Younger women more likely than men to present with acute coronary syndrome without chest pain

Image: PD 

1. Over 80% of younger patients (<55 years old) with acute coronary syndrome (ACS) reported chest pain, which is higher than the percentage of ACS in older populations presenting with chest pain. 

2. Among a cohort of ACS patients, women were more likely to present without chest pain in comparison to men.  

Evidence Rating Level: 2 (Good) 

Study Rundown:  It has been previously demonstrated that women are more likely than men to present without chest pain in acute coronary syndrome (ACS). Differential ACS presentations between sexes, however, have not been adequately examined in younger populations. This study found that chest pain was by far the most common symptom among both younger men and women (age 55 or younger) and that women were less likely than men to present with chest pain in this age group. Furthermore, women with ACS were more likely than men to report non-chest pain symptoms such as weakness, sensantion of warmth, cold sweats, and pain in left arm and/or shoulder. A limitation of the study is that the differential prevalence of co-morbidities by sex was not controlled for in the study design. For example, women were more likely to have diabetes, which has been associated with ACS presentation without chest pain. Nonetheless, this study supports the need to assess non-chest pain symptoms in patients in order to obtain a better clinical judgment regarding the possibility of ACS. Moving forward, future research is needed to delineate and identify the mechanisms for differential presentations between men and women.

Click to read the study, published today in JAMA Internal Medicine

Click to read an accompanying editorial in JAMA Internal Medicine

Relevant Reading: Association of Age and Sex with Myocardial Infarction Symptom Presentation and In-Hospital Mortality

In-Depth [Prospective cohort study]: This study examined 1,015 subjects aged 55 years or younger who were admitted to a cardiology ward, ICU, or CCU with ACS based on initial clinical presentation and enrolled in the ongoing GENESIS PRAXY study. Patients were assessed with the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS), and were required to have either EKG changes or positive cardiac enzymes. Of these ACS patients, women were less likely to have chest pain than men (81.0% vs. 86.3%, respectively, p=0.03). Women were more likely than men to present with weakness (58.0% vs. 46.9%, p=0.001), feeling hot (55.4% vs. 45.1%, p=0.003), and pain in left arm and/or shoulder (49.5% vs. 41.3%, p=0.02). Significant predictors of ACS without chest pain included female sex (OR, 1.95 [95%CI: 1.23-3.11]) and tachycardia (OR, 2.07 [95%CI, 1.20-3.56]).

By Jonathan Lichkus and Rif Rahman 

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