May 4, 2020Open Access

Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta‐analysis

RORoos E. M. van OosterhoutUtrecht University ABAnnemarijn R de BoerUtrecht University AMAngela H.E.M. MaasPreventive Cardiology

Structured PICO

Does female sex alter symptom presentation in patients with acute coronary syndromes compared to male sex?

Population

Patients with confirmed acute coronary syndromes (ACS) from 27 studies

Intervention

Female sex

Comparator

Male sex

Outcome

Symptom presentation (presence of specific symptoms including chest pain, pain between shoulder blades, nausea or vomiting, shortness of breath, and diaphoresis)patient reported

While women with ACS are more likely than men to present with symptoms like back pain and nausea, chest pain remains the most common symptom for both sexes, suggesting the terms 'typical' and 'atypical' symptoms should be abandoned.

Abstract

Background Timely recognition of patients with acute coronary syndromes (ACS) is important for successful treatment. Previous research has suggested that women with ACS present with different symptoms compared with men. This review assessed the extent of sex differences in symptom presentation in patients with confirmed ACS. Methods and Results A systematic literature search was conducted in PubMed, Embase, and Cochrane up to June 2019. Two reviewers independently screened title-abstracts and full-texts according to predefined inclusion and exclusion criteria. Methodological quality was assessed using the Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% CI of a symptom being present were calculated using aggregated and cumulative meta-analyses as well as sex-specific pooled prevalences for each symptom. Twenty-seven studies were included. Compared with men, women with ACS had higher odds of presenting with pain between the shoulder blades (OR 2.15; 95% CI, 1.95-2.37), nausea or vomiting (OR 1.64; 95% CI, 1.48-1.82) and shortness of breath (OR 1.34; 95% CI, 1.21-1.48). Women had lower odds of presenting with chest pain (OR 0.70; 95% CI, 0.63-0.78) and diaphoresis (OR 0.84; 95% CI, 0.76-0.94). Both sexes presented most often with chest pain (pooled prevalences, men 79%; 95% CI, 72-85, pooled prevalences, women 74%; 95% CI, 72-85). Other symptoms also showed substantial overlap in prevalence. The presence of sex differences has been established since the early 2000s. Newer studies did not materially change cumulative findings. Conclusions Women with ACS do have different symptoms at presentation than men with ACS, but there is also considerable overlap. Since these differences have been shown for years, symptoms should no longer be labeled as "atypical" or "typical."

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