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The diagnostic value of clinical symptoms in women and men presenting with chest pain at the emergency department, a prospective cohort study.

van der Meer MG, Backus BE, van der Graaf Y, Cramer MJ, Appelman Y, Doevendans PA, Six AJ, Nathoe HM - PLoS ONE (2015)

Bottom Line: In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD.The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).No significant differences were found between sexes.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands.

ABSTRACT

Background: Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking.

Methodology: Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes.

Results: A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).

Conclusion: The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

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Related in: MedlinePlus

ROC curves of model 1, A, consisting of symptoms.The black line describes the diagnostic value in men and the red line the diagnostic value in women. The AUC in women is not inferior to the AUC in men, p-value 0.45. ROC curves of model 2, B, consisting of symptoms added with baseline characteristics. The black line describes the diagnostic value in men and the red line in women. The AUC in women is not inferior to the AUC in men, p-value 0.11.
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pone.0116431.g003: ROC curves of model 1, A, consisting of symptoms.The black line describes the diagnostic value in men and the red line the diagnostic value in women. The AUC in women is not inferior to the AUC in men, p-value 0.45. ROC curves of model 2, B, consisting of symptoms added with baseline characteristics. The black line describes the diagnostic value in men and the red line in women. The AUC in women is not inferior to the AUC in men, p-value 0.11.

Mentions: In women and men, 8 clinical symptoms remained in this multivariable model (p-value < 0.15, Table 2). The presence of “pain located in the sternal region”, “pain started during exercise”, “pain diminished on nitrates” and “same chest pain in last weeks” were positive predictors for CAD in women and men. “Dizziness/syncope” had a negative predictive value in both sexes. There were some differences between women and men in the first model based on clinical symptoms. “Oppressive chest pain” still qualified as a positive predictor for CAD in women, but in men the p-value exceeded the 0.15 border because other clinical symptoms showed stronger associations. Other positive predictors in women were “nausea/ vomiting” and “diaphoresis”. “Palpitations” and “pulmonary complaints” were negative predictors in men, but had no predictive value in women. The combined diagnostic value of clinical symptoms for the presence of CAD, expressed by the AUC, was 0.74 (95%CI: 0.69–0.79) in women and 0.71 (95%CI: 0.68–0.75) in men (Fig. 3A). This difference in AUC between women and men was not significantly different (p-value 0.45).


The diagnostic value of clinical symptoms in women and men presenting with chest pain at the emergency department, a prospective cohort study.

van der Meer MG, Backus BE, van der Graaf Y, Cramer MJ, Appelman Y, Doevendans PA, Six AJ, Nathoe HM - PLoS ONE (2015)

ROC curves of model 1, A, consisting of symptoms.The black line describes the diagnostic value in men and the red line the diagnostic value in women. The AUC in women is not inferior to the AUC in men, p-value 0.45. ROC curves of model 2, B, consisting of symptoms added with baseline characteristics. The black line describes the diagnostic value in men and the red line in women. The AUC in women is not inferior to the AUC in men, p-value 0.11.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4295862&req=5

pone.0116431.g003: ROC curves of model 1, A, consisting of symptoms.The black line describes the diagnostic value in men and the red line the diagnostic value in women. The AUC in women is not inferior to the AUC in men, p-value 0.45. ROC curves of model 2, B, consisting of symptoms added with baseline characteristics. The black line describes the diagnostic value in men and the red line in women. The AUC in women is not inferior to the AUC in men, p-value 0.11.
Mentions: In women and men, 8 clinical symptoms remained in this multivariable model (p-value < 0.15, Table 2). The presence of “pain located in the sternal region”, “pain started during exercise”, “pain diminished on nitrates” and “same chest pain in last weeks” were positive predictors for CAD in women and men. “Dizziness/syncope” had a negative predictive value in both sexes. There were some differences between women and men in the first model based on clinical symptoms. “Oppressive chest pain” still qualified as a positive predictor for CAD in women, but in men the p-value exceeded the 0.15 border because other clinical symptoms showed stronger associations. Other positive predictors in women were “nausea/ vomiting” and “diaphoresis”. “Palpitations” and “pulmonary complaints” were negative predictors in men, but had no predictive value in women. The combined diagnostic value of clinical symptoms for the presence of CAD, expressed by the AUC, was 0.74 (95%CI: 0.69–0.79) in women and 0.71 (95%CI: 0.68–0.75) in men (Fig. 3A). This difference in AUC between women and men was not significantly different (p-value 0.45).

Bottom Line: In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD.The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).No significant differences were found between sexes.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands.

ABSTRACT

Background: Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking.

Methodology: Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes.

Results: A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).

Conclusion: The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

Show MeSH
Related in: MedlinePlus