Sex-specific chest pain traits may offer little diagnostic value

Assessing chest pain based on female-based characteristics is not a useful diagnostic tool for an acute MI (AMI), a study published online Nov. 25 in JAMA Internal Medicine found. The accuracy of most chest pain characteristics (CPCs) in men and women were low overall, and the likelihood of most CPCs was similar in both sexes.

While the difference in MI symptoms between men and women has received a lot of attention, “the important unanswered clinical question is whether detection of sex-specific CPCs is possible to allow physicians in the ED [emergency department] to differentiate women with AMI more accurately from women with other causes of acute chest pain,” wrote the authors, led by Maria Rubini Gimenez, MD, of the University Hospital Basel in Basel, Switzerland.

The Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) study is ongoing at nine centers in Europe. Its goal is to help improve early diagnosis of AMI. Researchers enrolled 2,475 men and women treated for acute chest pain in EDs between 2006 and 2012. They defined 34 CPCs, among them location, pain quality, onset, duration and aggravating factors. AMI was defined by myocardial necrosis along with ischemia, and two independent cardiologists verified diagnosis.

There were 143 women and 369 men diagnosed with AMI. Men and women reported having most CPCs with about equal frequency, but some were more common in women—pressure-type pain, attendant dyspnea, pain made worse by palpation, pain radiating to the throat or back and pain lasting longer than 30 minutes.

But only three of the 34 CPCs had statistically different likelihood ratios between men and women and were helpful for diagnosis. These CPCs were related to pain duration and pain dynamics. Pain lasting between two and 30 minutes decreased the likelihood of an AMI diagnosis in women, but increased it in men. Pain lasting longer than 30 minutes increased the likelihood of an AMI in women, but not in men. Pain that decreased in intensity decreased the likelihood of an AMI diagnosis in women, but increased the likelihood in men.

However, the authors noted that since the likelihood ratios were close to one, they “did not seem clinically helpful.”

The authors also acknowledged that among the limitations was the exclusion of all possible symptoms, including nausea, vomiting and sweating.

But they argued that “[d]ifferences 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.”