Sex Differences in Acute Coronary Syndrome Symptom Presentation in Young Patients

Study Questions:

Are there sex-related differences in acute coronary syndrome (ACS) presentation?


Data for the present analysis were collected as part of the GENESIS PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) study, a prospective cohort of 1,015 patients (30% women) 55 years or younger, enrolled between January 2009 and September 2012, from 26 sites predominately in Canada. Symptoms were measured with the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, which was administered during hospitalization.


The median age for both sexes was 49 years. More than one half of women enrolled in the study were premenopausal or perimenopausal, and 40% were obese. 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) and present without chest pain compared with men (19.0% vs. 13.7%; 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. 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% confidence interval [CI], 1.23-3.11; p = 0.005) and tachycardia (OR, 2.07; 95% CI, 1.20-3.56; p = 0.009) were independently associated with ACS presentation without chest pain. 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.


This study suggests that women presenting with ACS experience chest pain as a symptom. However, more women than men experience other symptoms. Educating women and their clinicians about both atypical and typical symptoms for ACS is recommended.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging, Hypertension

Keywords: Depression, Myocardial Infarction, Acute Coronary Syndrome, Coronary Stenosis, Coronary Angiography, Chest Pain, Canada, Hypertension, Diabetes Mellitus

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