Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease (Sep 2019)

Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex‐Specific Criteria

  • Amy V. Ferry,
  • Atul Anand,
  • Fiona E. Strachan,
  • Leanne Mooney,
  • Stacey D. Stewart,
  • Lucy Marshall,
  • Andrew R. Chapman,
  • Kuan Ken Lee,
  • Simon Jones,
  • Katherine Orme,
  • Anoop S. V. Shah,
  • Nicholas L. Mills

DOI
https://doi.org/10.1161/JAHA.119.012307
Journal volume & issue
Vol. 8, no. 17

Abstract

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Background Sex‐specific criteria are recommended for the diagnosis of myocardial infarction, but the impact of these on presenting characteristics is unknown. Methods and Results We evaluated patient‐reported symptoms in 1941 patients (39% women) with suspected acute coronary syndrome attending the emergency department in a substudy of a prospective trial. Standardized criteria defined typical and atypical presentations based on pain nature, location, radiation, and additional symptoms. Diagnosis of myocardial infarction was adjudicated using a high‐sensitivity cardiac troponin I assay with sex‐specific thresholds (>16 ng/L women, >34 ng/L men). Patients identified who were missed by the contemporary assay with a uniform threshold (≥50 ng/L) were reclassified by this approach. Type 1 myocardial infarction was diagnosed in 16% (184/1185) of men and 12% (90/756) of women, with 9 (5%) men and 27 (30%) women reclassified using high‐sensitivity cardiac troponin I and sex‐specific thresholds. Chest pain was the presenting symptom in 91% (1081/1185) of men and 92% (698/756) of women. Typical symptoms were more common in women than in men with myocardial infarction (77% [69/90] versus 59% [109/184]; P=0.007), and differences were similar in those reclassified (74% [20/27] versus 44% [4/9]; P=0.22). The presence of ≥3 typical features was associated with a positive likelihood ratio for the diagnosis of myocardial infarction in women (positive likelihood ratio, 1.18; 95% CI, 1.03–1.31) but not in men (positive likelihood ratio 1.09; 95% CI, 0.96–1.24). Conclusions Typical symptoms are more common and have greater predictive value in women than in men with myocardial infarction whether or not they are diagnosed using sex‐specific criteria. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier NCT01852123.

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