Among younger patients with acute coronary syndromes (ACS), chest pain is the most common presenting symptom among men and women. However, women are significantly more likely than men to present without chest pain, according to a study published Sept. 16 in JAMA Internal Medicine .

This prospective cohort study analyzed presenting symptoms in 1,015 patients 55 years or younger hospitalized for ACS and enrolled the GENESIS PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) study between January 2009 and September 2012. A majority of patients presented with chest pain, but 19 percent of women and 13.7 percent of men did not (p=0.03).

Results showed that young women without chest pain had fewer symptoms than women with chest pain, and more symptoms than men without chest pain. Weakness, feeling hot, shortness of breath, cold sweats and pain in the left arm or shoulder were the most common symptoms reported by patients without chest pain. Of these, only cold sweats and weakness were associated with disease severity. In multivariate analysis, only female gender (odds ratio [OR], 1.95 [95 percent CI, 1.23-3.11]; P=0.005) and tachycardia (OR, 2.07 [95 percent CI, 1.20-3.56]; P=0.009) were independently associated with ACS without chest pain, and there was no clear pattern of symptoms in patients without chest pain.

"Our findings indicate that chest pain is the predominant symptom that should direct diagnostic evaluation for ACS and be used for public health messages for young women and men, similar to older patients. However, health care providers should still maintain a high degree of suspicion for ACS in young patients, particularly women," wrote the investigators. "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 O. Akinkuolie, MBBS, MPH, and Samia Mora, MD, MHS, FACC, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, wrote that the study "extends the prior literature by demonstrating that sex-specific differences in ACS presentation occur earlier in life."

"Future research aimed at elucidating the basis for sex differences in ACS symptoms and outcomes is warranted,” they wrote. “Meanwhile, it is prudent for public health messages to 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."

Keywords: Odds Ratio, Health Personnel, Acute Coronary Syndrome, Multivariate Analysis, Chest Pain, Sweat, Shoulder, Pain, Dyspnea, Cold Temperature, Tachycardia