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Original Investigation |

Sex-Specific Chest Pain Characteristics in the Early Diagnosis of Acute Myocardial Infarction

Maria Rubini Gimenez, MD1,2; Miriam Reiter, MD1; Raphael Twerenbold, MD1,3; Tobias Reichlin, MD1,4; Karin Wildi, MD1,5; Philip Haaf, MD1; Katharina Wicki, MD1; Christa Zellweger, MD1,5; Rebeca Hoeller, MD1,5; Berit Moehring, MD1,5; Seoung Mann Sou, MD1,5; Mira Mueller, MD1; Kris Denhaerynck, PhD1; Bernadette Meller, MD1; Fabio Stallone, MD1; Sarah Henseler, MD1; Stefano Bassetti, MD6; Nicolas Geigy, MD7; Stefan Osswald, MD1; Christian Mueller, MD1
[+] Author Affiliations
1Department of Cardiology, University Hospital Basel, Basel, Switzerland
2Servicio de Urgencias y Pneumologia, Ciber de Enfermedades Raras, Carles III Institute for Health, Hospital del Mar–Institut Municipal d’Investigació Mèdica, Barcelona, Spain
3Department of Cardiology, Universitäres Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
4Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
5Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
6Department of Internal Medicine, Medizinische Klinik, Kantonsspital Olten, Olten, Switzerland
7Department of Internal Medicine, Notfallstation, Kantonsspital Liestal, Liestal, Switzerland
JAMA Intern Med. 2014;174(2):241-249. doi:10.1001/jamainternmed.2013.12199.
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Importance  Whether sex-specific chest pain characteristics (CPCs) would allow physicians in the emergency department to differentiate women with acute myocardial infarction (AMI) from women with other causes of acute chest pain more accurately remains unknown.

Objective  To improve the management of suspected AMI in women by exploring sex-specific CPCs.

Design, Setting, and Participants  From April 21, 2006, through August 12, 2012, we enrolled 2475 consecutive patients (796 women and 1679 men) presenting with acute chest pain to 9 emergency departments in a prospective multicenter study. The final diagnosis of AMI was adjudicated by 2 independent cardiologists.

Interventions  Treatment of AMI in the emergency department.

Main Outcomes and Measures  Sex-specific diagnostic performance of 34 predefined and uniformly recorded CPCs in the early diagnosis of AMI.

Results  Acute myocardial infarction was the adjudicated final diagnosis in 143 women (18.0%) and 369 men (22.0%). Although most CPCs were reported with similar frequency in women and men, several CPCs were reported more frequently in women (P < .05). The accuracy of most CPCs in the diagnosis of AMI was low in women and men, with likelihood ratios close to 1. Thirty-one of 34 CPCs (91.2%) showed similar likelihood ratios for the diagnosis of AMI in women and men, and only 3 CPCs (8.8%) seemed to have a sex-specific diagnostic performance with P < .05 for interaction. These CPCs were related to pain duration (2-30 and >30 minutes) and dynamics (decreasing pain intensity). However, because their likelihood ratios were close to 1, the 3 CPCs did not seem clinically helpful. Similar results were obtained when examining combinations of CPCs (all interactions, P ≥ .05).

Conclusions and Relevance  Differences in the sex-specific diagnostic performance of CPCs are small and do not seem to support the use of women-specific CPCs in the early diagnosis of AMI.

Trial Registration  clinicaltrials.gov Identifier: NCT00470587

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Figure 1.
Positive Likelihood Ratios (LRs) for Chest Pain Characteristics (CPCs)

Positive LRs for the diagnosis of acute myocardial infarction (AMI) are represented as means (95% CIs) of each CPC in men and women.

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Figure 2.
Pain Severity in Men and Women

Pain severity in a box-and-whisker plot is quantified using a visual analog scale (VAS) in men and women with a diagnosis of acute myocardial infarction (AMI) or no AMI. Boxes represent interquartile ranges; the horizontal line in each box, the median; and whiskers, minimum and maximum values. P value indicates the comparison of the diagnostic accuracy of the VAS for AMI in women vs men.

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