CardioExchange Archive

Younger women with an acute coronary syndrome are slightly less likely than men to present with the classic symptom of chest pain, according to a new study published in JAMA Internal Medicine. In recent years there has been a growing understanding that women with ACS are less likely to have chest pain and, partly as a result, often fail to receive a correct diagnosis in the emergency department. However, there has only been limited data on whether this pattern is also true for younger women.

Nadia Khan and colleagues prospectively analyzed data from more than 1000 ACS patients 55 years of age or younger — 30% of whom were women — participating in the GENESIS PRAXY study. When compared with older cohorts in previous studies, patients in GENESIS PRAXY were more likely to have chest pain, but even in these younger patients, women were less likely to have chest pain than men (19% of women versus 13.7% for men, p = 0.03). In addition, women were more likely than men to have a non-ST-segment elevation myocardial infarction (37.5% vs 30.7%; p = 0.03). Upon multivariate analysis, women and patients with tachycardia were less likely to have chest pain. The absence of chest pain did not herald any change in the type or severity of the ACS.

The investigators said that there was no clear reason for the lower prevalence of chest pain in younger patients and that there is “no discernible pattern of non-chest pain symptoms” that can be used to help identify ACS in these patients. They conclude:

Strategies that explicitly incorporate standardized assessment of common non–chest pain symptoms or signs, such as weakness, shortness of breath, or tachycardia in emergency departments also need to be evaluated.

In an accompanying editorial, Akintunde Akinkuolie and Samia Mora write that the study “extends the prior literature by demonstrating that sex-specific differences in ACS presentation occur earlier in life.” They acknowledge that “diagnosis of any disease with a lower prevalence but higher mortality, such as coronary artery disease in younger women, is more challenging” and recommend that public health messages should “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.”