For Women with Acute MI, Atypical Presentations Are Typical

Abstract & Commentary

Source: McSweeney JC, et al. Women’s early warning symptoms of acute myocardial infarction. Circulation 2003;108:2619-2623.

The authors of this study sought to characterize symptoms women experience in association with an acute myocardial infarction (MI). Patients were identified using hospital discharge codes and were contacted by phone 4-6 months after their cardiac events. All patients underwent a cognitive screening questionnaire, followed by administration of a survey of MI-associated symptoms using a well-validated survey instrument. The patients were questioned about both acute symptoms at the time of the MI and prodromal symptoms, defined as new or different symptoms occurring intermittently before the MI and resolving after the event.

The authors screened 712 women during a three-year period and obtained complete data on 515 subjects. The mean age was 66 years and the vast majority of patients were white. When asked about acute symptoms, only 57% of women experienced any type of chest discomfort at the time of their MI. Other common acute symptoms were shortness of breath (58%), weakness (55%), unusual fatigue (43%), cold sweat (39%), and dizziness (39%). Seventy-eight percent reported prodromal symptoms, but only 30% reported any type of prodromal chest discomfort. The most frequent prodromal symptom was unusual fatigue (71%), while sleep disturbances, shortness of breath, indigestion, and anxiety each were more common than chest discomfort. Any prodromal fatigue or sleep disturbance usually was described as severe. The authors conclude that prodromal symptoms of MI are very common in women and may be important, yet easily overlooked, predictors of MI.

Commentary by David J. Karras, MD, FAAEM, FACEP

Any physician can recite the "typical" symptoms of MI. What many fail to realize, however, is these textbook scenarios were derived from studies of white, middle-aged males. MI presentations of women and ethnic groups remain poorly described. There is mounting evidence that among women with MI, atypical presentations are more characteristic than are typical presentations. The authors’ prior studies found that women surveyed immediately after an MI were likely to miss important prodromal symptoms. This recall bias actually was minimized by delaying the interview until the patient had time to reflect on the symptoms she experienced before the event and determine which symptoms were, in retrospect, transient.

There are a few take-home messages from this study. Foremost is the excellent description of MI-associated symptoms in women, and the finding that only a little more than half of women recall any sort of chest discomfort with their acute MI. Physicians, therefore, should set a low threshold for obtaining an electrocardiogram (ECG) in a woman reporting acute diffuse weakness, profound fatigue, or dizziness. The second point is that prodromal symptoms—notably unusual fatigue, insomnia, indigestion, and anxiety—are common in women during the month prior to their MI. These symptoms may be analogous to "anginal equivalents," and women should be questioned about these nonspecific findings during an emergency department evaluation for potential acute coronary syndrome.

Dr. Karras, Associate Professor of Emergency Medicine, Department of Emergency Medicine Temple University School of Medicine, Director of Emergency Medicine Research, Temple University Hospital, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.