Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria

Amy V Ferry, Atul Anand, Fiona E Strachan, Leanne Mooney, Stacey D Stewart, Lucy Marshall, Andrew R Chapman, Kuan Ken Lee, Simon Jones, Katherine Orme, Anoop S V Shah, Nicholas L Mills, Amy V Ferry, Atul Anand, Fiona E Strachan, Leanne Mooney, Stacey D Stewart, Lucy Marshall, Andrew R Chapman, Kuan Ken Lee, Simon Jones, Katherine Orme, Anoop S V Shah, Nicholas L Mills

Abstract

Background Sex-specific criteria are recommended for the diagnosis of myocardial infarction, but the impact of these on presenting characteristics is unknown. Methods and Results We evaluated patient-reported symptoms in 1941 patients (39% women) with suspected acute coronary syndrome attending the emergency department in a substudy of a prospective trial. Standardized criteria defined typical and atypical presentations based on pain nature, location, radiation, and additional symptoms. Diagnosis of myocardial infarction was adjudicated using a high-sensitivity cardiac troponin I assay with sex-specific thresholds (>16 ng/L women, >34 ng/L men). Patients identified who were missed by the contemporary assay with a uniform threshold (≥50 ng/L) were reclassified by this approach. Type 1 myocardial infarction was diagnosed in 16% (184/1185) of men and 12% (90/756) of women, with 9 (5%) men and 27 (30%) women reclassified using high-sensitivity cardiac troponin I and sex-specific thresholds. Chest pain was the presenting symptom in 91% (1081/1185) of men and 92% (698/756) of women. Typical symptoms were more common in women than in men with myocardial infarction (77% [69/90] versus 59% [109/184]; P=0.007), and differences were similar in those reclassified (74% [20/27] versus 44% [4/9]; P=0.22). The presence of ≥3 typical features was associated with a positive likelihood ratio for the diagnosis of myocardial infarction in women (positive likelihood ratio, 1.18; 95% CI, 1.03-1.31) but not in men (positive likelihood ratio 1.09; 95% CI, 0.96-1.24). Conclusions Typical symptoms are more common and have greater predictive value in women than in men with myocardial infarction whether or not they are diagnosed using sex-specific criteria. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier NCT01852123.

Keywords: acute coronary syndrome; chest pain; chest pain diagnosis; myocardial infarction; sex.

Figures

Figure 1
Figure 1
Radar plot showing frequency of typical and atypical pain descriptors. Frequency of typical and atypical descriptors of pain, stratified by sex, in those with myocardial infarction (A, n=274) and without myocardial infarction (B, n=1667). Men are represented in blue; women are represented in red.
Figure 2
Figure 2
Positive likelihood ratios for the diagnosis of type 1 myocardial infarction of typical clinical features in men and women. Forest plot of the positive likelihood ratios and 95% CIs of 4 clinical features (pain nature, pain location, radiation, associated symptoms) in predicting the diagnosis of myocardial infarction.

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