Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta‐analysis

Abstract

Background Timely recognition of patients with acute coronary syndromes ( ACS ) is important for successful treatment. Previous research has suggested that women with ACS present with different symptoms compared with men. This review assessed the extent of sex differences in symptom presentation in patients with confirmed ACS . Methods and Results A systematic literature search was conducted in PubMed, Embase, and Cochrane up to June 2019. Two reviewers independently screened title‐abstracts and full‐texts according to predefined inclusion and exclusion criteria. Methodological quality was assessed using the Newcastle‐Ottawa Scale. Pooled odds ratios ( OR ) with 95% CI of a symptom being present were calculated using aggregated and cumulative meta‐analyses as well as sex‐specific pooled prevalences for each symptom. Twenty‐seven studies were included. Compared with men, women with ACS had higher odds of presenting with pain between the shoulder blades ( OR 2.15; 95% CI , 1.95–2.37), nausea or vomiting ( OR 1.64; 95% CI , 1.48–1.82) and shortness of breath ( OR 1.34; 95% CI , 1.21–1.48). Women had lower odds of presenting with chest pain ( OR 0.70; 95% CI , 0.63–0.78) and diaphoresis (OR 0.84; 95% CI , 0.76–0.94). Both sexes presented most often with chest pain (pooled prevalences, men 79%; 95% CI , 72–85, pooled prevalences, women 74%; 95% CI , 72–85). Other symptoms also showed substantial overlap in prevalence. The presence of sex differences has been established since the early 2000s. Newer studies did not materially change cumulative findings. Conclusions Women with ACS do have different symptoms at presentation than men with ACS , but there is also considerable overlap. Since these differences have been shown for years, symptoms should no longer be labeled as “atypical” or “typical.”

Cardiac symptom attribution and knowledge of the symptoms of acute myocardial infarction: a systematic review

“…Our review showed that there is insufficient knowledge of atypical symptoms, which are especially relevant for women as they have a more atypical symptom presentation than men. While there is also considerable overlap among the symptoms men and women display, men present more often with the best known symptom ‘chest pain’ as well as ‘sweating’, which was among the best known symptoms in our comparison [ 103 ]. On the other hand, women present more often with only non-chest-pain discomfort, showing symptoms as ‘neck-, back- and jaw pain’ which was considerably less known, or with ‘nausea or vomiting’ which we found to be insufficiently known [ 15 , 103 – 105 ].…”

“…While there is also considerable overlap among the symptoms men and women display, men present more often with the best known symptom ‘chest pain’ as well as ‘sweating’, which was among the best known symptoms in our comparison [ 103 ]. On the other hand, women present more often with only non-chest-pain discomfort, showing symptoms as ‘neck-, back- and jaw pain’ which was considerably less known, or with ‘nausea or vomiting’ which we found to be insufficiently known [ 15 , 103 – 105 ]. Similarly, the observation is relevant for elderly people who also experience more atypical symptoms [ 5 , 106 , 107 ].…”

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

“…10 11 A recent meta-analysis of 27 studies showed that women with ACS compared with men with ACS had higher odds of presenting with pain between the shoulder blades (OR 2.15, 95% CI 1.95 to 2.37), nausea or vomiting (OR 1.64, 95% CI 1.48 to 1.82), and shortness of breath (OR 1.34, 95% CI 1.21 to 1.48). 12 Women with ACS had lower odds of sweating (OR 0.84, 95% CI 0.76 to 0.94) and presenting with chest pain (OR 0.70, 95% CI 0.63 to 0.78), but in both sexes, chest pain remained the most common symptom (pooled prevalence: men 79% and women 74%). 12 Importantly, researchers suggested standardisation in methods of symptom assessment is needed because of the difficulties to formulate any definitive statements about symptom presentation, as studies assessed symptoms in different ways (questionnaires or abstracting from medical records).…”

“…12 Women with ACS had lower odds of sweating (OR 0.84, 95% CI 0.76 to 0.94) and presenting with chest pain (OR 0.70, 95% CI 0.63 to 0.78), but in both sexes, chest pain remained the most common symptom (pooled prevalence: men 79% and women 74%). 12 Importantly, researchers suggested standardisation in methods of symptom assessment is needed because of the difficulties to formulate any definitive statements about symptom presentation, as studies assessed symptoms in different ways (questionnaires or abstracting from medical records). 9 13-15 Abstracting symptom presentation from medical records may dilute symptom presentation, as they are translated by the clinician in medical terminology.…”

The Future of Women and Heart Disease in a Pandemic Era: Let’s Learn from the Past

“…Not only did women have to wait longer for lifesaving procedures compared to male patients arriving to the hospital, but women also had increased mortality rates compared with males. In fact, there was up to a two-fold increased rate of mortality, repeat heart attack and stroke due to co-morbidities, due to delay in care and suboptimal treatment [ 6 ].…”