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UNLV Theses/Dissertations/Professional Papers/Capstones

12-2000

Gender differences in presenting symptoms, treatment, and outcome in myocardial infarction Alona Dalusung-Angosta University of Nevada, Las Vegas, [email protected]

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GENDER DIFFERENCES IN PRESENTING SYMPTOMS, TREATMENT, AND OUTCOME IN MYOCARDIAL INFARCTION

by

Alona Dalusung-Angosta Bachelor of Science University of Nevada, Las Vegas 1994

A thesis submitted in partial fulfillment of the requirements for the

Master of Science Degree Department of Nursing College of Health Sciences

Graduate College University of Nevada, Las Vegas December 2000

© Copyright by Alona Dalusung-Angosta 2000 All Rights Reserved

ABSTRACT

Gender Differences in Presenting Symptoms, Treatment, and Outcome in Myocardial Infarction by Alona Dalusung-Angosta Dr. Susan Kowalski, Examination Committee Chair Professor of Nursing University of Nevada, Las Vegas

The purposes of this study were to compare the presenting symptoms, treatment, and outcome between men and women with MI. The study sample consisted of 300 patients (N = 300) who were diagnosed with MI in a county hospital in the Southwest area of the United States. Chest pain, shortness of breath, sweating, and left arm pain were the most common symptoms reported by both genders. Men had more chest pain than their women counterparts (p = .022). No significant difference was found in the cardiac enzyme levels between both genders. Men had more Q wave changes during MI than women (p = .019). Women suffer MI two and a half years later than men (p = .004). Oxygen, nitrates, morphine sulfate, and heparin were the most common treatments given to men and women. Men received more morphine sulfate (p = .013) and betablockers (p = .011) than women in the emergency department. No significant difference was found in the coronary diagnostic and therapeutic procedures or outcome between both genders.

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TABLE OF CONTENTS

ABSTRACT ....................................................................................................................... iii TABLE OF CONTENTS ................................................................................................... iv LIST OF TABLES ............................................................................................................ vii ACKNOWLEDGEMENTS ............................................................................................. viii CHAPTER I INTRODUCTION ......................................................................................... 1 Problem statement............................................................................................... 1 Background of the problem ................................................................................ 1 Significance of the problem ................................................................................ 3 Purpose of the study ............................................................................................ 3 CHAPTER II REVIEW OF RELEVANT LITERATURE ................................................ 5 Introduction ......................................................................................................... 5 Coronary Heart Disease ...................................................................................... 5 Myocardial Infarction ......................................................................................... 6 Presenting Symptoms of Myocardial Infarction ................................................. 6 Myocardial Infarction in Women ....................................................................... 6 Gender Differences in the Presentation of MI .................................................... 8 Gender Differences in Treatment and Management of MI................................. 9 Gender Differences in Evaluation for MI ......................................................... 10 Gender Differences in Pharmacological Treatment.......................................... 10 Gender Differences in Mortality ....................................................................... 11 Gaps in the Literature ....................................................................................... 12 Summary ........................................................................................................... 12 CHAPTER III FRAMEWORK ........................................................................................ 14 Introduction ....................................................................................................... 14 Conceptual Framework ..................................................................................... 14 Application of the Neuman Systems Model ..................................................... 16 Propositions ...................................................................................................... 17 Hypotheses ........................................................................................................ 17 Definitions of Variables .................................................................................... 18 Summary ........................................................................................................... 20 CHAPTER IV METHODS AND PROCEDURES .......................................................... 21 Introduction ....................................................................................................... 21 iv

Research Design ............................................................................................... 21 Sample .............................................................................................................. 21 Measurement Strategies .................................................................................... 23 Procedure for Data Collection .......................................................................... 24 Statistical Analyses ........................................................................................... 26 Methodological Limitations .............................................................................. 28 Summary ........................................................................................................... 28 CHAPTER V DATA ANALYSIS.................................................................................... 30 Introduction ....................................................................................................... 30 Description of Sample ...................................................................................... 30 Reliability Analysis........................................................................................... 30 Results of the Hypotheses ................................................................................. 31 Hypothesis 1 ................................................................................................ 31 Hypothesis 2 ................................................................................................ 32 Hypothesis 3 ................................................................................................ 32 Hypothesis 4 ................................................................................................ 33 Hypothesis 5 ................................................................................................ 33 Hypothesis 6 ................................................................................................ 34 Other Findings .................................................................................................. 34 Summary of Findings........................................................................................ 35 CHAPTER VI SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ........... 37 Introduction ....................................................................................................... 37 Summary of the Study ...................................................................................... 37 Discussion of the Findings ................................................................................ 38 Difference in the Presentation of MI ........................................................... 38 Difference in the Cardiac Enzyme Levels and Electrographic Changes in MI .............................................................................................. 39 Difference in the Mean Age of Patients with MI......................................... 40 Difference in the Treatment of MI ............................................................... 41 Difference in the Outcome of MI ................................................................ 41 Difference in the Coronary Diagnostic and Therapeutic Procedures .......... 42 Relationship of Findings to the Neuman Systems Model............................ 42 Limitations of the Study ................................................................................... 43 Conclusions ....................................................................................................... 43 Implications for Nursing ................................................................................... 44 Recommendations for Further Study ................................................................ 45 Summary ........................................................................................................... 46 REFERENCES ................................................................................................................. 47 APPENDIX A FIGURES ................................................................................................. 52 APPENDIX B TABLES ................................................................................................... 56 APPENDIX C THE GENDER MI DATA COLLECTION TOOL ................................. 72

APPENDIX D APPROVAL LETTERS........................................................................... 76 VITA ..................................................................................................................................87

LIST OF TABLES Table 1 Frequencies of Age of Patients with MI by Gender ...........................................57 Table 2 Frequencies of Presenting Symptoms of Patients with MI by Gender ...............58 Table 3 Chi-Square Results of Presenting Symptoms of Patients with MI by Gender ............................................................................................................60 Table 4 T-test Results of Cardiac Enzyme Levels of Patients with MI by Gender ............................................................................................................62 Table 5 Frequencies of Electrographic Changes in Patients with MI by Gender ............................................................................................................63 Table 6 Chi-Square Results of Electrographic Changes in Patients with MI by Gender ............................................................................................................64 Table 7 T-test Results of Mean Age of Patients with MI by Gender...............................65 Table 8 Frequencies of Treatment Received by Patients with MI by Gender ............................................................................................................66 Table 9 Chi-Square Results of Treatment in Patients with MI by Gender ............................................................................................................67 Table 10 T-test Results of Outcome of Patients with MI by Gender .................................68 Table 11 Frequencies of Outcome in Patients with MI by Gender ....................................69 Table 12 Frequencies of Coronary Diagnostic and Therapeutic Procedures in Patients with MI by Gender ............................................................................70 Table 13 Frequencies and Chi-Square Results of Morphine Sulfate Treatment by Chest Pain Symptom in Patients with MI by Gender ....................................71

vii

ACKNOWLEDGEMENTS

Thank you Lord for making this dream possible… To my son Audwin and my husband Terry, thank you for your love, understanding, and patience during the most difficult time of my graduate years – the away times, the late nights, and the stressful moments… Heartfelt thanks to my family for their support, encouragement, and prayers. Ma and Pa, thank you so much for your endless love and support. I am indebted to you for your tolerance and generosity. My profound thanks to my committee members: Ms. Roberta Williams, Dr. Margaret Louis, Dr. Cheryl Bowles, and my chairperson, Dr. Susan Kowalski for their time, guidance, and enthusiasm. Thank you Dr. Kowalski for your expert advice, commitment, and patience. I extend special thanks to the staff of UMC Medical Records department, especially to Grace, for her help and encouragement during my tedious data collection. Thanks to my friends and colleagues for their support and prayers. Special appreciation is given to Mr. Paul Nakayu. This work would not be possible without his assistance. His computer expertise and patience were invaluable in making this study possible.

viii

CHAPTER I

INTRODUCTION

Problem statement Recent studies in medical and nursing literature (Micevski, 1996 and Penque, et al., 1998) suggest that men and women present with different symptoms of myocardial infarction (MI). Furthermore, gender differerences in the treatment of MI and mortality outcome have been reported. However, the existing literature on gender differences in presenting symptoms, treatment, and outcome of MI is limited. The difference in the presenting symptoms, treatment, and outcome of MI in men and women needs to be further evaluated so that prompt and appropriate treatment will be provided to women as well as men experiencing an MI. This study seeks to add credibility to the existing literature on gender differences in presenting symptoms of MI. Background of the problem Coronary heart disease (CHD) is the single largest killer of men and women in the United States (American Heart Association, 1999). More men and women die from heart disease each year than from any other cause of death including cancer, accidents, pneumonia/influenza, and lung diseases (American Heart Association, 1999). Although recent CHD studies have included women, more information is needed regarding this deadly disease in relation to women. Women in the 1990s are dying of heart disease more often than men (American Heart Association, 1999). Recent research studies have indicated that mortality in women

1

2 is higher than in men following MI. Marrugat et al. (1998) studied mortality differences following MI in men and women. Their findings indicated that mortality after acute MI is greater in women than in men. A recent study by Vaccarino et al. (1999) reported similar findings and concluded that women have higher rates of death during hospitalization than men following MI. The American Heart Association (1999), the national standard source for cardiovascular disease, describes the common symptoms of MI. It does not address gender differences in the presenting symptoms of MI. The common symptoms of MI are uncomfortable pressure, fullness, squeezing, or pain in the center of the chest, pain that spreads to shoulders, neck, or arms, chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath. These symptoms are presented in most cardiovascular texts. Health care providers utilize these symptoms as guidelines for diagnosing MI. However, recent studies show that gender differences in presenting symptoms of MI exist. A recent study by Penque et al. (1998) noted that more women reported dyspnea, loss of appetite, and back pain than men. Chest pain was the common symptom reported by either gender. This finding is consistent with the results reported by Micevski (1996) who studied gender differences in the presenting symptoms of MI. In Micevski’s study, chest pain was the common symptom reported by both men and women. Men presented more often with diaphoresis and complaints of left and right arm pain; whereas, women presented more frequently with back pain/discomfort. Differences between men and women in their presenting symptoms may affect the treatment and evaluation of MI. Studies have reported the presence of a gender bias in the treatment and evaluation of patients with MI. Bergelson & Tommaso (1995) studied the differences in the clinical evaluation and treatment between men and women who presented with CHD. Their results indicated that women hospitalized with a coronary

3 diagnosis were less likely to undergo coronary arteriography than men. They further concluded that subjective interpretation of the symptoms and conditions prevented women from having coronary arteriography. Women who did undergo cardiac arteriography were more likely to be older. The latter finding was supported by Dellborg and Swedberg (1993) who noted that coronary angiography was performed more often in men than women during hospitalization. They concluded that women were older when referred for cardiac catheterization, coronary angioplasty, or coronary artery bypass surgery. Pharmacologic treatment for patients with MI was also given significantly less often in women than in men. In light of these issues, the need for further investigation on the differing symptoms of MI, treatment, and outcome in men and women is imperative. Mallory (1997) stated that if symptoms of MI remain unrecognized, patients may delay seeking medical treatment, and this could complicate their condition, possibly contributing to congestive heart failure. Significance of the problem It is of the utmost importance to educate nurses and other health care professionals as well as the public regarding the possible existence of gender differences in the presenting symptoms, treatment, and outcome in MI. Failure to recognize gender differences in the symptoms of MI can contribute to a delay in treatment and a higher mortality in women. Nurses play an important role in promoting health and in preventing and detecting diseases. The recognition of the signs and symptoms of patients with MI is imperative so that prompt and proper intervention, treatment, and management will be provided. Purpose of the study There are three purposes of this study. These are a) to compare the presenting symptoms of women and men who were diagnosed with MI in a county hospital in the

4 Southwest area of the United States b) to compare the treatments received by women and men with MI in the emergency department and c) to compare the outcome between women and men who were diagnosed with MI during hospitalization.

CHAPTER II

REVIEW OF RELEVANT LITERATURE

Introduction The literature on gender differences in presenting symptoms of myocardial infarction (MI) is quite sparse. These studies have not addressed the impact of gender differences in presenting symptoms on treatment and outcome of MI. Recent studies have focused on gender differences in treatment, management, and mortality of MI. This literature review addresses research studies and provides rationale and support for the present study. This chapter addresses coronary heart disease and the presenting symptoms of MI in general; impact of MI on women; gender differences in the presentation, treatment, management, and mortality of MI. The latter portion of the chapter identifies gaps in the literature and will provide a summary of the chapter.

Coronary Heart Disease Since 1900, cardiovascular disease has been the leading cause of death each year in America (American Heart Association, 1999). One form of cardiovascular disease that leads to MI is coronary heart disease. Coronary heart disease (CHD) is caused by atherosclerosis, a narrowing of the vessel, due to the formation of lipid-laden lesions of the coronary arteries (McCance & Huether, 1998). This contributes to the interference of blood flow to the heart and can eventually result in MI, what is commonly known as a heart attack.

5

6 Myocardial Infarction Myocardial infarction results from CHD – blood vessel disease in the heart (American Heart Association, 1999). This definition of MI by the American Heart Association, a national organization for cardiovascular diseases and stroke, is commonly accepted and utilized in the literature. McCance and Huether (1998) define MI as the end point of CHD. MI occurs when there is prolonged ischemia to the heart muscle causing irreversible cellular death (Lewis & Collier, 1992). The diagnosis of MI depends on the physiological symptoms, presence of electrographic changes, and elevated cardiac enzymes. Presenting Symptoms of Myocardial Infarction The presenting symptoms of MI vary widely. The American Heart Association (1999) reports the signs and symptoms of MI with no distinction between women and men. These are uncomfortable pressure, fullness, squeezing, or pain in the center of the chest, pain that spreads to shoulders neck or arms, chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath. McCance and Huether (1998) describe the common symptoms of MI as chest pain that is heavy or crushing, chest pain with nausea and/or vomiting, diaphoresis, shortness of breath, or radiation to neck, jaw, back, or left-arm. Patients may complain of a feeling of weakness, severe indigestion, shortness of breath, or chest discomfort (Lewis & Collier, 1992). Others may complain of chest pain lasting more than twenty minutes and not relieved by nitroglycerin or rest, and it is characterized as deep, unrelenting pressure, ache, and squeezing sensation with nausea and/or vomiting, and diaphoresis (Fruth, 1991). Myocardial Infarction in Women Knowledge about the natural history of CHD in women was limited until recent years (Thomas & Braus, 1998). More women are dying of heart disease than from breast or lung cancers (American Heart Association, 1999). The mortality rate in women

7 following MI continues to be greater than for men. Marrugat et al. (1998) investigated the mortality in women following their first MI. A sample of 331 women and 1,129 men diagnosed with first MI, from 1992 through 1994, in four teaching hospitals in northeastern Spain was studied. They concluded that older women had more lethal and severe first MIs. The 28-day mortality rates were significantly higher among women (18% for women, 8.3% for men; p < .001). The 6-month mortality rates were 25% in women and 10.8% in men with a significant level of < .001. A recent study was conducted by Vaccarino, et al., (1999). A sample of 384,878 subjects (n = 155,565 women, n = 229,313 men) who were enrolled in the National Registry of Myocardial Infarction Two (NRMI2) between the years of 1994 and 1998 was utilized in the study. The mortality rates were examined according to age group. They reported that younger women have higher rates of death after MI. The mortality rate during hospitalization was 16.7% among women and 11.5% among men. The mortality rate for women less than 50 years of age was more than twice as high than for men with a significant level of

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