Assessing the Need to Educate Prehospital Providers on the Sex Differences in the Clinical Presentation of Acute MI
DOI:
https://doi.org/10.65539/h26n0a63Keywords:
acute MI, sex differences, clinical presentation, prehospitalAbstract
Medical research has historically underrepresented females. As part of a movement to better represent women in research, U.S. Congress passed the National Institute of Health Revitalization Act of 1993, which mandated the inclusion of women and minority groups in clinical research (1). With the increase in female inclusion, sex differences in the clinical presentations of diseases and responses to medication have emerged. Previous research has found differences in how women and men might present with acute myocardial infarction (MI), with women more often experiencing signs and symptoms that are labeled as 'atypical' or 'nontraditional' (2-8). However, this information has not been robustly incorporated into the prehospital curriculum standards, including education for emergency medical technicians (EMTs) or paramedics (9). This paper investigates whether there is a need for the prehospital curriculum to discuss the lesser-known signs and symptoms of acute MI and the differences in disease presentation between men and women. First, some differences between women's and men's physiology and pathophysiology are explored. Next, the clinical presentation of acute MI is reviewed, including the research supporting the sex differences in clinical presentation. Additionally, the disparities in EMS quality of care will be discussed, as research has shown that women receive lower quality of care in the prehospital setting (10). Social factors that can affect delays to treatment will also be discussed. Since there is substantial evidence that health outcomes of acute MI differ between men and women, EMS education should include and emphasize these topics.
Downloads
References
1. Geller SE, Koch AR, Roesch P, Filut A, Hallgren E, Carnes M. The More Things Change, the More They Stay the Same: A Study to Evaluate Compliance With Inclusion and Assessment of Women and Minorities in Randomized Controlled Trials. Acad Med. Apr 2018;93(4):630-635. doi:10.1097/ACM.0000000000002027 DOI: https://doi.org/10.1097/ACM.0000000000002027
2. Lichtman JH, Leifheit EC, Safdar B, et al. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Circulation. Feb 20 2018;137(8):781-790. doi:10.1161/CIRCULATIONAHA.117.031650 DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.031650
3. Cardeillac M, Lefebvre F, Baicry F, et al. Symptoms of Infarction in Women: Is There a Real Difference Compared to Men? A Systematic Review of the Literature with Meta-Analysis. J Clin Med. Feb 27 2022;11(5) doi:10.3390/jcm11051319 DOI: https://doi.org/10.3390/jcm11051319
4. Ali M, van Os HJA, van der Weerd N, et al. Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis. Stroke. Feb 2022;53(2):345-354. doi:10.1161/STROKEAHA.120.034040 DOI: https://doi.org/10.1161/STROKEAHA.120.034040
5. Washington DL, Bird CE. Sex differences in disease presentation in the emergency department. Ann Emerg Med. Nov 2002;40(5):461-3. doi:10.1067/mem.2002.128859 DOI: https://doi.org/10.1067/mem.2002.128859
6. Shajahan S, Sun L, Harris K, et al. Sex differences in the symptom presentation of stroke: A systematic review and meta-analysis. Int J Stroke. Feb 2023;18(2):144-153. doi:10.1177/17474930221090133 DOI: https://doi.org/10.1177/17474930221090133
7. Jerath NU, Reddy C, Freeman WD, Jerath AU, Brown RD. Gender differences in presenting signs and symptoms of acute ischemic stroke: a population-based study. Gend Med. Oct 2011;8(5):312-9. doi:10.1016/j.genm.2011.08.001 DOI: https://doi.org/10.1016/j.genm.2011.08.001
8. Forster A, Gass A, Kern R, et al. Gender differences in acute ischemic stroke: etiology, stroke patterns and response to thrombolysis. Stroke. Jul 2009;40(7):2428-32. doi:10.1161/STROKEAHA.109.548750 DOI: https://doi.org/10.1161/STROKEAHA.109.548750
9. The National Emergency Medical Services Education Standards (U.S. Department of Transportation, National Highway Traffic Safety Administration) (2021).
10. Dylla L, Rice JD, Poisson SN, et al. Analysis of Stroke Care Among 2019-2020 National Emergency Medical Services Information System Encounters. J Stroke Cerebrovasc Dis. Mar 2022;31(3):106278. doi:10.1016/j.jstrokecerebrovasdis.2021.106278 DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106278
11. Haider A, Bengs S, Luu J, et al. Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. Eur Heart J. Apr 01 2020;41(13):1328-1336. doi:10.1093/eurheartj/ehz898 DOI: https://doi.org/10.1093/eurheartj/ehz898
12. Fahed AC, Jang IK. Plaque erosion and acute coronary syndromes: phenotype, molecular characteristics and future directions. Nat Rev Cardiol. Oct 2021;18(10):724-734. doi:10.1038/s41569-021-00542-3 DOI: https://doi.org/10.1038/s41569-021-00542-3
13. Seegers LM, Araki M, Nakajima A, et al. Sex Differences in Culprit Plaque Characteristics Among Different Age Groups in Patients With Acute Coronary Syndromes. Circ Cardiovasc Interv. Jun 2022;15(6):e011612. doi:10.1161/CIRCINTERVENTIONS.121.011612 DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.121.011612
14. Iorga A, Cunningham CM, Moazeni S, Ruffenach G, Umar S, Eghbali M. The protective role of estrogen and estrogen receptors in cardiovascular disease and the controversial use of estrogen therapy. Biol Sex Differ. Oct 24 2017;8(1):33. doi:10.1186/s13293-017-0152-8 DOI: https://doi.org/10.1186/s13293-017-0152-8
15. Kaur H, Werstuck GH. The Effect of Testosterone on Cardiovascular Disease and Cardiovascular Risk Factors in Men: A Review of Clinical and Preclinical Data. CJC Open. Oct 2021;3(10):1238-1248. doi:10.1016/j.cjco.2021.05.007 DOI: https://doi.org/10.1016/j.cjco.2021.05.007
16. Lopez-Cuenca A, Gomez-Molina M, Flores-Blanco PJ, et al. Comparison between type-2 and type-1 myocardial infarction: clinical features, treatment strategies and outcomes. J Geriatr Cardiol. Jan 2016;13(1):15-22. doi:10.11909/j.issn.1671-5411.2016.01.014
17. Gupta S, Vaidya SR, Arora S, Bahekar A, Devarapally SR. Type 2 versus type 1 myocardial infarction: a comparison of clinical characteristics and outcomes with a meta-analysis of observational studies. Cardiovasc Diagn Ther. Aug 2017;7(4):348-358. doi:10.21037/cdt.2017.03.21 DOI: https://doi.org/10.21037/cdt.2017.03.21
18. Lewis JF, Zeger SL, Li X, et al. Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest. Womens Health Issues. Mar-Apr 2019;29(2):116-124. doi:10.1016/j.whi.2018.10.007 DOI: https://doi.org/10.1016/j.whi.2018.10.007
19. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. Mar 16 2004;109(10):1223-5. doi:10.1161/01.CIR.0000121424.76486.20 DOI: https://doi.org/10.1161/01.CIR.0000121424.76486.20
20. Kosaraju A, Goyal A, Grigorova Y, Makaryus AN. Left Ventricular Ejection Fraction. StatPearls. StatPearls Publishing Copyright © 2025, StatPearls Publishing LLC.; 2025.
21. Nguyen HL, Saczynski JS, Gore JM, Goldberg RJ. Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review. Circ Cardiovasc Qual Outcomes. Jan 2010;3(1):82-92. doi:10.1161/CIRCOUTCOMES.109.884361 DOI: https://doi.org/10.1161/CIRCOUTCOMES.109.884361
22. Brown A. About 5% of young adults in the U.S. say their gender is different from their sex assigned at birth. Pew Research Center. Accessed 7/22, 2024.
23. Aranda G, Halperin I, Gomez-Gil E, et al. Cardiovascular Risk Associated With Gender Affirming Hormone Therapy in Transgender Population. Front Endocrinol (Lausanne). 2021;12:718200. doi:10.3389/fendo.2021.718200 DOI: https://doi.org/10.3389/fendo.2021.718200
24. James S.E. HJL, Rankin S., Keisling M., Mottet L.A., Anafi M. The Report of the 2015 U.S. Transgender Survey. 2016:92-129. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
Published
Issue
Section
License
Copyright (c) 2025 Anna Slebonick, Kristen Ryczak (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
