Holli A. DeVon

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Treatment seeking for acute myocardial infarction symptoms: differences in delay across sex and race.

BackgroundPatients experiencing an acute myocardial infarction are known to delay seeking treatment between 2 and 4 hours. This delay is problematic because individuals who receive treatment 2 or more hours after the onset of symptoms are less likely to benefit from emergent reperfusion techniques. Persons most likely to delay seeking treatment for an acute myocardial infarction and their reasons have not been clearly identified. ObjectiveThe purpose of this study was to identify the effect of selected demographic, clinical, cognitive, and environmental variables on the length of the time of delay. In addition, the study was designed to identify whether women delayed longer than men, and whether African Americans delayed longer than non-Hispanic Whites during an acute myocardial infarction. MethodA structured interview was conducted in a convenience sample (N eq> 212) of African American and non-Hispanic White patients hospitalized after acute myocardial infarction. Patients were asked detailed information about the sequence of events prior to the acute myocardial infarction, and the symptoms experienced. Medical records were examined for clinical information. ResultsWomen did not delay significantly longer than men (2.0 vs. 2.5 median hours). African Americans delayed significantly longer than non-Hispanic Whites (3.25 hours vs. 2.0 median hours). Race did not contribute unique variance to delay time in a simultaneous multiple regression analysis; however, race was a significant predictor variable in whether or not participants sought treatment within the first hour after the onset of symptoms. The variance in delay time for African American and Non-Hispanic White men and women that could be explained by the predictor variables ranged from 23–47%. ConclusionsThe reasons for delay differed in part by sex and race.

The symptoms of unstable angina: do women and men differ?

BackgroundResearch has shown that there are differences between women and men in the epidemiology, presentation, and outcomes of coronary heart disease. ObjectivesThe purpose of this study was to determine if there were sex differences in the symptoms of unstable angina (UA) and if so, to determine if these differences remained after controlling for age, diabetes, anxiety, depression, and functional status. MethodThis descriptive study used a nonexperimental, quantitative design. A convenience sample of 50 women and 50 men, hospitalized with UA, were recruited from an urban and a suburban medical center. Instruments included the Unstable Angina Symptoms Questionnaire (UASQ), the Hospital Anxiety and Depression Scale (HADS), and the Canadian Cardiovascular Society (CCS) classification of angina. ResultsMultivariate analysis indicated that women experienced significantly (p < .05) more shortness of breath (74% vs. 60%), weakness (74% vs. 48%), difficulty breathing (66% vs. 38%), nausea (42% vs. 22%), and loss of appetite (40% vs. 10%) than men. After controlling for age, diabetes, anxiety, depression, and functional status, women were still more likely than men to report weakness (p = .03), difficulty breathing (p = .02), nausea (p = .03), and loss of appetite (p = .02). Chi-square analysis of symptom descriptors revealed that women disclosed more (p < .05) upper back pain (42% vs. 18%), stabbing pain (32% vs. 12%), and knifelike pain (28% vs. 12%). Women also had a significantly higher incidence of depression (22% vs. 2%, p < .01). ConclusionsFindings suggest that women and men have similar symptoms during an episode of UA, however, a higher proportion of women have less typical symptoms.

The association of pain with protein inflammatory biomarkers: a review of the literature.

Background:Pain is a key diagnostic criterion in many medical conditions. In the absence of self-reported pain, measurement of a proxy for pain, such as an inflammatory biomarker, could aid in diagnosis and disease management. Objectives:The aim was to determine if there is an association between inflammatory biomarkers and self-reported pain in individuals with medical conditions associated with the symptom of pain and to clarify whether inflammatory biomarkers might aid in the diagnostic process. Methods:An integrative literature review was conducted. PubMed, CINAHL, and Cochrane databases were searched for articles published between January 2000 and September 2012. Inclusion criteria were original research testing a relationship between inflammatory biomarkers and pain, pain measurement, laboratory measure of inflammatory biomarkers, and a prospective single-group experimental design or comparative nonrandomized or randomized design. Excluded were studies describing an association between inflammatory biomarkers and treatment, risk, and generation; pathophysiology; or genetic polymorphisms/transcripts. Ten studies meeting inclusion criteria were reviewed. Results:In most of the studies, baseline elevations in both proinflammatory and anti-inflammatory cytokines were reported in painful conditions compared with healthy controls. In half of the studies, higher levels of proinflammatory markers (C-reactive protein, tumor necrosis factor-alpha, interleukin-2 [IL-2], IL-6, IL-8, IL-10, and CD40 ligand) were associated with greater pain. Proinflammatory cytokines decreased after treatment for pain in only two studies. Discussion:The association between inflammatory markers varied in the direction and magnitude of expression, which may be explained by differences in designs and assays, disease condition and duration, variations in symptom severity, and timing of measurement. Elevation in anti-inflammatory cytokines in the presence of pain represents a homeostatic immune response. Further study is required to determine the value of cytokines as biomarkers of pain.

Is the Medical Record an Accurate Reflection of Patients’ Symptoms During Acute Myocardial Infarction?

Documentation of symptoms in the medical record provides clinicians and researchers with valuable information about the patient’s experience during acute myocardial infarction (AMI). To examine the consistency between the patient’s reported symptoms and the medical record, 215 patients were interviewed and their medical records examined for information about their admission symptoms. Chest pain was the most frequently reported and recorded symptom, and there was good agreement between the patient’s report and the medical record. Although fatigue was the second most frequently reported symptom by patients, it was rarely documented in the medical record. Time of symptom onset was identified by 87.9% of patients but only documented in 60.5% of medical records. Clinicians may be recording those symptoms that support the AMI diagnosis and not those perceived to be less relevant. Findings suggest that the medical record is an inaccurate and inadequate source of information about patients’ actual experience of AMI symptoms.

Measures of Psychological Stress and Physical Health in Family Caregivers of Stroke Survivors: A Literature Review

Studies have demonstrated that the stress of family caregiving places caregivers at risk for developing depression, poor quality of life, and health problems. The purpose of this review was to identify the ways in which variables are operationalized in studies addressing psychological stressors and physical health of family caregivers of stroke survivors. The adapted Pittsburgh Mind-Body Center model provides the organizing conceptual framework for this literature review. A literature search for relevant articles was conducted using Ovid Medline, PsycINFO, and Ovid Nursing Database for the period of July 1999 through June 2009 using the following search terms: caregiver (or family caregiver), stroke, stress, and health. Articles were included if they met the following inclusionary criteria: (a) written in English, (b) published in peer-reviewed journal, (c) focused on adults who were caring for an adult who experienced stroke, (d) included measures of stress and physical health or health-related quality of life, and (e) primarily used quantitative research methods. Twenty-four articles were identified that met the inclusion criteria. Findings related to the variables included in the adapted Pittsburgh Mind-Body Center model are discussed. Variables were not well defined, a wide array of measurement instruments were used, and measures were taken at broadly divergent time frames following stroke. Future research guided by a theoretical framework, consistent measures of variables, and standardized measurement time points would allow for better comparison of findings across studies, thus enabling clinicians to better understand the health risks of family caregivers.

Moral distress and avoidance behavior in nurses working in critical care and noncritical care units

Nurses facing impediments to what they perceive as moral practice may experience moral distress. The purpose of this descriptive, cross-sectional study was to determine similarities and differences in moral distress and avoidance behavior between critical care nurses and non-critical care nurses. Sixty-eight critical care and 28 non-critical care nurses completed the Moral Distress Scale and Impact of Event Scale (IES). There were no differences in moral distress scores (F = 0.892, p = 0.347) or impact of event scores (F = 3.80, p = 0.054) between groups after adjusting for age. There was a small positive correlation between moral distress and avoidance behaviors for both the groups. Moral distress is present in both critical care and noncritical care nurses. It is important that nurses are provided with opportunities to cope with this distress and that retention strategies include ways to reduce suffering and mitigate the effects on professional practice.

Sensitivity, Specificity, and Sex Differences in Symptoms Reported on the 13‐Item Acute Coronary Syndrome Checklist

Background Clinical symptoms are part of the risk stratification approaches used in the emergency department (ED) to evaluate patients with suspected acute coronary syndromes (ACS). The objective of this study was to determine the sensitivity, specificity, and predictive value of 13 symptoms for a discharge diagnosis of ACS in women and men. Methods and Results The sample included 736 patients admitted to 4 EDs with symptoms suggestive of ACS. Symptoms were assessed with the 13‐item validated ACS Symptom Checklist. Mixed‐effects logistic regression models were used to estimate sensitivity, specificity, and predictive value of each symptom for a diagnosis of ACS, adjusting for age, obesity, diabetes, and functional status. Patients were predominantly male (63%) and Caucasian (70.5%), with a mean age of 59.7±14.2 years. Chest pressure, chest discomfort, and chest pain demonstrated the highest sensitivity for ACS in both women (66%, 66%, and 67%) and men (63%, 69%, and 72%). Six symptoms were specific for a non‐ACS diagnosis in both women and men. The predictive value of shoulder (odds ratio [OR]=2.53; 95% CI=1.29 to 4.96) and arm pain (OR 2.15; 95% CI=1.10 to 4.20) in women was nearly twice that of men (OR=1.11; 95% CI=0.67 to 1.85 and OR=1.21; 95% CI=0.74 to 1.99). Shortness of breath (OR=0.49; 95% CI=0.30 to 0.79) predicted a non‐ACS diagnosis in men. Conclusions There were more similarities than differences in symptom predictors of ACS for women and men.

Epigenetics and Social Context: Implications for Disparity in Cardiovascular Disease

BACKGROUND Although it is well established that African Americans (AA) experience greater social stressors than non-Hispanic Whites (NHW), the extent to which early life adversity and cumulative social stressors such as perceived discrimination, neighborhood violence, subjective social status, and socioeconomic status contribute to disparity in coronary heart disease (CHD) and stroke between AA and NHW are not well understood. PURPOSE The purpose of this paper is to propose a conceptual model based upon McEwens Allostatic Load Model suggesting how the relationships among social context, early life adversity, psychological stress, inflammation, adaptation, and epigenetic signature may contribute to the development of CHD and ischemic stroke. We hypothesize that social context and prior life adversity are associated with genome-wide as well as gene-specific epigenetic modifications that confer a proinflammatory epigenetic signature that mediates an enhanced proinflammatory state. Exposure to early life adversity, coupled with an increased allostatic load places individuals at greater risk for inflammatory based diseases, such as CHD and ischemic stroke. RESULTS Based on a review of the literature, we propose a novel model in which social context and psychological stress, particularly during early life, engenders a proinflammatory epigenetic signature, which drives a heightened inflammatory state that increases risk for CHD and stroke. In the proposed model, a proinflammatory epigenetic signature and adaptation serve as mediator variables. CONCLUSIONS Understanding the extent to which epigenetic signature bridges the psycho-social environment with inflammation and risk for CHD may yield novel biomarkers that can be used to assess risk, development, and progression of CHD/stroke. Epigenetic biomarkers may be used to inform preventive and treatment strategies that can be targeted to those most vulnerable, or to those with early signs of CHD, such as endothelial dysfunction. Furthermore, epigenetic approaches, including lifestyle modification and stress reduction programs, such as mindfulness-based stress reduction, offer promise to reduce health inequity linked to social disadvantage, as emerging evidence demonstrates that adverse epigenetic marks can be reversed.

The Association of Diabetes and Older Age With the Absence of Chest Pain During Acute Coronary Syndromes

Cardiac autonomic neuropathy associated with diabetes can cause silent myocardial ischemia and may influence the way that patients perceive symptoms of acute coronary syndromes (ACS). The purpose of this study was to examine symptoms of ACS in patients with and without diabetes while controlling for length of time with diabetes. A convenience sample of 256 patients from two large medical centers in the Midwest participated. Patients with diabetes comprised 33.2% of the sample and reported significantly less chest pain and more unusual fatigue. Patients with diabetes of longer duration (10 or more years) reported more difficulty breathing than did patients with diabetes of shorter duration (fewer than 10 years). Older patients with the same diabetes status also reported less chest pain. For older patients and for patients with diabetes, lack of chest pain during ACS could delay treatment and is thus a concern.