among women of reproductive age in Kenya.

CONCLUSION

We conclude that hypertension is the most prevalent NCD among women of reproductive age in Kenya. The findings underscore the multifaceted nature of NCD risk factors in Kenya, emphasising the importance of targeted interventions that consider age, economic status, education, marital status, occupation and lifestyle factors.

Women Acute Myocardial Infarction-Identifying and Understanding the Gender Gap (WAMy-GAP): A Study Protocol

Barriers to accessing care and misinterpretations of ischemic heart disease symptoms due to lack of awareness contribute to women's delay in seeking care. Women may delay seeking treatment for up to 3 h or even up to 5 days. They often perceive themselves to be at low risk of cardiovascular disease (CVD) and prioritize family responsibilities or household chores. The causes of this delay are multifactorial and influence the decision-making process, particularly in the pre-hospital phase. The objective of this study protocol is to evaluate prodromal symptoms and identify risk behaviors in women with acute myocardial infarction (AMI). This is a protocol for a multicenter study that will be conducted using the mixed-method methodology using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) to evaluate symptoms and semi-structured interviews to investigate behaviors. This study protocol is intended to fill an important knowledge gap on premonitory and acute symptoms of AMI in women in Italy, as well as to understand the causes and mechanisms underlying delays in accessing healthcare services during an acute event such as AMI. The investigation of this issue will facilitate the removal of gender-related inequalities in the diagnosis and treatment of acute myocardial infarction while also fostering dialogue on the barriers to behavior change.

Incidence, Pattern, Causes, and Outcome of Acute Chest Pain Among Patients Presenting in the Emergency Department of a Tertiary Care Hospital in North India

BACKGROUND

Acute chest pain is a common presentation in emergency departments worldwide. Differentiating between cardiac and non-cardiac chest pain is crucial for patient management and resource allocation.

METHODS

This study analyzed 714 patients presenting with acute chest pain in a tertiary care hospital in North India. We investigated demographic characteristics, chief complaints, risk factors, ECG findings, and final diagnoses to identify patterns associated with cardiac (CCP) and non-cardiac chest pain (NCCP).

RESULTS

CCP was diagnosed in 53.7% (n=383) and NCCP in 46.3% (n=331). Significant predictors of CCP included age (OR=1.05, p<0.001), smoking (OR=2.22, p<0.001), diabetes (OR=1.57, p=0.003), hypertension (OR=1.82, p<0.001), and family history of ischemic heart disease (IHD) (OR=1.42, p=0.01). Central chest pain was more common in CCP (60% vs. 40%, p<0.001), as were abnormal ECG findings such as ST-segment depression (35% vs. 10%, p<0.001) and elevation (29% vs. 6%, p<0.001). Normal ECG was more prevalent in NCCP (60%, p<0.001).

CONCLUSION

Traditional cardiovascular risk factors remain strongly associated with CCP. Smoking has a particularly high odds ratio, suggesting the need for targeted interventions. ECG findings significantly aid in differentiating CCP from NCCP. This study underscores the importance of a comprehensive approach in evaluating acute chest pain to ensure accurate diagnosis and effective treatment.

Emergency Nurses' Recognition of and Perception of Sex Differences in Acute Coronary Syndrome Symptoms

INTRODUCTION

Emergency nurses must quickly identify patients with potential acute coronary syndrome. However, no recent nationwide research has explored nurses' knowledge of acute coronary syndrome symptoms. The purpose of this study was to explore emergency nurses' recognition of acute coronary syndrome symptoms, including whether nurses attribute different symptoms to women and men.

METHODS

We used a cross-sectional, descriptive design using an online survey. Emergency nurses from across the United States were recruited using postcards and a posting on the Emergency Nurses Association website. Demographic data and participants' recognition of acute coronary syndrome symptoms, using the Acute Coronary Syndrome Symptom Checklist, were collected. Descriptive statistics and ordinal regression were used to analyze the data.

RESULTS

The final sample included 448 emergency nurses with a median 7.0 years of emergency nursing experience. Participants were overwhelmingly able to recognize common acute coronary syndrome symptoms, although some symptoms were more often associated with women or with men. Most participants believed that women and men's symptoms were either "slightly different" (41.1%) or "fairly different" (42.6%). Nurses who completed training for the triage role were significantly less likely to believe that men and women have substantially different symptoms (odds ratio 0.47; 95% CI 0.25-0.87).

DISCUSSION

Emergency nurses were able to recognize common acute coronary syndrome symptoms, but some reported believing that the symptom experience of men and women is more divergent than what is reported in the literature.

Gender Disparities in Patients' Decisions about the Management of Myocardial Infarction in East Chinese Province

Background

Previous studies showed that there are gender disparities in various respects of acute myocardial infarction (AMI), including risk factors, symptoms, and outcomes. However, few of them noticed the gender disparities in patients' decision about the management of AMI, which might also be associated with the outcome.

Aims

To identify gender disparities in patients' decisions about the management of myocardial infarction.

Methods

In this cohort study, the critical time points including the time of symptom onset, visiting hospital, diagnosis of AMI, consent to coronary angiography (CAG), beginning of CAG, and balloon dilation were recorded. Medication and major adverse cardiac event (MACE) within 6 months were also recorded.

Results

Female patients took more time from symptom onset to visiting hospital (P = 0.001), from diagnosis of AMI to consent to CAG (P < 0.05), and from door to needle/balloon than male (P < 0.05). Less female patients accepted CAG (P < 0.05) and coronary intervention/bypass grafting (P < 0.05). Less female patients kept good inherence to antiplatelet therapy (P < 0.05) and statins (P < 0.05) than male, more female preferred traditional Chinese medicine (TCM) than male patient (P < 0.05), and most of them had MACE within 6 months (P < 0.05). Patients' good adherence to antiplatelet therapy and statins and accepting coronary intervention/bypass grafting were associated with a reduced risk of MACE.

Conclusion

Female patients were more reluctant to make decisions about emergency management of AMI and tended to choose conservative treatment. More female patients preferred TCM than evidence-based medicine. Their reluctance about the critical management of AMI and poor adherence to evidence-based medicine were associated with an elevated risk of MACE.

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Prevalence and determinants of non-communicable diseases risk factors among reproductive-aged women: Findings from a nationwide survey in Bangladesh

INTRODUCTION

Knowing the risk factors like smoking status, overweight/obesity, and hypertension among women of reproductive age could allow the development of an effective strategy for reducing the burden of non-noncommunicable diseases. We sought to determine the prevalence and determinants of smoking status, overweight/obesity, hypertension, and cluster of these non-noncommunicable diseases risk factors among Bangladeshi women of reproductive age.

METHODS

This study utilized the Bangladesh Demographic and Health Survey (BDHS) data from 2017-2018 and analyzed 5,624 women of reproductive age (age 18-49 years). This nationally representative cross-sectional survey utilized a stratified, two-stage sample of households. Poisson regression models with robust error variance were fitted to find the adjusted prevalence ratio (APR) for smoking, overweight/obesity, hypertension, and for the clustering of non-noncommunicable diseases risk factors across demographic variables.

RESULTS

The average age of 5,624 participants was 31 years (SD = 9.1). The prevalence of smoking, overweight/obesity, and hypertension was 9.6%, 31.6%, and 20.3%, respectively. More than one-third of the participants (34.6%) had one non-noncommunicable diseases risk factor, and 12.5% of participants had two non-noncommunicable diseases risk factors. Age, education, wealth index, and geographic location were significantly associated with smoking status, overweight/obesity, and hypertension. Women between 40-49 years had more non-noncommunicable diseases risk factors than 18-29 years aged women (APR: 2.44; 95% CI: 2.22-2.68). Women with no education (APR: 1.15; 95% CI: 1.00-1.33), married (APR: 2.32; 95% CI: 1.78-3.04), and widowed/divorced (APR: 2.14; 95% CI: 1.59-2.89) were more likely to experience multiple non-noncommunicable diseases risk factors. Individuals in the Barishal division, a coastal region (APR: 1.44; 95% CI: 1.28-1.63) were living with a higher number of risk factors for non-noncommunicable diseases than those in the Dhaka division, the capital of the country. Women who belonged to the richest wealth quintile (APR: 1.82; 95% CI: 1.60-2.07) were more likely to have the risk factors of non-noncommunicable diseases.

CONCLUSIONS

The study showed that non-noncommunicable diseases risk factors are more prevalent among women from older age group, currently married and widowed/divorced group, and the wealthiest socio-economic group. Women with higher levels of education were more likely to engage in healthy behaviors and found to have less non-noncommunicable diseases risk factors. Overall, the prevalence and determinants of non-noncommunicable diseases risk factors among reproductive women in Bangladesh highlight the need for targeted public health interventions to increase opportunities for physical activity and reduce the use of tobacco, especially the need for immediate interventions in the coastal region.

Patient-centered care in Coronary Heart Disease: what do you want to measure? A systematic review of reviews on patient-reported outcome measures

Background

The number of published articles on Patient-Reported Outcomes Measures (PROMs) in Coronary Heart Disease (CHD), a leading cause of disability-adjusted life years lost worldwide, has been growing in the last decades. The aim of this study was to identify all the disease-specific PROMs developed for or used in CHD and summarize their characteristics (regardless of the construct), to facilitate the selection of the most adequate one for each purpose.

Methods

A systematic review of reviews was conducted in MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews. PROQOLID and BiblioPRO libraries were also checked. PROMs were classified by construct and information was extracted from different sources regarding their main characteristics such as aim, number of items, specific dimensions, original language, and metric properties that have been assessed.

Results

After title and abstract screening of 1224 articles, 114 publications were included for full text review. Finally, we identified 56 PROMs: 12 symptoms scales, 3 measuring functional status, 21 measuring Health-Related Quality of Life (HRQL), and 20 focused on other constructs. Three of the symptoms scales were specifically designed for a study (no metric properties evaluated), and only five have been included in a published study in the last decade. Regarding functional status, reliability and validity have been assessed for Duke Activity Index and Seattle Angina Questionnaire, which present multiple language versions. For HRQL, most of the PROMs included physical, emotional, and social domains. Responsiveness has only been evaluated for 10 out the 21 HRQL PROMs identified. Other constructs included psychological aspects, self-efficacy, attitudes, perceptions, threats and expectations about the treatment, knowledge, adjustment, or limitation for work, social support, or self-care.

Conclusions

There is a wide variety of instruments to assess the patients’ perspective in CHD, covering several constructs. This is the first systematic review of specific PROMs for CHD including all constructs. It has practical significance, as it summarizes relevant information that may help clinicians, researchers, and other healthcare stakeholders to choose the most adequate instrument for promoting shared decision making in a trend towards value-based healthcare.

The Lay Public's Knowledge of the Most Common Acute Coronary Syndrome Symptoms Experienced by Women and Men

BACKGROUND

Although extensive research and public education for the last 2 decades has focused on symptom differences experienced by men and women, little is known about what acute coronary syndrome symptoms the lay public associates with men, with women, and with both men and women.

OBJECTIVE

The aim of this study was to describe what acute coronary syndrome symptoms the lay public associates with men, with women, and with both men and women and to explore whether differences in participant gender affect how these symptoms are associated.

METHODS

A descriptive, cross-sectional survey design was used, using an online survey. We recruited women (n = 209) and men (n = 208) living in the United States from the crowdsourcing platform Mechanical Turk in April and May 2021.

RESULTS

Most participants (78.4%) selected a chest symptom as the most common acute coronary syndrome symptom experienced by men, compared with only 49.4% who selected a chest symptom as the most common for women. Almost half (46.9%) of women indicated that they believe men and women have "fairly different" or "very different" acute coronary syndrome symptoms, compared with 17.3% of men.

CONCLUSIONS

Whereas most participants associated symptoms with both men and women's experiences of acute coronary syndrome symptoms, some associated symptoms in ways that are not reflected in the literature. Additional research is needed to further understand the impact of messaging on acute coronary syndrome symptom differences between men and women and the lay public's interpretation of these messages.

There is little association between prehospital delay, persistent symptoms, and post-discharge healthcare utilization in patients evaluated for acute coronary syndrome

AIMS

Test for an association between prehospital delay for symptoms suggestive of acute coronary syndrome (ACS), persistent symptoms, and healthcare utilization (HCU) 30-days and 6-months post hospital discharge.

BACKGROUND

Delayed treatment for ACS increases patient morbidity and mortality. Prehospital delay is the largest factor in delayed treatment for ACS.

METHODS

Secondary analysis of data collected from a multi-center prospective study. Included were 722 patients presenting to the Emergency Department (ED) with symptoms that triggered a cardiac evaluation. Symptoms and HCU were measured using the 13-item ACS Symptom Checklist and the Froelicher's Health Services Utilization Questionnaire-Revised instrument. Logistic regression models were used to examine hypothesized associations.

RESULTS

For patients with ACS (n = 325), longer prehospital delay was associated with fewer MD/NP visits (OR, 0.986) at 30 days. Longer prehospital delay was associated with higher odds of calling 911 for any reason (OR, 1.015), and calling 911 for chest related symptoms (OR, 1.016) 6 months following discharge. For non-ACS patients (n = 397), longer prehospital delay was associated with higher odds of experiencing chest pressure (OR, 1.009) and chest discomfort (OR, 1.008) at 30 days. At 6 months, longer prehospital delay was associated with higher odds of upper back pain (OR, 1.013), palpitations (OR 1.014), indigestion (OR, 1.010), and calls to the MD/NP for chest symptoms (OR, 1.014).

CONCLUSIONS

There were few associations between prehospital delay and HCU for patients evaluated for ACS in the ED. Associations between prolonged delay and persistent symptoms may lead to increased HCU for those without ACS.

Prevalence of Prolonged Length of Stay in an Emergency Department in Urban Denmark: A Retrospective Health Records Repository Review

INTRODUCTION

Prolonged length of stay in emergency departments is associated with increased hospitalization, hospital-acquired pressure ulcers, medication errors, and mortality. In acute admissions in Denmark in 2018, 67% of patients experienced waiting time from arrival to examination. This study aimed to estimate the prevalence of prolonged length of stay (≥6 hours) and identify risk factors related to input, throughput, and output components.

METHODS

A retrospective health records repository review included 4743 patients admitted to a single urban emergency department in Denmark in January 2019. Data collected from the electronic health record system repository included demographic and organizational characteristics and were analyzed using descriptive statistics and logistic regression.

RESULTS

Among patients admitted in the study period, 31% had a prolonged length of stay of ≥6 hours. Prolonged length of emergency department stay was associated with being female (male odds ratio [OR], 0.86; 95% confidence interval [CI], 0.75-0.98), treatment by medical service (OR, 4.25, 95% CI, 3.63-4.98) vs surgical or injury, triage acuity of 2-Orange (OR, 1.45; 95% CI, 1.18-1.78) or 3-Yellow (OR, 1.47; 95% CI, 1.23-1.75) on a 5-level scale, evening (OR, 1.44; 95% CI, 1.24-1.66) or night (OR, 2.36; 95% CI, 1.91-2.91) arrival, ages 56 to 80 (OR, 1.79; 95% CI, 1.52-2.11) and >81 (OR, 2.40; 95% CI, 1.99-2.88) years, and hospital admission (OR, 1.19; 95% CI, 1.04-1.38) vs discharge from the emergency department to home.

DISCUSSION

Female, elderly, and medical patients were each identified as at-risk characteristics for ≥6-hour length of stay in the emergency department. Acute care patient pathways in the emergency department, particularly for evening and night, with guideline-based care and system level improvements in patient flow are warranted. Further research with larger populations is needed to identify and support interventions to decrease prolonged length of stay.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Atypical Manifestations of Women Presenting with Myocardial Infarction at Tertiary Health Care Center: An Analytical Study

Introduction:

Typical chest pain symptoms are the cause that requires individuals to seek out medical care in Acute coronary syndrome(ACS). Evidence suggests, symptoms labelled as 'atypical 'is more common in women with ACS. The present study focuses on the need for the implementation of a gender specific approach in the current scenario by identifying gender based differences that exist in clinical presentations of the patients with ACS. Early identification of women's prodromal and acute symptoms of Myocardial Infarction is an important step in provision of appropriate treatment modality. Present study focus on need for implementation of gender-specific approach in current scenario by identifying gender based differences that exist in risk factors, clinical manifestations in patients presenting with MI.

Methodology:

Cross- sectional analytical study was conducted among 240 Participants (120 males and 120 females). Both men and women diagnosed with MI, who survived, stabilized after admission was included in the study. Consecutive sampling technique was used to select the participants. Data was collected on risk factors profile, clinical manifestations by administering structured questionnaire.

Results:

Risk factors such as history of diabetes, history of dyslipidemia was found to be homogenous among both men and women. 60% of men were ever smokers. Hypertension and known IHD was noted to be significant in women (p<0.002, p <0.001) but men presented with higher BMI (p<0.030). Females increasingly presented with atypical presentations when compared to males (p<0.005). Women commonly had squeezing and tightness type of pain and men reported tightness, burning, pricking type of pain (p<0.003). The majority of the women reported the onset of pain occurrence between 6am to 12 pm(p<0.004), whereas men significantly reported the onset of pain between 12 am -6 am(p<0.001).

Conclusion:

Gender based differences in risk factors and clinical presentation in men and women with myocardial infarction had been a focus in researches that emphasized need for focused assessment for women as they increasingly presents with atypical symptoms. The current study also supports the need of a gender specific approach to avoid delay in diagnosis and care of them.

The Yentl Syndrome: A Case Report

Cardiovascular disease, including ischemic heart disease, is one of the most common causes of death and disability in both sexes. The traditional concept of ischemic heart disease as a "man's disease" is debunked. Yentl syndrome is used to describe the underdiagnosis of ischemic heart disease in females and its associated effects. This article reports a 48-year-old female presented to the emergency department with acute epigastric discomfort. Her initial diagnostic tests did not reveal any abnormalities, and she was discharged. Subsequently, after four days, she again visited the emergency department with chest pain, the evaluation of which furthermore revealed no abnormalities. However, we admitted her. After 40 hours of hospitalization, her evaluation revealed anterior wall ST elevation myocardial infarction, and she underwent emergent reperfusion via coronary catheterization. This combination of atypical signs and symptoms and chances of delayed manifestations in the diagnostic investigations provides evidence for a need for thorough assessment in a female with chest pain.

An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group

This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.

Dying from COVID-19 in nursing homes-sex differences in symptom occurrence

Background

Coronavirus disease 2019 (COVID-19), is a disease with diverse presentation. Several studies have shown different occurrence of symptoms for women and men, but no studies have been found examining sex differences in clinical presentation for nursing home residents dying from COVID-19.

The objective of this study was to describe sex and age differences and the impact of a dementia diagnosis on symptom occurrence during the last week in life for persons dying from COVID-19 in nursing homes.

Methods

This is a population-based retrospective study based on data from the Swedish Register of Palliative Care. A total of 1994 residents aged 65 or older who died from COVID-19 in nursing homes were identified. The impact of sex, age and a dementia diagnosis on six different symptoms was analysed using chi2-test and multivariate logistic regression.

Results

Residents dying from COVID-19 were more often men (p < .002). Men more often had dyspnoea and death rattles (p < .001). Nausea was more common in women (p < .001). No sex differences in the occurrence of pain, anxiety or confusion were seen. Dyspnoea and nausea were less commonly reported in residents with dementia (p < .001).

Conclusions

We found sex differences in symptom presentation for fatal COVID-19 in nursing home settings which remained after adjusting for age. Residents with a dementia diagnosis had fewer symptoms reported before death compared to those without dementia.

Clinical presentation of fatal COVID-19 differs between women and men in nursing homes. Residents with fatal COVID-19 present with more unspecific and less prominent symptoms when also suffering from dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02228-4.

Characteristic differences of chest pain in male and female patients with acute coronary syndrome: A pilot study

Background: The typical sign or main symptom in acute coronary syndrome (ACS) patients is chest pain, which is an initial benchmark or early sign for diagnosis. Certain factors, such as gender differences, the presence of diabetes mellitus or other clinical conditions, may make the patient not realize they have ACS. Therefore, this study aims to identify the characteristics of chest pain symptoms in male and female patients with ACS.

Design and Methods: This is a non-experimental quantitative study, namely analytical observation using a cross-sectional approach within 4 months (January-April 2019). Furthermore, the samples were 53 ACS patients (28 male and 25 female).

Results: The chest pain characteristics that have a significant relationship with gender differences in ACS patients are shown based on the aspects of location, pain duration and quality. Male patients are more likely to feel pain at the left or middle chest, the duration is between <20 to >20 min with moderate pain quality, which tends to become severe, while females are more likely to feel pain at the chest which radiates to the neck and chin, the duration is usually >20 min, with mild to moderate pain quality.

Conclusions: The result showed a significant difference in chest pain characteristics in male and female patients with ACS. Regarding location, duration and quality of chest pain, male ACS patients mostly have more typical symptoms, while females’ symptoms are atypical.

An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group

This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.

Unusual Fatigue and Failure to Utilize EMS Are Associated With Prolonged Prehospital Delay for Suspected Acute Coronary Syndrome

BACKGROUND

Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS), but efficacy is time dependent. The aim of this study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS, stratified by final diagnosis (ACS vs. no ACS).

METHODS

A heterogeneous sample of emergency department (ED) patients with symptoms suggestive of ACS was enrolled at 5 US sites. Accelerated failure time models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis.

RESULTS

Enrolled were 609 (62.5%) men and 366 (37.5%) women, predominantly white (69.1%), with a mean age of 60.32 (±14.07) years. Median delay time was 6.68 (confidence interval 1.91, 24.94) hours; only 26.2% had a prehospital delay of 2 hours or less. Patients presenting with unusual fatigue [time ratio (TR) = 1.71, P = 0.002; TR = 1.54, P = 0.003, respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR = 1.93, P < 0.001; TR = 1.71, P < 0.001, respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR = 0.65, P = 0.013 and TR = 0.67, P = 0.022, respectively). Predictors of shorter delay for patients ruled out for ACS were chest pain and sweating (TR = 0.071, P = 0.025 and TR = 0.073, P = 0.032, respectively).

CONCLUSION

Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is important for patients with possible ACS symptoms. Calling 911 can be positively framed to at-risk patients and the community as having advanced care come to them because EMS capabilities include 12-lead ECG acquisition and possibly high-sensitivity troponin assays.

Prevalence and Risk Factors of Elevated Blood Pressure and Elevated Blood Glucose among Residents of Kajiado County, Kenya: A Population-Based Cross-Sectional Survey

Kenya is experiencing a rising burden of non-communicable diseases (NCDs), yet data to inform effective interventions are limited. We investigated the prevalence of elevated blood pressure, elevated blood glucose and their determinants in a rapidly urbanizing area in Kenya. Data on socio-demographics, dietary and behavioural risk factors, anthropometric measurements, blood pressure, blood glucose, plasma lipids and urinary biomarkers were collected from 221 men and 372 women (25-64 years). Multivariable logistic regression models assessed correlates of elevated blood pressure (EBP) and elevated blood glucose (EBG). Participants' mean age was 38.0. ± 11.1 years. The prevalence rates of pre-hypertension and hypertension were 49.0% and 31.6% in men and 43.7% and 20.1% in women, respectively, while those of pre-diabetes and diabetes were 8.4% and 8.0% in men and 11.6% and 7.4% in women, respectively. The prevalence of Body Mass Index (BMI) ≥ 25 kg/m² was higher in women (60.2%) than in men (39.7%). However, both the risk of EBP and EBG were stronger among men than among women. The high prevalence rates of EBP, EBG and overweight/obesity coupled with low physical activity and low fruit and vegetable intake predispose this population to a higher NCD risk. Interventions to mitigate this risk considering the sex differences are urgently required.

Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome

Emergency department (ED) nurses need to identify patients with potential acute coronary syndrome (ACS) rapidly because treatment delay could impact patient outcomes. Aims of this secondary analysis were to identify key patient factors that could be available at initial ED nurse triage that predict ACS. Consecutive patients with chest pain who called 9-1-1, received a 12-lead electrocardiogram in the prehospital setting, and were transported via emergency medical service were included in the study. A total of 750 patients were recruited. The sample had an average age of 59 years old, was 57% male, and 40% Black. One hundred and fifteen patients were diagnosed with ACS. Older age, non-Caucasian race, and faster respiratory rate were independent predictors of ACS. There was an interaction between heart rate by Type II diabetes receiving insulin in the context of ACS. Type II diabetics requiring insulin for better glycemic control manifested a faster heart rate. By identifying patient factors at ED nurse triage that could be predictive of ACS, accuracy rates of triage may improve, thus impacting patient outcomes.

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

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

Prevalence and determinants of non-communicable diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016

INTRODUCTION

Non-Communicable Diseases (NCDs) are the major killer diseases globally. They share the common risk factors such as smoking, harmful use of alcohol, physical inactivity, and low fruits/vegetable consumption. The clustering of these risk factors multiplies the risk of developing NCDs. NCDs affect women inequitably causing significant threats to the health of women and future generations. But, the distribution and clustering of NCDs risk factors among Nepalese women are not adequately explored yet. This study aimed to assess the clustering and socio-demographic distribution of major NCD risk factors in Nepalese women.

METHODS

We used the data of 6,396 women age 15 to 49 years from the recent Nepal Demographic and Health Survey (NDHS). The survey applied a stratified multi-stage cluster sampling method to select the eligible women participants from across Nepal. We analyzed data using the multiple Poisson regression and reported the adjusted prevalence ratio (APR).

RESULTS

A total of 8.9% of participants were current smokers, 22.2% were overweight and obesity and 11.5% of the participants were hypertensive. Around 6% of participants had co-occurrence of two NCDs risk factors. Smoking, overweight and obesity and hypertension were significantly associated with age, education, province, wealth index, and ethnicity. Risk factors were more likely to cluster in women of age40-49 years (ARR = 2.95, 95%CI: 2.58-3.38), widow/separated (ARR = 3.09; 95% CI:2.24-4.28) and among Dalit women (ARR = 1.34; 95% CI:1.17-1.55).

CONCLUSION

This study found that NCDs risk factors were disproportionately distributed by age, education, socio-economic status and ethnicity and clustered in more vulnerable groups such as widow/separated women and the Dalit women.

Risk stratification of patients with chest pain or anginal equivalents in the emergency department

We studied whether previously developed cardiac risk scores-including history, ECG, age, risk factors, and troponin (HEART); Thrombolysis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); and Emergency Department Assessment of Chest Pain (EDACS)-could be applied to predict major adverse cardiac events (MACE) in patients with possible coronary artery disease, including anginal equivalents. Patients with chest pain or anginal equivalents who underwent coronary computed tomographic angiography were included. The primary outcome was 30-day MACE. We compared the cardiac risk scores by the area under the receiver-operating characteristic curves (AUC). The primary outcome occurred in 200 patients (16.0%) of the 1247 patients included. For the prediction of MACE, the AUC of the HEART score (0.765) was superior to those of the TIMI (0.726), GRACE (0.612), and EDACS (0.631) scores. Among patients identified by each score as being at low risk, the MACE rate was the lowest for the HEART score (5.7%), followed by the TIMI (8.8%), EDACS (11.2%), and GRACE (12.2%) scores. At a sensitivity level of a < 2% rate of misses, the negative predictive value of the HEART score (1.0) outperformed those of the GRACE (0.932) and EDACS (0.964). The HEART score appeared to be more predictive of MACEs than the TIMI, GRACE, and EDACS in patients with chest pain or anginal equivalents. However, previously suggested cutoff could not safely identify low-risk patients for early discharge because of the unacceptably high rate of missed MACEs.

Words Matter: Sex and Gender as Unique Variables in Research

Sex and gender are not equivalent concepts, even though these 2 variables are often used interchangeably by researchers. The precise use of variables is critical to ensure that research and theoretical work is of the highest quality. This article defines sex and gender and the importance of recognizing both of these variables as being unique and then demonstrates the benefit of measuring both of these variables using the cardiovascular disease literature as an exemplar. Additionally, recommendations for scholars regarding the use of sex and gender in the research and theoretical literature are provided.

Evaluation of the cardiovascular symptom index for midlife women in multiethnic/racial midlife women

The authors' purpose of this study was to evaluate the validity and reliability of the Cardiovascular Symptom Index for Midlife Women in four ethnic/racial groups of midlife women in the U.S. Data from two internet surveys were used for this secondary analysis. In the construct validity test, five factors were extracted among White and Hispanic women, while more than five factors were extracted among Asian and African American women. In the convergent validity test, all ethnic/racial groups showed similar patterns. Adequate internal consistency among was shown. The Cardiovascular Symptom Index for Midlife Women is useful for assessing cardiovascular symptoms in multiethnic/racial women.

Characteristics of Prehospital Electrocardiogram Use in North Carolina Using a Novel Linkage of Emergency Medical Services and Emergency Department Data

Objective: Prehospital electrocardiography (ECG) is recommended for patients with suspected acute coronary syndrome (ACS), yet only 20-80% of chest pain patients receive a prehospital ECG. Less is known about prehospital ECG use in patients with less common complaints (e.g., fatigue) suspicious for ACS who are transported by emergency medical services (EMS). The aims of this study were to determine: (1) the proportion of patients with chest pain and less typical complaints, and (2) patient characteristics associated with prehospital ECG use in patients transported by EMS to emergency departments across North Carolina. Methods: A novel linked database was created between prehospital and emergency department (ED) patient care data from the North Carolina Prehospital Medical Information System and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. Institutional review board approval and a data use agreement were received prior to the start of the study. Patients ≥21 transported during 2010-14 by EMS with select variables were included. We examined patients' complaints (symptoms), characteristics (e.g., race, ethnicity, final hospital diagnosis), and prehospital ECG use (yes/no). Analysis included descriptive statistics and mixed logistic regression. Results: During 2010-14, there were 1,967,542 patients with linked EMS-ED data (mean age: 56.9 [SD: 22.2], 43.2% male, 63.7% White). Of these, 643,174 (32.6%) received a prehospital ECG. Patients with prehospital ECG presented with the following complaints: 20% chest pain; 10% shortness of breath; 6% abdominal pain/problems; 6% altered level of consciousness; 5% syncope/dizziness; 4% palpitations; 12% other complaints; and 37% missing. Patients' presenting complaints were the strongest predictor of prehospital ECG use, adjusting for age, sex, race, ethnicity, urbanicity, and date and time of EMS dispatch. Conclusions: Patients with chest pain were significantly more likely to receive a prehospital ECG compared to those with less typical but suspicious complaints for ACS. Patients with less common presentations remain disadvantaged for early triage, risk stratification, and intervention prior to the hospital.

The Research Progress of Direct Thrombin Inhibitors

Blood coagulation is the process of changing the blood from the flowing state to the gel state. It is an important part of the hemostatic function. Coagulation is a process by which a series of coagulation factors are sequentially activated, and finally thrombin is formed to form fibrin clot. Direct thrombin inhibitors are important anticoagulant drug. These drugs can selectively bind to the active site of thrombin, inhibit thrombin activity, have strong action and high specificity, and have important significance in the clinical treatment of thrombus diseases. Some of them come from natural products of animals or plants, and many of them have been applied in the clinic. The other part is derived from the design, synthesis and activity studies of small molecule inhibitors. This review discusses the progress of direct thrombin inhibitors in recent years.

Protein Cytokines, Cytokine Gene Polymorphisms, and Potential Acute Coronary Syndrome Symptoms

The purpose of this study was to determine whether relationships exist among protein cytokines, cytokine gene polymorphisms, and symptoms of potential acute coronary syndrome (ACS). Participants included 438 patients presenting to the emergency department (ED) whose symptoms triggered a cardiac evaluation (206 ruled in and 232 ruled out for ACS). Presence or absence of 13 symptoms was recorded upon arrival. Levels of tumor necrosis factor α (TNF-α), interleukin (IL)-6, and IL-18 were measured for all patients. A pilot analysis of 85 patients (ACS = 49; non-ACS = 36) genotyped eight single-nucleotide polymorphisms (SNPs; four TNF and four IL6 SNPs). Logistic regression models were tested to determine whether cytokines or SNPs predicted symptoms. Increased levels of TNF-α and IL-6 were associated with a decreased likelihood of chest discomfort for all patients. Increased levels of IL-6 were associated with a lower likelihood of chest discomfort and chest pressure for ACS patients, and an increased likelihood of shoulder and upper back pain for non-ACS patients. Elevated IL-18 was associated with an increased likelihood of sweating in patients with ACS. Of the four TNF SNPs, three were associated with shortness of breath, lightheadedness, unusual fatigue, and arm pain. In all, protein cytokines and TNF polymorphisms were associated with 11 of 13 symptoms assessed. Future studies are needed to determine the predictive ability of cytokines and related SNPs for a diagnosis of ACS or to determine whether biomarkers can identify patients with specific symptom clusters.

No time to delay reperfusion: A cross-sectional study of primary percutaneous coronary intervention times

AIMS AND OBJECTIVES

To establish and report cross-sectional data of reperfusion times for emergency primary percutaneous coronary interventions (PPCI) and to examine factors associated with times to reperfusion.

BACKGROUND

Rapid coronary reperfusion can salvage myocardial tissue, preserve left ventricular function and reduce mortality. PPCI is the gold standard of management. Researchers have reported on international median reperfusion times, but this is the first Irish study to do so.

METHODS

This observational, prospective, cross-sectional study included patients diagnosed with ST-segment elevation myocardial infarction (STEMI) and admitted for emergency PPCI. Descriptive and inferential statistics were used. The study was ethically approved. We adopted the STROBE guidelines.

RESULTS

All patients (N = 133) who met the inclusion criteria were included initially. Of these, 105 (79%) were diagnosed with STEMI and received emergency PPCI. The majority of STEMIs were diagnosed by paramedics and most (67%) were reperfused within 120 min, with a median time of 96 min. The results suggested that younger patients achieved timelier PPCI and source of referral was also significant in that more of those transferred directly to the coronary catheterisation laboratory achieved reperfusion within 120 min, compared with those who presented to the emergency department.

CONCLUSION

A timely reperfusion service is achieved for the majority. Attention is needed in respect of the ageing and those admitted directly to the emergency departments with STEMI.

RELEVANCE TO CLINICAL PRACTICE

Further international research is recommended to compare current reperfusion times against guidelines and to identify areas for improvement. Clinicians should be mindful of the importance of rapid reperfusion and the implications of its delay for patients with STEMI. Those presenting to emergency departments with chest pain should be prioritised.

Myocardial Ischemia and Diabetes Mellitus: Role of Oxidative Stress in the Connection between Cardiac Metabolism and Coronary Blood Flow

Ischemic heart disease (IHD) has several risk factors, among which diabetes mellitus represents one of the most important. In diabetic patients, the pathophysiology of myocardial ischemia remains unclear yet: some have atherosclerotic plaque which obstructs coronary blood flow, others show myocardial ischemia due to coronary microvascular dysfunction in the absence of plaques in epicardial vessels. In the cross-talk between myocardial metabolism and coronary blood flow (CBF), ion channels have a main role, and, in diabetic patients, they are involved in the pathophysiology of IHD. The exposition to the different cardiovascular risk factors and the ischemic condition determine an imbalance of the redox state, defined as oxidative stress, which shows itself with oxidant accumulation and antioxidant deficiency. In particular, several products of myocardial metabolism, belonging to oxidative stress, may influence ion channel function, altering their capacity to modulate CBF, in response to myocardial metabolism, and predisposing to myocardial ischemia. For this reason, considering the role of oxidative and ion channels in the pathophysiology of myocardial ischemia, it is allowed to consider new therapeutic perspectives in the treatment of IHD.

Acute Coronary Syndrome Symptom Clusters: Illustration of Results Using Multiple Statistical Methods

Researchers have employed various methods to identify symptom clusters in cardiovascular conditions, without identifying rationale. Here, we test clustering techniques and outcomes using a data set from patients with acute coronary syndrome. A total of 474 patients who presented to emergency departments in five United States regions were enrolled. Symptoms were assessed within 15 min of presentation using the validated 13-item ACS Symptom Checklist. Three variable-centered approaches resulted in four-factor solutions. Two of three person-centered approaches resulted in three-cluster solutions. K-means cluster analysis revealed a six-cluster solution but was reduced to three clusters following cluster plot analysis. The number of symptoms and patient characteristics varied within clusters. Based on our findings, we recommend using (a) a variable-centered approach if the research is exploratory, (b) a confirmatory factor analysis if there is a hypothesis about symptom clusters, and (c) a person-centered approach if the aim is to cluster symptoms by individual groups.

Gender difference of symptoms of acute coronary syndrome among Chinese patients: a cross-sectional study

BACKGROUND

The incidence of acute coronary syndrome is increasing in China.

OBJECTIVE

To investigate gender differences in Chinese patients' acute coronary syndrome symptoms, attribution of symptoms and reasons for seeking medical service.

METHODS

This was a cross-sectional, multicentre study. Acute coronary syndrome patients were recruited from five university hospitals located in four cities, between June 2013 and February 2014. Data were collected using the McSweeney acute and prodromal myocardial infarction symptom survey.

RESULTS

A total of 806 patients with acute coronary syndrome (323 men, 483 women) participated in the study. Adjusted (diabetes, smoking, age) logistic regression models revealed that women were significantly more likely to have pain or discomfort in the: central high chest; back, between, or under the shoulder blades; neck or throat; or arms relative to men. Women were also more likely to have unusual fatigue, weakness, shortness of breath or difficulty breathing, or dizziness relative to men. Conversely, women were significantly less likely to have generalised chest pain relative to men. Gender difference in the attribution of symptoms was largely driven by women's attribution to having a heart attack more frequently than men. Finally, women were more often told by a friend to seek medical help or they knew their symptoms were different, while men more frequently sought medical help because their symptoms did not go away.

CONCLUSIONS

There were gender differences in pain, discomfort and other symptoms. Both potential patients and healthcare providers need to be more aware of potential gender differences in acute coronary syndrome symptoms and decisions to seek care to ensure quick access.

What's the Risk? Older Women Report Fewer Symptoms for Suspected Acute Coronary Syndrome than Younger Women

The purpose of the study was to determine whether older (≥65 years) and younger (<65 years) women presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome (ACS) varied on risk factors, comorbid conditions, functional status, and symptoms that have implications for emergent cardiac care. Women admitted to five EDs were enrolled. The ACS Symptom Checklist was used to measure symptoms. Comorbid conditions and functional status were measured with the Charlson Comorbidity Index and Duke Activity Status Index. Logistic regression models were used to evaluate symptom differences in older and younger women adjusting for ACS diagnosis, functional status, body mass index (BMI), and comorbid conditions. Analyses were stratified by age, and interaction of symptom by age was tested. Four hundred women were enrolled. Mean age was 61.3 years (range 21–98). Older women (n = 163) were more likely to have hypertension, hypercholesterolemia, never smoked, lower BMI, more comorbid conditions, and lower functional status. Younger women (n = 237) were more likely to be members of minority groups, be college-educated, and have a non-ACS discharge diagnosis. Younger women had higher odds of experiencing chest discomfort, chest pain, chest pressure, shortness of breath, nausea, sweating, and palpitations. Lack of chest symptoms and shortness of breath (key symptoms triggering a decision to seek emergency care) may cause older women to delay seeking treatment, placing them at risk for poorer outcomes. Younger African American women may require more comprehensive risk reduction strategies and symptom management.

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

Acute Myocardial Infarction Experience Among Mexican American Women

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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.

Test Selection for Women with Suspected Stable Ischemic Heart Disease

Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.

Sex differences in presenting symptoms of acute coronary syndrome: the EPIHeart cohort study

OBJECTIVES

Prompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study aimed to identify sex differences in presenting symptoms of ACS.

DESIGN

Data were collected within a prospective cohort study (EPIHeart).

SETTING

Patients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014.

PARTICIPANTS

Presenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview.

OUTCOME MEASURES

Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex.

RESULTS

Chest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P<0.001).

CONCLUSIONS

While there are no significant differences in the frequency or location of pain between sexes, women are more likely to feel pain of higher intensity and to present with referred pain and symptoms other than pain. Knowledge of these ACS presentation profiles is important for health policy decisions and clinical practice.

Care delays in patients with signs and symptoms of acute myocardial infarction

AIM

More than six million patients with signs and symptoms suggestive of a heart attack present to emergency departments (EDs) in the US each year. Of those diagnosed with acute myocardial infarction (AMI), one third die in the acute phase. Rapid ED triage can reduce the mortality rate, yet there are still delays in patient care. The aim of this study is to explore the relationship between patient and nurse characteristics, patient presentations, delays in triage, and delays in obtaining electrocardiograms (ECGs) of patients with signs and symptoms of AMI.

METHODS

A retrospective correlational study drawing on data from the records of 286 patients with signs and symptoms of AMI.

RESULTS

Delays in triage are related significantly to patients' gender and race. Most patients were triaged by nurses with associate degrees in nursing, a mean age of 45 and a mean of 18 years' experience. An increase in nurse years of experience predicted greater delay in triage. Delays in obtaining ECGs were also significantly greater with more experienced nurses and when patients reported no chest pain.

CONCLUSION

The study adds to the literature on delays in triage and ECGs in care of patients with possible AMI, and further research of the effects of ED crowding and availability of resources in emergency cardiac care is warranted. Studies should identify the processes that cause delays in the emergency care of patients with signs and symptoms of AMI to ensure timely treatment and care.

Treatment and outcomes of acute coronary syndromes in women: An analysis of a multicenter quality improvement Chinese study

BACKGROUND

Variations in care and outcomes by sex in patients with acute coronary syndrome (ACS) have been reported worldwide. The aims of this study are to describe ACS management according to sex in China and the effects of a quality improvement program in Chinese male and female ACS patients.

METHODS AND RESULTS

Clinical Pathways for Acute Coronary Syndromes - Phase 2 (CPACS-2) was a cluster randomized trial to test whether a clinical pathways-based intervention would improve ACS management in China. The study enrolled 15,141 hospitalized patients [4631 (30.6%) were women] from 75 hospitals throughout China between October 2007 and August 2010. The intervention included clinical pathway implementation and performance measurement using standardized indicators with 6 monthly audit-feedback cycles. Eight key performance indicators reflecting in hospital management of ACS were measured. After adjustment for differences in patient characteristics and comorbidities at presentation, women were significantly less likely to undergo coronary angiography when indicated (RR 0.88 [0.85 to 0.92], P<0.001), less likely to receive guideline recommended medical therapies at discharge (RR 0.94 [0.91 to 0.98], P=0.003) and more likely to be hospitalized for shorter (mean difference -0.42 [-0.73 to -0.12] days, P=0.007). However, in-hospital clinical outcomes did not differ by sex. There was no evidence of heterogeneity in the relative effects of the quality improvement initiative by sex.

CONCLUSIONS

Sex disparities were apparent in some key quality of care indicators for patients with suspected with ACS presenting to hospitals in China. The beneficial effect of the quality improvement program was consistent in women and men.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.

Effect of gender on evidence-based practice for Australian patients with acute coronary syndrome: A retrospective multi-site study

BACKGROUND

Early acute coronary syndrome (ACS) care occurs in the emergency department (ED). Death and disability from ACS are reduced with access to evidence-based ACS care. In this study, we aimed to explore if gender influenced access to ACS care.

METHODS

A retrospective descriptive study was conducted for 288 (50% women, n=144) randomly selected adults with ACS admitted via the ED to three tertiary public hospitals in Victoria, Australia from 1.1.2013 to 30.6.2015.

RESULTS

Compared with men, women were older (79 vs 75.5 years; p=0.009) less often allocated triage category 2 (58.3 vs 71.5%; p=0.026) and waited longer for their first electrocardiograph (18.5 vs 15min; p=0.001). Fewer women were admitted to coronary care units (52.4 vs 65.3%; p=0.023), but were more often admitted to general medicine units (39.6 vs 22.9%; p=0.003) than men. The median length of stay was 4days for both genders, but women were admitted for significantly more bed days than men (IQR 3-7 vs 2-5; p=0.005).

CONCLUSIONS

There were a number of gender differences in ED care for ACS and women were at greater risk of variation from evidence-based guidelines. Further research is needed to understand why gender differences exist in ED ACS care.

Impact of comorbidities by age on symptom presentation for suspected acute coronary syndromes in the emergency department

BACKGROUND

It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions.

AIMS

Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis.

METHODS

A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis.

RESULTS

The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS.

CONCLUSIONS

Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.