The telltale traits of acute myocardial infarction–associated chest pain may differ in women and men, but they aren’t diagnostically telling enough to determine which women with chest pain are having a heart attack, according to a report published online Nov. 25 in JAMA Internal Medicine.
In a large international study, 11 of 34 possible traits related to chest pain were found to be significantly different in women compared with men who presented to an emergency department with acute chest pain and possible MI. But none of these pain characteristics was clinically useful in distinguishing MI from other, non-MI causes of chest pain in women, said Dr. Maria Rubini Gimenez of the cardiology department, University Hospital Basel (Switzerland), and her associates (JAMA Intern. Med. 2013 Nov. 25 [doi: 10.1001/jamainternmed.2013.12199]).
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Chest pain often accompanies myocardial infarctions, but Dr. Maria Gimenez says pain characteristics were not clinically useful in distinguishing MI from other, non-MI causes of chest pain in women.
The investigators performed the ongoing APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation) study to determine whether sex-specific chest pain characteristics could be used to differentiate women who had acute MI from women who had other causes of chest pain, including unstable angina, cardiac but noncoronary disease such as tachyarrhythmia or perimyocarditis, or noncardiac chest pain.
They assessed 2,475 consecutive patients – 796 women and 1,679 men – who presented with symptoms suggestive of acute MI to nine medical centers in Switzerland, Spain, and Italy during a 6-year period.
In addition to receiving a routine clinical assessment, all of the study’s patients were assessed for 34 characteristics of chest pain, including severity, location (midchest, left side, right side, inframammillary, or supramammillary), size of the pain area (more than or less than 3 cm in diameter), pain quality (pressure, stabbing, burning, aching, and related or unrelated to dyspnea), radiation pattern, onset, duration, dynamics (whether it was currently increasing, decreasing, or stable), aggravating or inducing factors (whether pain was worsened by exertion, change in position, coughing, palpation, or emotional stress), and relieving factors (such as nitrate therapy).
A total of 143 women (18%) and 369 men (22%) were found to have acute MI.
Most of the 34 chest pain characteristics were reported with similar frequency in women and men. Only 11 traits differed significantly between the sexes. Women were significantly more likely than men to report greater pain severity, pressurelike pain, accompanying dyspnea, pain aggravated by palpation, pain radiating to the throat or back, sudden onset of pain, and pain duration of longer than 30 minutes. And women were significantly less likely to report no pain radiation, radiation to the right side, or shorter pain duration.
When the analysis was restricted to patients who had only acute MI, only 5 of the 34 chest pain characteristics differed significantly between women and men. Women with acute MI were less likely than men with acute MI to report pain radiation to the right arm/shoulder, short duration of pain, and pain that decreased with time. They were more likely than men to report pain radiation to the back and pain duration of 30 minutes or more, the investigators reported.
When the analysis turned to chest pain characteristics that could distinguish acute MI from other causes, only 3 of the 34 traits (8%) contributed to sex-specific diagnosis. Chest pain duration of only 2-30 minutes weakly decreased the likelihood of an MI diagnosis in women but weakly increased it in men. Pain duration of more than 30 minutes weakly increased the likelihood of an MI diagnosis in women but was neutral in men. And decreasing pain intensity weakly decreased the likelihood of an MI diagnosis in women but weakly increased the likelihood in men.
However, none of those three chest pain characteristics was considered to be clinically helpful in establishing an MI diagnosis, Dr. Gimenez and her associates said.
"Our data confirm that [chest pain characteristics] are not powerful enough to be used as a single tool in the diagnosis of AMI [acute myocardial infarction] and need to be used always in conjunction with the ECG and [cardiac troponin] test results in the diagnosis of AMI," the researchers noted. Given that the differences were small in those characteristics’ sex-specific diagnostic performance, "our findings do not seem to support the use of [chest pain characteristics] specific to women in the early diagnosis of AMI in women," they concluded.
This study was supported by the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University of Basel, and University Hospital Basel. Dr. Gimenez reported no financial conflicts of interest, and her associates reported ties to 8sense, Abbott, Alere, and other companies.