Gender differences in atypical chest pain presentation among cardiac patients

Demographic Perception Survey of Patients with Atypical CP Who Present to Cardiac Care Doctors and Patient Outcomes

This study intends to examine gender differences in individuals who present to cardiac doctors with chest pain and specifically, atypical chest pain in women. The work of Debra L. Issac (2000) states that over the past ten years "there has been increasing awareness of both the importance of CAD in women and of the significant differences between men and women who have the disease. Potential gender biases, both within the medical community and within the general population of women themselves also have been identified. These gender differences and biases have the potential to influence investigation and management of suspected or confirmed CAD in women, and should be taken into consideration when faced with a woman with potential cardiovascular disease." (p.157)

Issac also states that chest pain in women is "common and often non-ischemic. Conversely, the presentation of atypical and non-chest pain CAD, including acute myocardial infarction (MI), is more common in women than men." (2000, p.158) Isaac reports that women's presenting symptoms are different from those of men "even in the setting of acute MI…women are more likely to experience back, jaw, abdominal and neck pain, nausea, shortness of breath and congestive symptoms, while they are less likely to complain of diaphoresis." (2000, p.158) In addition, women are reported to have "an increased incidence of silent or unrecognized MI, as compared with men." (Isaac, 2000, p. 158)

Chest pain in women is reported to account for "a significant number of visits to primary-care physicians and subsequent referral to cardiovascular specialists." (Isaac, 2000, p.158) Additionally reported is that women are "much more likely to present with angina than MI as their initial symptom of CAD." (Isaac, 2000, p.158)

Statement of the Problem

Gender differences have the potential to influence the investigation and the management of coronary artery disease in women therefore, it is necessary that physicians recognize these differences when women present with atypical chest pain.

Purpose of the Study

The purpose of this study is to investigate gender differences in cardiovascular disease.

Research Questions

The research questions addressed in this study include those as follows:

(1) What gender differences exist in those presenting to cardiac doctors with chest pain?

(2) What is atypical chest pain and what are the causes of atypical chest pain?

Assumptions

The assumptions of this study relate to the truthfulness of the responses provided by participants as this research assumes that the participants have truthfully answered the questions posed in the survey.

Significance of Contribution to Nursing

The significance of the contribution of this work to nursing is the additional knowledge that will be added to the already existing knowledge base in this area of study.

Summary

Chapter 2, which follows, contains a review of the literature in this area of study while chapter three contains the methodology of this study.

Demographic Perception Survey of Patients with Atypical CP Who Present to Cardiac Care Doctors and Patient Outcomes

Research Proposal

Chapter II

Review of the Literature

The work of Zbierajewski-Eischeid (2009) entitled "Myocardial Infarction in Women: Promoting Symptom Recognition, Early Diagnosis and Risk Assessment" reports that even with "national campaigns to help increase awareness, most people do not realize that heart disease is now the leading cause of death for women. Women experiencing an acute cardiac event often do not recognize the symptoms or are misdiagnosed by healthcare providers because of atypical symptom presentation. This can lead to a significant delay in treatment and a less desirable recovery outcome. To help promote early identification of cardiac risk and cardiac events, this article highlights the range of symptom presentation in women with myocardial infarction and focuses on how advanced clinical nurses can increase nurses' and the public's understanding of this disease in women." (Zbierajewski-Eischeid, 2009)

It is reported that approximately 267,000 women "die annually from a myocardial infarction (MI) and each year, as many as 9,000 women who have had an MI are younger than 45 years." (Zbierajewski-Eischeid, 2009) Cayley (2005) reports that chest pain "presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia." (Cayley, 2005)

Key clinical recommendations are inclusive of the following:

(1) Determination of whether chest pain is angina, atypical angina or nonanginal is recommended to help determine a patient's cardiac risk;

(2) The Rouan decision rule is recommended to help predict which patients are at a higher risk of MI;

(3) A Wells score of less than 2 plus normal D-Dimer assay should rule out PE;

(4) In patients with an abnormal D-Dimer assay or a Wells score including moderate to high risk, helical CT and lower extremity venous ultrasound examination should be used to rule in or rule out PE;

(4) The Diehr diagnostic rule is recommended to predict the likelihood of pneumonia based on clinical findings;

(5) Patients should be screened for panic disorder using two set questions;

(6) Patients presenting with chest pain should have an ECG evaluation for ST segment elevation, Q waves, and conduction defects. Results should be compared with previous tracings;

(7) Serum troponin-level testing is recommended to aid in the diagnosis of MI and help predict the likelihood of death or recurrent MI within 30 days.

(8) Patients with chest pain and a negative initial cardiac evaluation should have further testing with stress ECG, perfusion scanning, or angiography depending on their level of risk. (Cayley, 2005)

The epidemiology of chest pain in primary care and emergency department settings is shown in the following table labeled Figure 1 in this study.

Figure 1

Epidemiology of Chest Pain in Primary Care and Emergency Department Settings

Primary care in United Stat Primary care in Europe Emergency Department

Musculoskeletal condition 36-20 7

Gastrointestinal disease 19-10 3

Serious cardiovascular disease 16-13 54

Unstable coronary artery disease 10 8 13

Unstable coronary artery disease 1.5-13

Psychosocial or psychiatric disease 8-17 9

Nonspecific chest pain 16-11 15

Psychosocial or psychiatric disease 8-17 9

Pulmonary disease 5-20 12

Nonspecific chest pain 16-11 15

Source: Cayley (2005)

Clarification of whether chest pain is typical angina pain is based upon whether pain is: (1) substernal; (2) provoked by exertion; or (3) relieved by rest or nitroglycerine. Typical angina pain has all three characteristics while atypical angina pain has only two of the three characteristics and nonanginal pain only has one characteristic. (Cayley, 2005)

Caley (2005) reports that heart failure "alone is an uncommon cause of chest pain, it may accompany acute coronary syndrome, valvular disease or MI. A displaced apical impulse and a history of MI also support this diagnosis. Almost all patients with heart failure have exceptional dyspnea, so that absence of exertional dyspnea is helping in ruling out this diagnosis." It is reported that two questions that are quite simply are highly sensitive in screening for panic disorder as follows: (1) In the past six months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy?"; and (2) "In the past six months, did you ever have a spell or an attack when for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath? (Cayley, 2005) Yes on either item results in a positive screen while no on each question makes panic disorder unlikely. (Cayley, 2005)

Another cause for chest pain is gastrointestinal disease however it is stated that the history and physical examination are "relatively inaccurate for ruling in or ruling out serious gastroindigestion pathology and it is important first to rule out immediately life-threatening cardiovascular and pulmonary causes of chest pain." (Cayley, 2005)

Methodology

The methodology utilized in this study will be one of a qualitative nature and one, which involves examination of the literature on women presenting with atypical chest pain to cardiac doctors.

Introduction

Individuals who present and are diagnosed with atypical chest pain should get a complete physical examination, ECG and undergo exercise stress testing as well as other testing. The research questions addressed in this study include those as follows: (1) "What factors deter African-American women from seeking breast cancer screening? (2) What can doctors and staff in medical and health care facilities do to encourage African-American women to seek out breast cancer scanning?

Research design

The proposed research study is one that is qualitative in nature and that seeks to understand the diagnosis of chest pain in women presenting to cardiac doctors. According to Kleen (1995) "Case studies using qualitative methods are most valuable when the question being posed requires an investigation of a real life intervention in detail, where the focus is on how and why the intervention succeeds or fails, where the general context will influence the outcome and where researchers asking the questions will have no control over events. As a result, the number of relevant variables will be far greater than can be controlled for, so that experimental approaches are simply not appropriate."

Sample

The sample in this study is a group of women presenting with atypical chest pain to cardiac doctors.

Instruments

The instrument utilized in this study is that of a survey which will be distributed to the individuals/participants in this study to be answered and returned to the researcher for analysis.

Procedure

Upon receipt of approval for the research study, there will be a sampling of approximately 80 subjects who have presented to their doctor with atypical chest pain. Sampling will be accomplished through random selection patients and specifically women presenting to cardiac doctors with atypical chest pain.

Data Analysis

Data analysis will take place through qualitative analysis of the answers provided by participants in this research study. Qualitative research is interpretive and descriptive in nature. Qualitative research is such "generally involves an iterative, spiraling, or cyclical process that proceeds from more general to more specific observations. Data analysis may begin informally during interviews or observations and continue during transcription, when recurring themes, patterns, and categories become evident. Once written records are available, analysis involves the coding of data and the identification of salient points or structures. Data reduction may include quantification or other means of data aggregation and reduction, including the use of data matrices, tables, and figures." (Miles & Huberman, 1994 in TESOL, 2011)