doi: 10.1161/01.CIR.0000116211.72297.C2
(Circulation. 2004;109:e59-e61.)
© 2004 American Heart Association, Inc.
AHA/NHLBI Conference Proceedings |
Women’s Ischemic Syndrome Evaluation
Current Status and Future Research Directions: Report of the National Heart, Lung and Blood Institute Workshop: October 2–4, 2002: Section 6: Key Messages About Acute Ischemic Heart Disease in Women and Recommendations for Practice
Key Words: AHA Scientific Statements • women • ischemia • cardiovascular diseases
Numerous studies have found that women have poorer outcomes than men after a diagnosis of acute coronary syndrome (ACS), including myocardial infarction (MI) and unstable angina. Explanations have included gender differences in pathophysiology and response to treatment, prehospital delays in symptom recognition and action, and gender differences in emergency medical services (EMS) evaluation and treatment. Recent reports of similar or better outcomes in women with ACS compared with men suggest that pathophysiological differences can be overcome with early, aggressive therapy.1,2 Therefore, a focus on improving symptom recognition by women and their healthcare providers and on reducing prehospital delay has the potential to increase the proportion of women with ACS who are eligible for this aggressive treatment.
The REACT Study and Presenting Symptoms in Women
The National Heart Attack Alert Program (NHAAP) was launched by the National Heart, Lung and Blood Institute in 1991 to reduce death and disability from acute MI by reducing time to treatment through education of healthcare providers, patients, and the public about early recognition and response to acute MI symptoms.3 As part of this effort, community intervention research was designed in the form of the Rapid Early Action for Coronary Treatment (REACT) study, a randomized controlled community trial testing multistrategy campaigns to reduce patient delay in seeking care for heart attack symptoms.4 One goal of the study was to develop insights into demographic trends and message components with regard to women and their understanding of, and response to, messages about heart disease and heart attack. Conducted from 1994 to 1998 in 20 communities assigned as pairs to receive an intervention or act as reference, the study arrived at several important conclusions. There was a strong trend of reduced patient delay in seeking care for heart attack symptoms; this was evident in both reference (-6.8%) and intervention communities (-4.7%) (P=NS). Campaigns did not accelerate the difference in trend, but intervention communities experienced a significant 16% increase in EMS use, compared with a 3% decrease in reference communities.5 Women did not differ significantly from men on most study measures, and delay was not significantly different between men and women either before or after intervention.6 Women and men had similar knowledge of heart attack symptoms and intention to respond quickly. The REACT study suggested that although men and women do not differ significantly in knowledge, beliefs, or behavior with regard to heart attack symptoms and response, differences in socialization, cultural background, and social setting may influence women to be more attracted to some interventions and messages than others.
Recognition of symptoms by both women and healthcare providers remains problematic. Women report symptoms differently and have enhanced pain perception compared with men. These differences may be due to many difficult-to-measure factors, including gender-specific prior expectations, varying estimates of personal risk, and gender differences in pain threshold or communication style. If women believe that severe chest pain is a necessary hallmark of MI, the problem of late treatment of MI is compounded because a substantial minority of patients with MI present with no chest pain whatsoever or only mild chest pain.7 REACT investigators found, in focus groups conducted as formative evaluation, that the expected symptoms of heart attack were unrealistic and contributed to delay. Both men and women expected a "Hollywood" heart attack, during which a person suddenly clutches his chest and drops to the ground.8
Limited data exist about possible gender differences in symptoms of ACS. Past studies have differed substantially in methodology, inclusion and exclusion criteria, and study population, as well as in their conclusions.6,7,9–11 For example, studies that had chest pain as an inclusion criterion6 eliminated the 20% to 40% of individuals who have MI or ACS without chest symptoms. Most relied on retrospective chart review, where lack of standardization in eliciting and recording symptoms limits detail in terms of being able to differentiate the presenting symptom from minor or associated ones and discerning the severity, duration, and number of symptoms. Real differences in the way that men and women experience and interpret their cardiac symptoms and therefore how they convey this information to their healthcare providers may not be captured in these analyses. Despite these limitations, most studies do not show fundamental gender differences in the types of presenting symptoms, with women experiencing a constellation of reported symptoms similar to those experienced by men, primarily focused on chest pain, arm pain, dyspnea, sweating, and nausea, with varying differences in the frequency of nonchest pain symptoms.6,12
NHAAP Heart Attack Warning Signs Messages Targeting Women
Women need to better understand that MI may manifest itself with many symptoms in addition to chest pain, pressure, or discomfort, and that they are not necessarily likely to experience dramatic, severe, or expected symptoms. The current NHAAP MI symptom list for women is acceptable, although the message should be periodically revisited and revised as the science dictates. Public education literature should directly link the symptom list to the message that symptoms may not be dramatic or sudden. The range of potential symptoms should be described, and it should be clear that multiple or alternative symptoms may also occur in ACS. The term "atypical" should be abandoned in describing symptoms of ACS in women because data suggest that a myriad of symptoms occur in both men and women. Education about the benefits of early EMS activation is critical because many women still do not perceive that rapid action actually saves lives. Messages and techniques that are effective in getting these messages across will differ according to the age, socioeconomic status, and cultural background of individual women. These differences in how and where population subgroups get health information and the specific vehicle or channel of exposure influence the type of message each subgroup receives, and the challenge is to determine the best "fit" for each subgroup in the community. Messaging efforts should build on and expand the National Heart, Lung and Blood Institute’s existing efforts, the "Act in Time" and "Heart Truth" campaigns, and expand to include additional partners and various community gender- and race/ethnicity-specific initiatives to target individuals and groups that are not currently being impacted.
Healthcare Providers and Diagnosis
A better understanding of the full spectrum of the pathophysiological basis of ACS in women is necessary to optimize treatment recommendations and to fully reap the benefits of earlier recognition of symptoms. This should include research and practice initiatives such as determination of institutional and individual missed-diagnosis rates; healthcare provider education on avoiding stereotypes and using technology appropriately; and translational research to help implement decision-making tools. Better communication and systemization of messages about strategies proven to aid identification and treatment of women with ACS should be used. The education efforts should include prehospital, community-based, and nonphysician healthcare professionals in addition to EMS staff.
Future Research
To fully discern the range of symptoms in men and women diagnosed with ACS and MI, a more standardized, prospective approach to collection of data is required. Future studies should include all patients with ACS regardless of symptoms and context of initial evaluation (whether by EMS, in the outpatient setting, or in the home) and should include those who die before admission, those who are inappropriately dismissed after evaluation, and those whose diagnosis is not suspected at admission but is later diagnosed. Standardization of eliciting and recording symptoms is critical, as are careful determination of symptom onset and duration and delineation of the chief complaint from associated symptoms.
Real differences in the way that men and women experience and interpret their cardiac symptoms, and therefore how they convey this information to their healthcare providers, should be investigated. Differences in the perception and reporting of symptoms of ACS by women and men may be due to many difficult-to-measure factors, including gender-specific prior expectations of symptomatology, varying estimates of personal risk, or gender differences in pain threshold or communication style. Every effort to account for these factors should be made.
Prodromal symptoms, defined as those symptoms that occur in the hours, days, or weeks before the event, should be elucidated to better assess additional messages. Correlating age and menstrual status at ACS presentation with symptoms is critical because age- and/or menopausal status–related pathophysiological differences likely exist but have not been fully defined. These findings need to be correlated with the pathophysiological events occurring immediately before and during ACS.
Section 6 Recommendations
- Patient awareness of symptoms in women. Current public health ACS messaging is associated with modestly improved trends in reduced delay to presentation of ACS. New studies are needed, but current data are supportive of current public health ACS messaging continuation.
- Recognition of symptoms by both women and healthcare providers. Further research is needed in the areas of (a) prodromal syndromes; (b) pretesting of public messages, particularly with regard to gender and minority differences; and (c) dissemination of existing information and critical pathway systems to healthcare providers.
- NHAAP heart attack warning sign messages targeting women. The current NHAAP MI symptom list is acceptable for both men and women, although the message should be periodically revisited and revised as the science dictates. Public education literature should directly link the symptom list to the message that symptoms may not be dramatic or sudden.
- Healthcare providers and diagnosis. Better communication and systemization of messages about strategies proven to aid identification and treatment of women with ACS should be used. The education efforts should include prehospital, community-based, and nonphysician healthcare professionals in addition to EMS staff.
- Future research. A better understanding of the full spectrum of the pathophysiological basis of ACS in women is necessary to optimize treatment recommendations and to fully reap the benefits of earlier recognition of symptoms. This should include research and practice initiatives, such as determination of institutional and individual missed-diagnosis rates; healthcare provider education on avoiding stereotypes and using technology appropriately; and translational research to help implement decision-making tools.
Footnotes
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This paper represents a summary of a scientific conference sponsored by the National Heart, Lung and Blood Institute on October 2–4, 2002. The opinions expressed in this paper are those of the authors and do not necessarily represent those of the editor or the American Heart Association.
The publication of this statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 5, 2003. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0277. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail kgray@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
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