Sex Differences in Acute Coronary Syndrome Symptom Presentation in Young Patients

Study Questions:

Do symptoms differ by gender among younger patients presenting with acute coronary syndromes (ACS)?


Data from the GENESIS PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) study, a prospective cohort of patients hospitalized for ACS (in 26 sites), were used for this study. Women and men 55 years of age or younger were included, from January 2009 to September 2012. Symptoms were assessed via the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, which assesses the presence and intensity of 37 acute myocardial infarction symptoms present from onset to time of diagnosis. The survey was administered during hospitalization.


Of the 1,174 eligible patients who were approached for study enrollment, 10% of women and 18% of men declined participation in the study, resulting in a final participation rate of 86% (n = 1,015). The median age of women and men was 49 years, 40% were obese, and more than half of women enrolled in the study were premenopausal or perimenopausal. Women were more likely than men to have hypertension, diabetes, and depression. Women were more likely to have non–ST-segment elevation myocardial infarction (37.5 vs. 30.7; p = 0.03). Among those who underwent coronary angiography, men were more likely to have >50% coronary stenosis in at least one vessel than women. There was no significant sex difference in prevalence of triple-vessel disease or presence of left main disease. Of all patients in the ACS cohort, 96.6% of men and 97.0% of women reported at least one symptom: either chest pain, shortness of breath, or one of the non–chest pain symptoms included in the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey. Women were more likely to present without chest pain compared with men (19.0% vs. 13.7%; p = 0.03). Patients without chest pain reported fewer symptoms overall and no discernable pattern of non–chest pain symptoms was found. In the multivariate model, being a woman (odds ratio [OR], 1.95 [95%CI, 1.23-3.11]; P = .005) and tachycardia (OR, 2.07 [95%CI, 1.20-3.56]; P = .009) were independently associated with ACS presentation without chest pain. The most common non–chest pain symptoms in both sexes regardless of ACS type were weakness, feeling hot, shortness of breath, cold sweats, and pain in the left arm or shoulder. Patients without chest pain did not differ significantly from those with chest pain in terms of ACS type, troponin level elevation, or coronary stenosis.


The investigators concluded that chest pain was the most common ACS symptom in both sexes. Although women were more likely to present without chest pain than men, absence of chest pain was not associated with markers of coronary disease severity. Strategies that explicitly incorporate assessment of common non–chest pain symptoms need to be evaluated.


These data support the observation that many women do experience chest pain at the time of an ACS event; however, among patients who are without chest pain, there is a higher prevalence of women. The present study observed that such patterns exist among younger ACS patients. Findings such as these from the GENESIS PRAXY study assist clinicians and public health professions to education women in the signs and symptoms of ACS.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging, Hypertension

Keywords: Depression, Odds Ratio, Myocardial Infarction, Acute Coronary Syndrome, Stroke, Women, Ischemic Attack, Transient, Dyspnea, Cold Temperature, Tachycardia, Prevalence, Coronary Angiography, Coronary Stenosis, Chest Pain, Hypertension, Diabetes Mellitus, Troponin

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