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Use of sex-specific chest pain symptoms unsupported in early MI diagnosis
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The diagnostic performance of sex-specific chest pain characteristics did not differ significantly between men and women for the early diagnosis of MI.
In the ongoing prospective, multicenter APACE study, researchers evaluated the diagnostic performance of 34 chest pain characteristics among 796 women and 1,679 men who presented with acute chest pains at nine EDs from April 21, 2006, to Aug. 12, 2012. A final diagnosis of acute MI, adjudicated twice by a core laboratory, was reported in 18% of women and 22% of men.
Across the entire cohort, women reported pressure-like pain, sudden onset, duration of longer than 30 minutes, pain radiating to the throat or back, attendant dyspnea and aggravation from palpation significantly more frequently than men, and also indicated a slightly greater severity of pain. By contrast, men were more likely to experience a pain duration between 2 and 30 minutes and either no pain radiation or radiation to the right side, compared with women (P<.05 for all comparisons).
All but three of the evaluated chest pain characteristics yielded similar likelihood ratios for acute MI diagnosis among men and women, with most unable to discriminate between acute MI and other causes of chest pain. Stabbing pain, inframammillary pain, no radiation, duration of fewer than 2 minutes, pain located on the left side and aggravation through breathing, movement or palpation were significantly less likely to lead to acute MI diagnosis, regardless of sex. A pain area larger than 3 cm, radiation to the shoulders or arms, pain located in the center and/or on the right side of the chest, aggravation through exertion and pain relief from nitrates significantly increased the risk for acute MI diagnosis in both sexes. No combination of the evaluated characteristics significantly interacted with patient sex.
Researchers noted that a pain duration between 2 and 30 minutes increased the likelihood of acute MI diagnosis among men (likelihood ratio [LR]=1.06, 95% CI, 1-1.13) but decreased the likelihood among women (LR=0.73, 95% CI, 0.5-1.06). A duration of longer than 30 minutes increased the risk for diagnosis among women (LR=1.13, 95% CI,1.02-1.25) but had no effect among men (LR=0.99, 95% CI, 0.91-1.08). Also, a decrease in pain intensity decreased acute MI diagnosis risk among women (LR=0.72, 95% CI, 0.5-1.05), but increased risk among men (LR=1.1, 95% CI, 0.91-1.32).
“Differences in the sex-specific diagnostics performances of chest pain characteristics overall are small,” the researchers concluded. “Our findings do not seem to support the use of [these characteristics] specific to women in the early diagnosis of acute MI in women.”
In a related editorial, Louise Pilote, MD, MPH, PhD, of McGill University Health Center Research Institute in Montreal, said these data lend further clarification to the similarities between men and women in the presentation of chest pain.
“Although modest differences occur between men and women in their presentations of acute MI, overall they are similar,” Pilote wrote. “… Clinicians will have to maintain a high level of clinical suspicion and increasingly use sensitive biomarkers, such as high-sensitivity cardiac troponin tests, to help diagnose acute MI in high-risk women.”
For more information:
Gimenez MR. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.12199.
Pilote L. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.12097.
Disclosure: See the full study for a list of relevant financial disclosures.
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