This comical, fundamentally flawed publication has already been skewered online in just the handful of days since it hit publication. But, any press is good press, right?
We’ve been practicing under the prevailing notion women more frequently manifest atypical constellations of symptoms when presenting with acute myocardial infarction. We’ve inferred this from observational cohort data, and from studies indicating we miss more diagnoses of AMI in women. So, these authors set to prospectively validate this notion.
It’s rather sad, unfortunately, how much effort and time was spent prospectively enrolling the 2,475 patients recruited for this study. Each patient underwent a structured clinical interview to determine the presence or absence of specific chest pain features, and these were correlated with final adjucated diagnosis of AMI. And, in the end, the positive and negative likelihood ratios for AMI for nearly every recorded feature were identical for men and women.
But, when you exclusively enroll patients with “symptoms suggestive of AMI”, you’ve designed precisely the type of study that will never detect atypical presentations of AMI. If clinicians didn’t suspect acute coronary syndrome associated with an episode of chest pain, these patients are discarded from follow-up. Unfortunately, then, this work is unable to conclusively answer any question regarding gender-specific symptoms.
To truly evaluate this question, the inclusion criteria would have be far more expansive. Essentially, nearly all atraumatic patients with a somatic complaint above the pelvis should be screened and followed for a definitive diagnosis of AMI. Perhaps that study would be too large and unwieldy to successfully execute, but that would be the scope required to answer this question once and for all (within the bounds of external validity).
Finally, I just want to point back to Seth Trueger’s write-up of a lovely ED chest pain study, where expert rheumatologists made gold standard diagnoses of costochondritis in the Emergency Department. Incidence of AMI in “costochondritis” patients? 6%.
“Sex-Specific Chest Pain Characteristics in the Early Diagnosis of Acute Myocardial Infarction”
http://archinte.jamanetwork.com/article.aspx?articleid=1783306
I missed the other online skewering of this study – why is it criticized so savagely?
The stated aim of the study – to find elements of the history that would be diagnostic for AMI in women – is likely a fool’s errand, since the question sort of presumes that we have such a decision aid for men. It is also true that the study by Gimenez et al. cannot prove, because of study design, that men and women have similar rates of atypical symptoms of ACS.
However, I’m not sure that this makes the study fundamentally flawed, let alone “comical.”. It’s too easy to criticize a study for not being a highly-powered, well-controlled (yet externally valid!) “gold-standard” investigation. Why not analyze the study on it’s own terms?
Foremost, this was notable for being a prospective study of undifferentiated chest symptoms. Too much of the literature that is cited on this topic uses registry data, or only enrolls patients with confirmed ACS, or interviews subjects long after the onset of symptoms. While this study may not be perfect, its methods are far more robust than most other literature in this area.
Furthermore, a prospective study of typical and atypical symptoms in men and women has been conducted in the ED setting. “Typical symptoms are predictive of acute coronary syndromes in women” came to a similar conclusion as the present study.
(http://www.ncbi.nlm.nih.gov/pubmed/11835032)
I missed the other online skewering of this study – why is it criticized so savagely?
The stated aim of the study – to find elements of the history that would be diagnostic for AMI in women – is likely a fool’s errand, since the question sort of presumes that we have such a decision aid for men. It is also true that the study by Gimenez et al. cannot prove, because of study design, that men and women have similar rates of atypical symptoms of ACS.
However, I’m not sure that this makes the study fundamentally flawed, let alone “comical.”. It’s too easy to criticize a study for not being a highly-powered, well-controlled (yet externally valid!) “gold-standard” investigation. Why not analyze the study on it’s own terms?
Foremost, this was notable for being a prospective study of undifferentiated chest symptoms. Too much of the literature that is cited on this topic uses registry data, or only enrolls patients with confirmed ACS, or interviews subjects long after the onset of symptoms. While this study may not be perfect, its methods are far more robust than most other literature in this area.
Furthermore, a prospective study of typical and atypical symptoms in men and women has been conducted in the ED setting. “Typical symptoms are predictive of acute coronary syndromes in women” came to a similar conclusion as the present study.
(http://www.ncbi.nlm.nih.gov/pubmed/11835032)
Daniel Pallin uses the Journal Watch platform to criticize this study (http://www.jwatch.org/na32982/2013/11/25/are-there-sex-differences-symptoms-acute-myocardial) and Amal Mattu lectures regarding the atypical presenting symptoms of women.
As you say, this study cannot prove the relative incidence of atypical symptoms in MI – which is, essentially, the myth that needs to be busted. I absolutely agree this evidence is superior than the prior evidence – but, in the end, it simply adds to the confusion rather than finally answering the question. I just don't see the point of putting forth this much prospective effort to give us evidence that simply isn't that profound.
Daniel Pallin uses the Journal Watch platform to criticize this study (http://www.jwatch.org/na32982/2013/11/25/are-there-sex-differences-symptoms-acute-myocardial) and Amal Mattu lectures regarding the atypical presenting symptoms of women.
As you say, this study cannot prove the relative incidence of atypical symptoms in MI – which is, essentially, the myth that needs to be busted. I absolutely agree this evidence is superior than the prior evidence – but, in the end, it simply adds to the confusion rather than finally answering the question. I just don't see the point of putting forth this much prospective effort to give us evidence that simply isn't that profound.