In the Journals

One in five women with ACS present without chest pain

Chest pain is the most common ACS symptom in patients, but women are more likely than men to present without chest pain, according to a new report.

Researchers evaluated a cohort of 1,015 patients (30% women; mean age, 49 years; 40% obese) who were hospitalized for ACS and enrolled in the ongoing GENESIS PRAXY study between 2009 and 2012. The study was designed to determine differences in ACS symptom presentation between men and women younger than 55 years.

Overall, 96.6% of men and 97% of women presented with at least one symptom, including chest pain, shortness of breath or other symptoms from the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) such as weakness, cold sweats and left arm pain. Regardless of ACS type, chest pain was the most common symptom for men and women.

More women than men presented without chest pain (19% vs. 13.7%; P=.03). Younger patients of both sexes without chest pain reported fewer symptoms overall, although the mean number of symptoms was higher in women. Women were also more likely to have non-STEMI (37.5% vs. 30.7%; P=.03).

According to multivariate analysis, female sex (OR=1.95; 95% CI, 1.23-3.11) and tachycardia (OR=2.07; 95% CI, 1.2-3.56) were independently associated with ACS presentation without chest pain.

The researchers found no correlation between a lack of chest pain and ACS severity, as defined by disease type, troponin level elevation or coronary stenosis.

In other results, women in the study were more likely to have hypertension, diabetes and depression.

“Health care providers should still maintain a high degree of suspicion for ACS in younger patients, particularly women, given that one in five women with diagnosed ACS do not report chest pain,” the researchers wrote. “Strategies that explicitly incorporate standardized assessments of common non-chest pain symptoms or signs, such as weakness, shortness of breath or tachycardia in [EDs], also need to be evaluated.”

In an accompanying editorial, Akintunde O. Akinkuolie, MBBS, MPH, and Samia Mora, MD, MHS, of Brigham and Women’s Hospital, wrote that sex differences in ACS presentation warrant public health messages.

“Although all participants in the study by Khan et al were admitted for ACS, their results shed light on the potential for physicians to miss a case of ACS when the cardinal symptom of chest pain is not experienced or elicited,” Akinkuolie and Mora wrote. “It is prudent for public health messages to target both men and women regarding ACS symptom presentation with our without chest pain so as to encourage earlier and more widespread access to appropriate and lifesaving care.”

Disclosure: The researchers report no relevant financial disclosures. Akinkuolie and Mora were supported by the NHLBI; Mora also reports funding, consultation or honoraria from or for Abbott, AstraZeneca, Merck, Pfizer and Quest Diagnostics.