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The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain

A report from the multicenter chest pain study group

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Abstract

Objective: To identify differences in the incidences of myocardial infarction in women and men with chest pain.

Design: Prospective multicenter cohort study.

Setting: Emergency rooms of three university and four community bospitals.

Patients: 7,734 emergency room patients with acute chest pain.

Measurements and main results: Myocardial infarction was diagnosed in 10% of the 3,896 women, compared with 19% of the 3,838 men, yielding an age-adjusted relative risk of myocardial infarction for women of 0.54 (95% confidence interval 0.48, 0.60). Physicians were equally adept at admitting women and men with myocardial infarctions, but men without myocardial infarction or unstable angina were significantly more likely to be admitted than were women without these diagnoses. Most clinical and electrocardiographic features indicating a risk of myocardial infarction were present in both women and men, but several high-risk features were less commonly present in women. After adjusting for the other factors that correlate with each patient’s probability of having acute myocardial infarction, the relative risk of myocardial infarction was the same in women as men when the emergency department electrocardiogram showed the classic changes associated with acute myocardial infarction, but the risk was 40% lower in women when such electrocardiographic changes were not present.

Conclusions: Clinical features that predict myocardial infarction in men predict myocardial infarction in women to a similar extent. However, female gender is associated with about a 40% lower rate of myocardial infarction except when classic electrocardiographic evidence is present on the emergency department electrocardiogram.

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References

  1. United States Department of Health and Human Services, National Center for Health Statistics. Advance report of final mortality statistics, 1983. Monthly Vital Statistics Report. Sept. 26, 1985;34(6;suppl 2):35.

    Google Scholar 

  2. Castelli WP. Epidemiology of coronary heart disease: the Framingham study. Am J Med. 1984;76:4–12.

    Article  PubMed  CAS  Google Scholar 

  3. Butler WJ, Ostrander LD, Carman WJ, Lamphear DE. Mortality from coronary heart disease in the Tecumseh study. Am J Epidemiol. 1985;121:541–7.

    PubMed  CAS  Google Scholar 

  4. Elveback LR, Connolly DC, Kurland LT. Coronary heart disease in residents of Rochester, Minnesota. II. Mortality, incidence and survivorship. 1950 – 1975. Mayo Clin Proc. 1981;56:665–72.

    PubMed  CAS  Google Scholar 

  5. Reunanen A, Suhonen O, Aomaa A, Knekt P, Pyorala K. Incidence of different manifestations of coronary heart disease in middle-aged Finnish men and women. Acta Med Scand. 1985;218:19–26.

    Article  PubMed  CAS  Google Scholar 

  6. Deubner DC, Wilkinson WE, Helms MJ, Tyroler HA, Hames CG. Logistic model estimation of death attributable to risk factors for cardiovascular disease in Evans County, Georgia. Am J Epidemiol. 1980;122:135–43.

    Google Scholar 

  7. Chaitman BR, Bourassa MR, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. 1981;64:360–7.

    PubMed  CAS  Google Scholar 

  8. Welch CC, Proudfit WL, Sheldon WC. Coronary arteriographic findings in 1,000 women under age 50. Am J Cardiol. 1975;35:211–5.

    Article  PubMed  CAS  Google Scholar 

  9. Hung J, Chaitman BR, Lam J, et al. Noninvasive diagnostic test choices for the evaluation of coronary artery disease in women: a multivariate comparison of cardiac fluoroscopy, excercise electrocardiography, and exercise thallium myocardial perfusion scintigraphy. J Am Coll Cardiol. 1984;4:8–16.

    Article  PubMed  CAS  Google Scholar 

  10. Detry JM, Kapita BM, Cosyns J, Sottiaux B, Brassuer LA, Rousseau MF. Diagnostic value of history and maximal exercise electrocardiography in men and women suspected of coronary heart disease. Circulation. 1977;56:756–69.

    PubMed  CAS  Google Scholar 

  11. Weiner DA, Ryan TJ, McCabe CH, et al. Correlations among history of angina, ST-segment response and prevalence of coronary artery disease in the coronary artery surgery study (CASS). N Engl J Med. 1979;301:230–4.

    Article  PubMed  CAS  Google Scholar 

  12. Barolsky SM, Gilbert CA, Faruqui A, Nutter DO, Schlant RC. Differences in electrocardiographic response to exercise of women and men: a non-Bayesian factor. Circulation. 1979;60:1021–7.

    PubMed  CAS  Google Scholar 

  13. Sketch MH, Mohiuddin SM, Lynch JD, Zencka AE, Runco V. Significant sex differences in the correlation of electrocardiographic exercise testing and coronary arteriograms. Am J Cardiol. 1975;36:169–73.

    Article  PubMed  CAS  Google Scholar 

  14. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med. 1979;300:1350–8.

    Article  PubMed  CAS  Google Scholar 

  15. Buonanno C. The female left ventricle: a pathophysiological entity? Int J Cardiol. 1983;4:382–6.

    Article  PubMed  CAS  Google Scholar 

  16. Goldman L, Weinberg M, Weisberg M, et al. A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med. 1982;307:588–96.

    Article  PubMed  CAS  Google Scholar 

  17. Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room: identification and examination of low risk patients. Arch Intern Med. 1985;145:65–9.

    Article  PubMed  CAS  Google Scholar 

  18. Lee TH, Weisberg M, Cook EF, et al. Evaluation of creatine kinase and creatine kinase-MB for diagnosing myocardial infarction: clinical impact in the emergency room. Arch Intern Med. 1987;147:115–21.

    Article  PubMed  CAS  Google Scholar 

  19. Lee TH, Rouan GW, Weisberg M, et al. Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 hours of hospitalization. Ann Intern Med. 1987;106:181–6.

    PubMed  CAS  Google Scholar 

  20. Lee TH, Rouan GW, Weisberg M, et al. Patients with acute myocardial infarction sent home from the emergency room: clinical characteristics and natural history. Am J Cardiol. 1987;60:219–24.

    Article  PubMed  CAS  Google Scholar 

  21. Rouan GW, Hedges JR, Toltzis R, et al. A chest pain clinic to improve the follow-up of patients released from an urban university teaching hospital emergency department. Ann Emerg Med. 1987;16:1145–50.

    Article  PubMed  CAS  Google Scholar 

  22. Beamer AD, Lee TH, Cook EF, et al. Diagnostic implications for myocardial ischemia of the circadian variation of the onset of chest pain. Am J Cardiol. 1987;60:998–1002.

    Article  PubMed  CAS  Google Scholar 

  23. Lee TH, Short LW, Brand DA, et al. Patients with acute chest pain who leave emergency departments against medical advice. Prevalence, clinical characteristics, and natural history. J Gen Intern Med. 1988;3:21–4.

    Article  PubMed  CAS  Google Scholar 

  24. Goldman L, Cook EF, Brand DA, et al. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med. 1988;318:797–803.

    Article  PubMed  CAS  Google Scholar 

  25. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. New York: Van Nostrand Reinhold, 1982;320–76.

    Google Scholar 

  26. Walker SH, Duncan DB. Estimation of the probability of an event as a function of several variables. Biometrika. 1967;54:167–9.

    PubMed  CAS  Google Scholar 

  27. Miettinen OS. Stratification by a multivariate confounder score. Am J Epidemiol. 1976;104:609–20.

    PubMed  CAS  Google Scholar 

  28. Pell S, Fayerweather WE. Trends in the incidence of myocardial infarction and in associated mortality and morbidity in a large employed population, 1957–83. N Engl J Med. 1985;312:1005–11.

    Article  PubMed  CAS  Google Scholar 

  29. Feinleib M. The magnitude and nature of the decrease in coronary heart disease mortality. Am J Cardiol. 1984;54:2C-5C.

    Article  PubMed  CAS  Google Scholar 

  30. Weinblatt E, Spiro S, Frank CW. Prognosis of women with newly diagnosed coronary disease—a comparison with course of disease among men. Am J Public Health. 1973;63:577–93.

    Article  PubMed  CAS  Google Scholar 

  31. Toffier GH, Stone PH, Muller JE, et al. Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women. J Am Coll Cardiol. 1987;9:473–82.

    Article  Google Scholar 

  32. Elveback LR, Connolly DC. Coronary heart disease in residents of Rochester, Minnesota. V. Prognosis of patients with CAD based on initial manifestation. Mayo Clin Proc. 1985;60:305–31.

    PubMed  CAS  Google Scholar 

  33. Kannel WB, Sorlie PD, McNamara PM. Prognosis after initial myocardial infarction: the Framingham study. Am J Cardiol. 1979;44:53–9.

    Article  PubMed  CAS  Google Scholar 

  34. Puletti M, Sunseri L, Curione M, Erba SM, Borgia C. Acute myocardial infarction: sex-related differences in prognosis. Am Heart J. 1984;108:63–6.

    Article  PubMed  CAS  Google Scholar 

  35. Gazes PC, Kitchell R, Meltzer LE, et al. Death rate among 795 patients in first year after myocardial infarction. JAMA. 1966;197:905–8.

    Google Scholar 

  36. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J. 1986;111:383–90.

    Article  PubMed  CAS  Google Scholar 

  37. Douglas PS. Gender, cardiology and optimal medical care. Circulation. 1986;74:917–9.

    PubMed  CAS  Google Scholar 

  38. Pozen MW, D’Agostino RB, Mitchell JB, et al. The usefulness of a predictive instrument to reduce inappropriate admissions to the coronary care unit. Ann Intern Med. 1980;92:238–42.

    PubMed  CAS  Google Scholar 

  39. Vlietstra RE, Frye RL, Kronmal RA, et al. Risk factors and angiographic coronary artery disease: a report from the coronary artery surgery study (CASS). Circulation. 1980;62:254–61.

    PubMed  CAS  Google Scholar 

  40. Kannel WB, McGee D, Gordon T. A general cardiovascular risk profile: the Framingham study. Am J Cardiol. 1976;38:46–51.

    Article  PubMed  CAS  Google Scholar 

  41. Fineberg HV, Scadden D, Goldman L. Care of patients with a low probability of acute myocardial infarction: cost effectiveness of alternatives to coronary care unit admission. N Engl J Med. 1984;310:1301–6.

    Article  PubMed  CAS  Google Scholar 

  42. Lee TH, Goldman L. The coronary care unit turns 25: historical trends and future directions. Ann Intern Med. 1988;108:887–94.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Clinical Epidemiology, Consolidated Department of Medicine, Brigham and Women’s and Beth Israel Hospitals, 75 Francis Street, 02115, Boston, MA

    Lee Goldman MD

Authors
  1. Moira A. Cunningham MD, MPH
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  2. Thomas H. Lee MD
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  3. E. Francis Cook ScD
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  4. Donald A. Brand PhD
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  5. Gregory W. Rouan MD
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  6. Monica C. Weisberg RN
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  7. Lee Goldman MD
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Additional information

Received from the Divisions of Clinical Epidemiology and General Medicine and the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; Yale—New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut; and the University of Cincinnati Hospital and University of Cincinnati, Cincinnati, Ohio.

Supported in part by grant No. 83102-2H from the John A. Hartford Foundation, New York, New York. Dr. Cunningham was an Andrew W. Mellon Foundation Fellow in Clinical Epidemiology. Dr. Lee is the recipient of a Public Health Service Clinical Investigator Award (HL01594-01) from the National Heart, Lung, and Blood Institute. Dr. Rouan is a Teaching and Research Scholar of the American College of Physicians and was supported in part by a grant to the Training Program in Clinical Effectiveness from the W.K. Kellogg Foundation.

The Multicenter Chest Pain Study Group includes Lee Goldman, MD (co-principal investigator), Thomas H. Lee, MD, E. Francis Cook, ScD, Monica Weisberg, RN, Karen Daley, RN, and Barbara C. Rosen, BA (Brigham and Women’s Hospital, Boston, Massachusetts; George Terranova, MD (site director), Carol Stasiulewicz, PA, and David Copen, MD (Danbury Hospital, Danbury, Connecticut; Alan Brandt, MD (site director), and Jay Walshon, MD (Milford Hospital, Milford, Connecticut); Louis Gottlieb, MD (site director), (St. Mary’s Hospital, Waterbury, Connecticut); Gregory Rouan, MD (site director), Jerris R. Hedges, MD, Robert Toltzis, MD, and Beth Goldstein-Wayne, RN (University of Cincinnati Hospital), Cincinnati, Ohio); Michael Kobernick, MD (site director), Carolyn Guidot, MD, and Daniel Jones, MPH (William Beaumont Hospital, Royal Oak, Michigan); and Donald A. Brand, PhD (co-principal investigator), Denise Acampora, MPH, John Mellors, MD, Kathryn Trainor, MS, Rita M. Jakubowski, RN, and Sue Healy, RN (Yale—New Haven Hospital, New Haven, Connecticut).

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Cunningham, M.A., Lee, T.H., Cook, E.F. et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain. J Gen Intern Med 4, 392–398 (1989). https://doi.org/10.1007/BF02599688

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