In the Journal of Emergency Nursing form July of 2019 I found an article titled “Not Just Chest Pain: Presenting Symptoms of Acute Coronary Syndrome by Gender: A Research to Practice Summary. This article focuses on the difference of presentation of chest pain between men and women. The example given in the article relates to a triage nurse who is running or is out of room in a busy ER and has two patients presenting at triage with chest pain or discomfort. One is a man and one is a women, both of which are over 50 yrs of age and have unremarkable medical or surgical history. The man reports “crushing” chest pain of 9/10 that radiates to his left shoulder and began 30 minutes prior to arrival. The women standing next to him and is being triaged as well with reports of “heaviness” or “full” chest discomfort with a rating of 4/10 that has been going on for 4 hours with pain that radiates to her upper back and both arms with nausea, fatigue, and indigestion. Which of these two patients is more critical and needs attention first? I hope we can all agree that neither of them should be more important than the other. They should be equally important and be treated as quickly as possible with a 12 lead EKG looking for ST elevation or cardiac abnormalities in presenting rhythms or arrhythmia. Not to mention on the spot blood draw for quick troponin levels. But the point of the article is to establish the difference between genders and how they report, describe, and present at the ER with chest pain. What is found in this retrospective study and secondary analysis of 1,064 subjects is that “women tend to present with less distressing and less obvious ACS system clusters”. Men tend to present with a higher level of distress and is a predictor of ACS in men but not women. Women did not have a specific rule in factor for ACS and had “vague, nonspecific cardiac related symptom clusters”. What else is interesting is that 40% of women ruled in for ACS had the complaint of upper back pain, with 13% women complaining of jaw, neck, or throat pain. 47% of all subjects reported the main complaint as “chest pressure”. Men reported “mid chest pain” at 21.6% for rule-in of ACS. Both men and women shared one common symptom together and that was simultaneous arm and shoulder pain for rule-in ACS at 26.2%. Again, let me reiterate that the importance of receiving immediate care with rapid 12 lead EKG and blood draw checking cardiac enzymes is crucial for patients with any complaint of chest pain, chest pressure, chest discomfort, etc. The study is pointing out how genders present and report cardiac symptoms differently which can be used to hone in your assessment skills but should not be used to deprioritize mild cardiac symptoms or give less attention to vague nonspecific cardiac complaints that aren’t presenting in significant distress. Some factors to remember from the study are women who report “chest pressure” and upper back pain are strong indicators of ACS even when reported as mild. Men reporting “mid chest pain” with high levels of distress upon presentation are also strong indicators of ACS. It’s hard to pay attention to the study findings when you are trained to treat chest pain and cardiac symptoms all equally until ruled out.
References
Foley, A. L. (2019). Not Just Chest Pain: Presenting Symptoms of Acute Coronary Syndrome by Gender: A Research to Practice Summary. Journal of Emergency Nursing, 45(4), 462–464. doi: 10.1016/j.jen.2019.05.004
Josh
You are right on all accounts. So many people do not read the book on chest pain and AMI’s. To many times we as medical providers can get jaded on people coming in over and over with chest pain and it turning out not to be cardiac in origin. However, it is very important that if someone comes in complaining of chest pain, shortness of breath, dizziness, nausea, vomiting, pain or discomfort in the arms, back, neck, jaw, or stomach that we should consider it cardiac until proven otherwise (Harvard Health Publishing, 2020.) As you have I have experienced before it can be hard particularly with providers even after the test results have comeback for them to take some people seriously, that is why we must stand up and advocate for our patients.
Harvard Health Publishing. (2020, January 20). 5 overlooked symptoms that may signal heart trouble. Retrieved from https://www.health.harvard.edu/heart-health/5-overlooked-symptoms-that-may-signal-heart-trouble
Interesting article that you referenced in our discussion. I am drawn to the statement that says “Any symptoms that seem to be provoked by excretion and are relieved by rest may be heart related” (Harvard Health Publishing 2020). Some people may not present with classic signs of chest pain or even refer to the complaint as chest pain, but there are other questions and signs to look for when providers may be quick to under estimate or down play the non-classical signs of chest pain. The statement mentioned above is about excretion and rest is a great assessment tool for cardiac related issues that may not be as obvious as “chest pain” but just as dangerous. As you mentioned, this is why it is important to rule out cardiac not only in the classic signs but also the vague and non specific signs as well. Another way to accurately assess chest pain is to know non-cardiac sings. Non-cardiac symptoms can present acutely and strong at first and usually are not related to excretion. Pain in the chest that is constant and does not change, lasting for days or even weeks is highly not likely to be cardiac in origin. (Aroesty & Kannam, 2018)
References
Aroesty, J. M., & Kannam, J. P. (2018, April 27). Patient education: chest pain (beyond the basics). Retrieved from http://www.uptodate.com/contents/chest-pain-beyond-the-basics
Harvard Health Publishing. (2020, January 20). 5 overlooked symptoms that may signal heart trouble. Retrieved from https://www.health.harvard.edu/heart-health/5-overlooked-symptoms-that-may-signal-heart-trouble
This is a very interesting article and really important because women can present to the ED with vague symptoms and can lead to many being undiagnosed which can lead to higher risk of death. Its important for everyone to be aware that symptoms present differently in women. As health care workers we are able to provide public health messages to inform as many people as we can. In a study published by Jama Internal Medicine, “women in this study were more likely than men to report non-chest pain symptoms such as weakness, flushing, back pain, right arm/shoulder pain, nausea, vomiting, headache and neck or throat pain.” (Jama Internal Medicine, 2013) Receptionists in the ED should also be aware of this vital information so they can relay it to the triage nurse which can help the patient get quicker treatment.
Reference:
Sex differences in presentation of acute coronary syndrome. (2013, September 16). Retrieved from https://www.sciencedaily.com/releases/2013/09/130916161741.htm
jbonilla exactly! Compare the difference between a triage nurse who has received mandatory education on chest pain and the different types of symptoms and presentation between men and women to a triage nurse who has not had the education or lacks the knowledge of ACS symptoms and presentation. Sooner or later a situation will present itself where the difference of an experienced triage nurse and an inexperienced nurse will make a huge difference. Identifying rule in and rule out ACS takes the testing of blood bio markers. But what if there was a test that could rule in a rule out ACS at triage by a nurse? Such a test is being researched and studied to find out how well it is working. That test is the HE-MACS test. HE for history and electrocardiogram and MACS for Manchester Acute Coronary Syndrome. HE-MACS can be used without bio marking to determine ACS rule out of low risk patients presenting to the ED. A study of 796 patients was completed with HE-MACS effectively ruling out 10% of the patients immediately without blood biomarkers, only using history and ECG. 10% may seem like a small number but if you think about the amount of patients and it being the number one reason people visit the ER the number becomes significant and can take the burden off of an busy ER and facility over time(Alghamdi et al., 2019)
Reference
Alghamdi, A., Howard, L., Reynard, C., Moss, P., Jarman, H., Mackway-Jones, K., … Body, R. (2019). Enhanced triage for patients with suspected cardiac chest pain. European Journal of Emergency Medicine, 26(5), 356–361. https://doi.org/10.1097/mej.0000000000000575
That’s interesting to know that such test is being researched. I’m excited to see what happens with this test going forward. Thank you for sharing great information!
Chest pain is one of the most common complaints that is seen in the emergency department. Chest pain can be caused from many different things that may not be related to the heart. Patients used to be admitted for chest pain regardless if there was a cardiovascular event or not. Now patients are evaluated for immediate risk for a cardiac event. Patients are either admitted as an inpatient for a cardiac event, evaluated in the chest pain unit (CPU) for further work up, or dismissed home after an evaluation. The use of a CPU can reduce the amount of resources needed in the emergency department setting. A CPU can benefit a patient without adversely impacting long term outcomes. Do you think that a CPU is beneficial to patients?
Cullen, M. W., Reeder, G. S., Farkouh, M. E., Kopecky, S. L., Smars, P. A., Behrenbeck, T. R., & Allison, T. G. (2011). Outcomes in patients with chest pain evaluated in a chest pain unit: The Chest Pain Evaluation in the Emergency Room study cohort. American Heart Journal, 161(5), 871–877. doi: 10.1016/j.ahj.2011.02.008