Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study

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Abstract

Objectives

To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men.

Design

Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS.

Setting

Nine OHS-PC in the Netherlands.

Participants

993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016.

Primary outcome measure

Diagnosis of ACS retrieved from the patient’s medical record in general practice, including hospital specialists’ discharge letters.

Results

Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.

Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%).

Conclusion

Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses.

Trial registration number

NTR7331.

Related collections

Most cited references 41

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Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association.

Laxmi S Mehta, Theresa M Beckie, Holli DeVon … (2016)

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

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Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes.

Vera Regitz-Zagrosek, Sabine Oertelt-Prigione, Eva Prescott … (2016)

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Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.

John Canto, William J Rogers, Robert J. Goldberg … (2012)

Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality. To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI. Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men). We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality. The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P < .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001). In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2021

Publication date (Electronic): 25 June 2021

Volume: 11

Issue: 6

Electronic Location Identifier: e042406

Affiliations

[1 ]departmentJulius Center for Health Sciences and Primary Care , Universitair Medisch Centrum Utrecht , Utrecht, The Netherlands

[2 ]departmentEpidemiology , Julius Center for Health Sciences and Primary Care , Utrecht, The Netherlands

Author notes

[Correspondence to ] Dr Loes T C M Wouters; L.T.C.Wouters-2@ 123456umcutrecht.nl

Author information

Loes T C M Wouters http://orcid.org/0000-0002-1525-9803

Daphne C A Erkelens http://orcid.org/0000-0002-5846-5201

Esther De Groot http://orcid.org/0000-0003-0388-385X

Article

Publisher ID: bmjopen-2020-042406

DOI: 10.1136/bmjopen-2020-042406

PMC ID: 8237735

PubMed ID: 34172542

SO-VID: fe079c00-5bfe-4d84-8ea4-245e07744d8b

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 03 July 2020

Date accepted : 12 May 2021

Funding

Funded by: Foundation ’The Netherlands Triage Standard’;

Funded by: Personal promotion grant of D.L. Zwart, MD, PhD;

Funded by: Dutch Heart Foundation/Dutch Cardiovascular Alliance (DHF/DCVA).;

Funded by: Department of general practice of the University Medical Center Utrecht;

Funded by: Foundation ‘Stoffels-Hornstra’.;

Custom metadata

special-feature unlocked

ScienceOpen disciplines: Medicine

Keywords: primary care,telemedicine,myocardial infarction

Data availability: