Although chest pain is the most common symptom of acute coronary syndrome (ACS) in both young men and women, many women do not present with chest pain and have more non-chest pain symptoms than men, according to a study published online Sept. 16 in JAMA Internal Medicine.

In the Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome (GENESIS PRAXY) prospective cohort study, researchers evaluated differences between men and women in the presentation of ACS.

“[W]omen are more likely to present without chest pain than men or have only mild chest pain symptoms,” wrote the authors, led by Nadia A. Khan, MD, of the University of British Columbia in Vancouver, British Columbia, Canada. “Whether these sex differences in ACS presentation and predictors of non-chest pain presentation exist in young ACS populations remains unknown because this group has not been sufficiently studied.”

For their study, the researchers enrolled more than 1,100 patients 55 years of age or younger with ACS admitted to hospitals in Canada, the U.S. and Switzerland between 2009 and 2012. They evaluated what symptoms were present during hospitalization and linked symptoms to sex, sociodemographic, psychosocial, gender identity, some clinical factors, markers of coronary disease severity and absence of chest pain.

Women were more likely than men to have no complaints of chest pain (19 percent vs. 13.7 percent). Both young women and young men without chest pain had fewer symptoms in general compared with patients who complained of chest pain.

Women who did not have chest pain, however, had more symptoms than men without chest pain. Most of the men and women who did not have chest pain had at least one other symptom, such as shortness of breath or weakness.

Other than being a woman and having tachycardia, the authors did not determine any consistent symptom pattern in either sex that was independently associated with ACS presentation without chest pain. Patients who had no chest pain were not significantly different from patients with chest pain in type of ACS, elevated troponin level or coronary stenosis.

“Our findings indicate that chest pain is the predominant symptom that should direct diagnostic evaluation for ACS and be used for public health messages for young women and men, similar to older patients,” the authors concluded.

However, providers should also be attuned to other symptoms in addition to chest pain, especially in women, since 20 percent of women do not report chest pain.

“Given that the majority of patients without chest pain express at least one other non-chest pain symptom, standardized collection of all ACS related symptoms is needed,” they wrote.

In an accompanying editorial, Akintunde O. Akinkuolie, MBBS, MPH, and Samia Mora, MD, MHS, of Harvard Medical School in Boston, agreed with the recommendation for a standardized ACS symptom assessment and added that public health efforts should emphasize what other signs of ACS to look for.

“Future research aimed at elucidating the basis for sex differences in ACS symptoms and outcomes is warranted. Meanwhile, it is prudent for public health messages to target both men and women regarding ACS symptom presentation with or without chest pain so as to encourage earlier and more widespread access to appropriate and lifesaving care,” they wrote.