不能依据胸痛特征识别女性心肌梗死

《美国医学会杂志-内科学》(JAMA Internal Medicine)11月25日在线发表的一项研究显示，急性心肌梗死(MI)相关胸痛的提示性特征具有性别差异，但在诊断中尚不足以据此确定哪些胸痛女性正在发生心脏病发作。在到急诊科就诊的急性胸痛和疑似MI的患者中，发现34种可能与胸痛相关的特征中有11种特征存在显著性别差异。但这些疼痛特征在临床上均无助于在女性中区别MI与其他非MI原因的胸痛(JAMA Intern. Med. 2013 Nov. 25[doi: 10.1001/jamainternmed.2013.12199])。

这项目前正在进行的国际APACE研究由巴塞尔大学医院心脏病科的Maria Rubini Gimenez医生及其同事开展，目的是确定性别特异性胸痛特征是否可用于区别急性MI女性与其他原因(不稳定型心绞痛、心脏性但非冠状动脉疾病如快速性心律失常或心包心肌炎、或非心脏性胸痛)所致胸痛的女性。研究对象是6年内因提示急性MI的症状而到瑞士、西班牙和意大利9个医学中心就诊的2475例连续患者，其中796例为女性，1679例为男性。

除了对所有这些患者进行常规临床评估之外，还评估34种胸痛特征，包括严重程度、位置(胸部中间、左侧、右侧、乳头下、或乳头上)、疼痛区域大小(直径＞或＜3 cm)、疼痛质量(压迫、刺痛、灼热、疼痛，以及与呼吸困难相关或无关)、放射模式、发作、持续时间、动态(胸痛当前是否增加、减少或稳定)、加重或诱发因素(疼痛是否因劳作、体位改变、咳嗽、触诊、或情绪应激而加重)和缓解因素(如硝酸盐治疗)。

共143例女性(18%)和369例男性(22%)患有急性MI。34种胸痛特征中的大部分在女性中的发生频率与在男性中相似。仅11种特征存在显著性别差异。与男性相比，女性明显更常出现以下情况：疼痛严重程度较高、压迫样疼痛、伴随呼吸困难、触诊加重的疼痛、疼痛放射至喉咙或背部、疼痛突然发作、疼痛持续时间＞30分钟。此外，女性明显较少出现以下情况：无疼痛放射、放射至右侧、疼痛持续时间较短。

对仅患有急性MI的患者进行分析发现，34种胸痛特征中仅5种特征存在显著性别差异。与急性MI男性相比，急性MI女性较少发生：疼痛放射至右臂/肩、疼痛持续时间短、疼痛随时间推移而减少。急性MI女性更常发生：疼痛放射至背部、疼痛持续时间≥30分钟。

当分析转向于可区分急性MI与其他原因的胸痛特征时，34种特征中仅3种(8%)有助于性别特异性诊断。胸痛持续时间仅2~30分钟的话，女性诊断MI的几率轻微降低，但男性诊断MI的几率轻微增加。疼痛持续时间＞30分钟的话，女性诊断MI的几率轻微增加，但男性诊断MI的几率不受影响。疼痛强度降低的话，女性诊断MI的几率轻微降低，但男性诊断MI的几率轻微增加。然而，这3种胸痛特征均不被认为在临床上有助于确立MI诊断。

研究者表示，研究结果证实单纯依靠胸痛特征不足以诊断急性MI，通常需要联合心电图和心肌肌钙蛋白检测结果来诊断急性MI。鉴于这些特征的性别特异性诊断性能方面的差异较小，研究结果不支持使用女性特异性胸痛特征来进行女性急性MI的早期诊断。

该研究获瑞士国立科学基金会等机构支持。Gimenez医生声明无经济利益冲突。其他研究者声明与8sense、雅培、美艾利尔等公司存在联系。

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By: MARY ANN MOON, Cardiology News Digital Network

The telltale traits of acute myocardial infarction–associated chest pain may differ in women and men, but they aren’t diagnostically telling enough to determine which women with chest pain are having a heart attack, according to a report published online Nov. 25 in JAMA Internal Medicine.

In a large international study, 11 of 34 possible traits related to chest pain were found to be significantly different in women compared with men who presented to an emergency department with acute chest pain and possible MI. But none of these pain characteristics was clinically useful in distinguishing MI from other, non-MI causes of chest pain in women, said Dr. Maria Rubini Gimenez of the cardiology department, University Hospital Basel (Switzerland), and her associates (JAMA Intern. Med. 2013 Nov. 25 [doi: 10.1001/jamainternmed.2013.12199]).
 
The investigators performed the ongoing APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation) study to determine whether sex-specific chest pain characteristics could be used to differentiate women who had acute MI from women who had other causes of chest pain, including unstable angina, cardiac but noncoronary disease such as tachyarrhythmia or perimyocarditis, or noncardiac chest pain.

They assessed 2,475 consecutive patients – 796 women and 1,679 men – who presented with symptoms suggestive of acute MI to nine medical centers in Switzerland, Spain, and Italy during a 6-year period.

In addition to receiving a routine clinical assessment, all of the study’s patients were assessed for 34 characteristics of chest pain, including severity, location (midchest, left side, right side, inframammillary, or supramammillary), size of the pain area (more than or less than 3 cm in diameter), pain quality (pressure, stabbing, burning, aching, and related or unrelated to dyspnea), radiation pattern, onset, duration, dynamics (whether it was currently increasing, decreasing, or stable), aggravating or inducing factors (whether pain was worsened by exertion, change in position, coughing, palpation, or emotional stress), and relieving factors (such as nitrate therapy).

A total of 143 women (18%) and 369 men (22%) were found to have acute MI.

Most of the 34 chest pain characteristics were reported with similar frequency in women and men. Only 11 traits differed significantly between the sexes. Women were significantly more likely than men to report greater pain severity, pressurelike pain, accompanying dyspnea, pain aggravated by palpation, pain radiating to the throat or back, sudden onset of pain, and pain duration of longer than 30 minutes. And women were significantly less likely to report no pain radiation, radiation to the right side, or shorter pain duration.

When the analysis was restricted to patients who had only acute MI, only 5 of the 34 chest pain characteristics differed significantly between women and men. Women with acute MI were less likely than men with acute MI to report pain radiation to the right arm/shoulder, short duration of pain, and pain that decreased with time. They were more likely than men to report pain radiation to the back and pain duration of 30 minutes or more, the investigators reported.

When the analysis turned to chest pain characteristics that could distinguish acute MI from other causes, only 3 of the 34 traits (8%) contributed to sex-specific diagnosis. Chest pain duration of only 2-30 minutes weakly decreased the likelihood of an MI diagnosis in women but weakly increased it in men. Pain duration of more than 30 minutes weakly increased the likelihood of an MI diagnosis in women but was neutral in men. And decreasing pain intensity weakly decreased the likelihood of an MI diagnosis in women but weakly increased the likelihood in men.

However, none of those three chest pain characteristics was considered to be clinically helpful in establishing an MI diagnosis, Dr. Gimenez and her associates said.

"Our data confirm that [chest pain characteristics] are not powerful enough to be used as a single tool in the diagnosis of AMI [acute myocardial infarction] and need to be used always in conjunction with the ECG and [cardiac troponin] test results in the diagnosis of AMI," the researchers noted. Given that the differences were small in those characteristics’ sex-specific diagnostic performance, "our findings do not seem to support the use of [chest pain characteristics] specific to women in the early diagnosis of AMI in women," they concluded.

This study was supported by the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University of Basel, and University Hospital Basel. Dr. Gimenez reported no financial conflicts of interest, and her associates reported ties to 8sense, Abbott, Alere, and other companies.