Women present with “typical” heart attack symptoms more often than men, according to research published August 20 in the Journal of the American Heart Association.
We’re all familiar with the classic symptoms of an MI—usually chest, arm or jaw pain accompanied by a feeling of tightness, pressure, aching, crushing or gripping. But recent clinical guidelines and news coverage suggest we often automatically pair those symptoms with male patients, assuming female victims will present with more atypical symptoms like epigastric pain, dyspepsia or breathlessness.
According to Amy V. Ferry, BSc, and colleagues’ paper, international guidelines in 2019 state that women with myocardial infarction are likely to present with atypical heart attack symptoms. The fourth universal definition of MI, however, extends beyond symptom analysis to recommend the use of sex-specific troponin thresholds to accurately diagnose a heart attack.
“Women with myocardial infarction are at risk of underdiagnosis and undertreatment if correct symptom presentations are not recognized,” Ferry, of the BHF Centre for Cardiovascular Science at the Royal Infirmary of Edinburgh, and co-authors wrote in JAHA. “Our aim was to prospectively evaluate the frequency and predictive value of patient-reported symptoms in men and women with suspected acute coronary syndrome and to determine whether symptoms differ when the diagnosis of myocardial infarction is based on sex-specific criteria.”
Ferry and her team evaluated patient-reported symptoms among 1,941 patients—39% of whom were women—with suspected acute coronary syndrome who were enrolled in a substudy of a prospective trial. Standardized criteria defined typical versus atypical symptoms based on the nature of patients’ pain, the location of pain, radiation and other symptoms. For the study, atypical pain was classified as epigastric or back pain or pain that was burning, stabbing or felt like indigestion.
The researchers adjudicated MI diagnoses with a high-sensitivity cardiac troponin I assay that used sex-specific thresholds (16 ng/L in women and 34 ng/L in men). Patients who were missed by the contemporary assay with a uniform threshold of 50 ng/L or higher were reclassified using the high-sensitivity approach.
Sixteen percent of men and 12% of women in the study were diagnosed with type 1 myocardial infarction, with 5% of men and 30% of women reclassified using high-sensitivity cardiac troponin I and sex-specific thresholds. Chest pain was the most common indicator of MI in both men and women—it was the primary presenting symptom in 91% and 92% of the groups, respectively.
Contrary to international guidelines, which currently state that women with MI are likely to present with atypical symptoms, Ferry et al. found typical symptoms were more common in women, affecting 77% of female patients as opposed to 59% of men. Differences were similar in patients who were reclassified using high-sensitivity troponin I assays—74% in women compared to 44% in men.
The authors also reported that the presence of three or more typical symptoms was associated with a positive likelihood ratio for the diagnosis of MI in women (ratio, 1.18) but not in men (ratio, 1.09).
“Ferry and co-authors are presenting us with interesting and compelling evidence that women with typical chest pain symptoms should be triaged properly for ACS therapies similarly to men and that associated symptoms are also to be taken seriously in women, even more so than in men,” M. Chadi Alraies, MD, MPH, and Illeana L. Pina, MD, MPH, wrote in a related editorial. “Clinicians should not forget that the major source of mortality in women is heart disease, just as in men.”
Alraies and Pina said further work needs to be done to identify patients who fall outside Ferry et al.’s findings.
“Should authors of international guidelines now deemphasize the atypical nature of women’s symptoms and reemphasize the recognition of typical chest pain and associated symptoms and move quickly to diagnose and intervene?” they wrote. “Only time will tell.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.