Myth vs Reality
John G. Canto, MD, MSPH; Robert J. Goldberg, PhD; Mary M. Hand, MSPH, RN; Robert O. Bonow, MD; George Sopko, MD, MPH; Carl J. Pepine, MD; Terry Long, BA
Arch Intern Med. 2007;167(22):2405-2413.
Background Optimal diagnosis and timely treatment of patients with an acute coronary syndrome (ACS) depends on distinguishing differences between popular "myths" about ischemic symptoms in women and men. Chest pain or discomfort is regarded as the hallmark symptom of ACS, and its absence is regarded as "atypical" presentation. This review describes the presenting symptoms of ACS in women compared with men and ascertains whether women should have a symptom message that is separate or different from that for men.
Methods MEDLINE (1970-2005), bibliographies of articles, and pertinent abstracts were reviewed, focusing on studies of ACS presentation, especially those reporting differences in symptoms by sex. This analysis included 69 of 361 possible studies. Data regarding symptom presentation were recorded.
Results The published literature lacks standardization in characterizing ACS presentation, data collection, and reporting of symptoms. Approximately one-third of patients in the large cohort studies and one-quarter of patients in the smaller reports and direct patient interviews presented without chest pain or discomfort. The absence of chest pain or discomfort with ACS was noted more commonly in women than in men in both the cumulative summary from large cohort studies (37% vs 27%) and the single-center and small reports or interviews (30% vs 17%).
Conclusions Women are significantly less likely to report chest pain or discomfort compared with men. These differences, however, are not likely large enough to warrant sex-specific public health messages regarding the symptoms of ACS at the present time. Further research must systematically investigate sex differences in the clinical presentation of ACS symptoms and must include standardized data collection efforts.
Among the findings:
Compared with men, women are more likely to present with unstable angina and less likely to present with acute myocardial infarction.
In nine large cohort studies, 27.4% of men with ACS had no chest pain at presentation; 37.5% of women had no pain.
In the single-center and small reports or interviews, 30% of women and 17% of men did not have chest pain.
In the setting of acute MI, women are more likely to have ST-elevation MI than non-STEMI.
Women are less likely to have obstruction of coronary vessels and more likely to have Prinzmetal angina, syndrome X, and mitral valve prolapse.
Even in the presence of ischemic damage, women are likely to have normal findings on angiography.