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Do you Understand the Symptoms of Myocardial Infarction?
An evaluation of clinical symptoms is a major part of the risk stratification of patients presenting to the emergency department with the suspected acute coronary syndrome.
The accurate interpretation of clinical symptoms has implications for patient triage, treatment, and subsequent management.
The last 2 revisions of the universal definition of myocardial infarction recommend the use of sex-specific troponin thresholds for the diagnosis of myocardial infarction. The use of sex-specific thresholds has identified a population of patients with previously unrecognised myocardial infarction. These patients would not have been included in previous study populations investigating sex differences in symptom presentation.
Atypical symptom presentations associated with myocardial infarction in women are thought to contribute to lower rates of diagnosis and treatment, and worst outcomes compared with men with myocardial infarction. International guidelines reinforce the view that women are more likely to present with atypical symptoms, such as epigastric pain, dyspepsia, or breathlessness. It is unknown how the identification of these newly identified patients will impact the symptom profile of patients with myocardial infarction.
Clinical Perspective
What is New
- The fourth universal definition of myocardial infarction now recommends the use of sex-specific diagnostic criteria, but the impact of these criteria on the presentation and clinical features of men and women with the suspected acute coronary syndrome is unknown.
- Many previous students have relied on clinician-reported symptoms that may be susceptible to ascertainment bias, whereas we prospectively recorded patient-reported symptoms in 1,941 patients with the suspected acute coronary syndrome.
- We report that typical symptoms are more common and have greater predictive value in women than in men with myocardial infarction, whether diagnosed using sex-specific or uniform criteria.
What are the Clinical Implications?
- International guidelines currently state that women with myocardial infarction commonly present with atypical symptoms, which is contrary to evidence supported in this study.
- The accurate interpretation of clinical symptoms has implications for patient triage, treatment, and subsequent management.
- Women with myocardial infarction are at risk of underdiagnosis and undertreatment if correct symptom presentations are not recognised.
Our aim was to prospectively evaluate the frequency and predictive value of patient-reported symptoms in men and women with the suspected acute coronary syndrome and to determine whether symptoms differ when the diagnosis of myocardial infarction is based on sex-specific criteria.
Symptom Characteristics
Chest pain was the most common presenting symptom, reported by 92% of women and 91% of men with the suspected acute coronary syndrome. Pain with typical nature descriptors, the presence of radiation, and the presence of additional symptoms were all more common in women with the suspected acute coronary syndrome.
Women, compared with men, more often reported palpitations as a presenting symptom. Women were also more likely to report that their pain radiated to the left arm, the back or to the neck or jaw than were men, and were more likely to report associated nausea.
The adjudicated diagnosis was type 2 myocardial infarction in 5.1% of women and 3.2% of men. Chest pain remained the most common presenting symptom for women and men with type 2 myocardial infarction but was less likely to have radiating pain, and more likely to present with palpitations when compared with patients with type 1 myocardial infarction.
Consistent with our finding in those with type 1 myocardial infarction, typical symptom features (pain with typical nature descriptors, the presence of radiation, and the presence of additional symptoms) were more frequently reported in women than in men with type 2 myocardial infarction.
Conclusion
Women more frequently describe pain of a typical nature than do men, and typical symptoms are more predictive of a diagnosis of myocardial infarction in women than in men. We advocate that guidelines and educational material be updated to minimise the risk of underdiagnosis and treatment of women with myocardial infarction.
Adapted from American Heart Association.
Commentary by Prof Tan Huay Cheem, Chairman, Singapore Heart Foundation, Senior Consultant, Department of Cardiology, National University Heart Centre, Singapore
Typical chest pain is more likely the presentation. While women are likely to present typical chest pain for heart attack, the likelihood for atypical symptom presentation is more common among women.
The reason for the difference in the article quoted is perhaps the way in which typical and atypical symptoms are being described. Many of the women who complains of dyspnea / palpitation would have been called ‘typical’ in this study as opposed to our usual classification as atypical.
Atypical pain was classified in patients reporting epigastric or back pain or pain that was burning, stabbing, indigestion-like, or any other pain description or presentation. Guidelines also state that radiation of pain and the presence of associated symptoms form part of a typical presentation; therefore the presence of radiation (right arm, left arm, neck, jaw, back) and presence of any associated feature (nausea, vomiting, sweating, dyspnea, palpitations) was also documented.
