Gender and acute myocardial infarction symptoms
Patti Rager Zuzelo
Traditionally, research investigating acute myocardial infarction (AMI) has focused on men (Gurwitz, Coi, & Avorn, 1992; Kannel, & Wilson, 1995; Paul, 1997), leading to an understanding of AMI that is primarily based upon the male experience. While research focusing on women’s experiences with cardiac disease has been increasing (Chandra et al., 1998; Dempsey, Dracup, & Moser, 1995; La Charity, 1997; McSweeney & Crane, 2000; Warner, 1995), there remains a need to develop a more comprehensive gender-specific understanding of heart disease. This enhanced knowledge will lead to improved assessment, reduced delay in treatment time, and more effective teaching strategies.
This phenomenologic study was conducted to describe the symptom experience of AMI for women and men and to compare the symptom experience based on gender. The research questions of this study were: (a) What is the symptom experience of women and men who are admitted to a cardiac care unit with a diagnosis of AMI? (b) What are the meanings and essences of the experience? and (c) What are the differences in the AMI symptom experience of men and women?
Gender, Morbidity, and Mortality
Heart disease is the nation’s number one killer, but there is ample evidence that symptom patterns, interventions, and outcomes vary between men and women (American Heart Association, 2001). Indeed, Chandra et al. (1998) suggest that there are AMI mortality differences based upon sex. Some researchers (Fiebach, Viscoli, & Horwitz, 1990) have concluded that when in-hospital mortality rates are adjusted for baseline differences, men and women have similar mortality statistics and women have a lower incidence of mortality at 3 years post AMI. This uncertainty regarding the role gender plays in heart disease warrants closer review.
There are anatomic and physiologic differences between men and women that must be considered when investigating the etiology of cardiovascular disease and treatment responses (Becker et al., 1994; Chandra et al., 1998; Paul, 1997; Stone et al., 1995). However, the role risk factors play in contributing to heart disease is less well understood in women versus men. Until recently, very few controlled trials and longitudinal studies included female subjects (Kannel & Wilson, 1995). Nevertheless, many experts contend that estrogen protects women from coronary artery disease (Kannel & Wilson, 1995; Thomas & Braus, 1998). Once menopause occurs, all the major cardiovascular risk factors that promote coronary artery disease (CAD) in men, except cigarette smoking, also increase the CAD risk for women (Arnstein, Buselli, & Rankin, 1996; Kannel & Wilson, 1995).
Some suggest that a sex bias in diagnosing and treating CAD exists, and physicians persist in seeing women’s complaints as trivial (Beery, 1995). Differences between the response of men and women to thrombolytics when treating AMI have been shown (Becker et al., 1994; Stone et al., 1995). In an exploration of the demographics, treatments, and outcomes of AMI patients, investigators have found that while women are older when they suffer an infarct, when age is controlled, they still experience a higher mortality rate than do men (Chandra et al., 1998). Additionally, women receive fewer invasive therapies and are administered thrombolytic therapy 14 minutes later than men. When researchers used a multiple logistic regression model to predict AMI, gender differences were identified (Zucker, Griffith, Beshansky, & Selker, 1997). In this study, demographic and clinical characteristics were calculated to assess the influence of sex on the probability of AMI among patients presenting to an emergency department. The associations between presenting signs or symptoms and between gender were examined. AMI study findings suggested that signs of congestive heart failure (CHF) were associated with AMI among women. Also, male sex was a significant AMI predictor, but the significance of sex was eliminated among patients with ST segment elevation and signs of CHF.
Gender differences in symptom patterns and treatment have been explored. In a descriptive, correlational study, Warner (1995) compared the relationship between the level of somatic awareness and CAD in women experiencing chest pain and concluded that women with chest discomfort are greater diagnostic challenges than men. Later, McSweeney and Crane (2000) used a phenomenologic approach and described the prodromal and acute symptoms of AMI for 40 women. The most frequent prodromal symptoms were unusual fatigue, shoulder blade area discomfort, and chest sensations. The most frequent acute symptoms were chest sensations, shortness of breath, feeling hot and flushed, and unusual fatigue. Additionally, other researchers found that women experiencing AMI reported neck and back pain more frequently than men (Everts, Karlson, Wahrborg, Hedner, & Herlitz, 1996). Some data suggest that women may also differ from men in the psychological processes that they use to make decisions about seeking care when experiencing AMI symptoms (Dempsey et al., 1995).
Recognizing that men and women experience and respond to AMIs within the context of societal influences, Zerwic (1998) explored a community’s expectations of heart attack symptoms. The lay public expected chest pain, irregular heartbeats, shortness of breath, and an inability to move. These expected symptoms differed from the classic symptoms of diaphoresis, nausea, vomiting, weakness, and syncope that clinicians are advised to evaluate when assessing the patient who may be experiencing an AMI (Panju, Hemmelgarn, Guyatt, & Simel, 1998).
Numerous studies support the possibility of gender-related differences in cardiac functioning, CAD progression, AMI symptoms, and responses to AMI interventions. Differences in the way that men and women experience the symptoms associated with AMI have also been found. Additionally, there is evidence that suggests that there are gender-based differences in the medical modalities used to manage CAD. However, taken as a whole, the literature pertaining to the role that gender plays in the incidence, prevalence, and outcomes associated with CAD fails to paint a cohesive picture. Many uncertainties hinder clinicians’ ability to use knowledge-based practice to improve prevention, care, and prognosis. Hence, this study was proposed to explore in greater detail how gender affects AMI symptoms.
This qualitative research study used a descriptive phenomenologic design (Polit & Hungler, 1999) to explore sex-based differences in the symptom experience of AMI. Phenomenology is a philosophy and research perspective used to gain an understanding of human experience and the meaning of the experience. This method was chosen due to the need for a basic understanding of symptom experiences.
A purposively selected sample of women (N=10) and men (N=10) diagnosed with an AMI by a board-certified cardiologist was chosen. There was a concern for potential race-related influences on the symptom experience. Therefore, the variable of race was controlled by choosing only Caucasian participants. Demographics are summarized in Table 1. Exclusion criteria included mechanical ventilation; physical instability defined by vital sign fluctuations requiring vasopressor agents, intravenous antidysrhythmic therapy, or temporary external pacemaker support; extreme anxiety requiring exceptional psychological support using either pharmacologic or psychiatric intervention; dyspnea at rest or with conversation; and, unresolved chest pain. Patients’ cardiologists and the nursing staff had the right to exercise their judgment and exclude participants they deemed unfit from the sample pool. The institutional review boards of both the health care institution and the university reviewed and approved the study. Each participant signed the informed consent form and received a copy of the form. Participants were interviewed at their bedside in the cardiac care unit of a suburban teaching hospital over an 8-month time period.
The principal researcher telephoned the cardiac care unit charge nurse regularly to identify potential participants meeting selection criteria. Participants were interviewed within 36 to 72 hours of hospital admission. The researcher obtained informed consent from the participants immediately prior to the interview. Each participant was interviewed once. The interview was audiotaped and lasted between 15 minutes and 45 minutes. The researcher posed the open-ended question, “Tell me what your symptoms were like when you had your heart attack?” Prompters such as “What were you thinking about when you were having these symptoms?” and “What did the symptoms mean to you?” were used to obtain an exhaustive description of the symptom experience (Colaizzi, 1978). The men and women were encouraged to continue describing the experience until they had nothing else to add. After the interview, an informal note was placed in the front of the chart documenting patient participation in the study.
Reliability and Validity
Reliability and validity were addressed in several ways. Descriptive validity (Maxwell, 1992) was addressed by audiotaping the interviews, verifying the accuracy of the interview transcriptions, and using an audit trail that was developed to insure that indicators could be traced directly back to the original transcript. Threats to interpretive validity (Maxwell, 1992) were addressed through the use of literature review, discussion with nursing and physician experts, and analyzing data with research colleagues. Possible biases of the principal researcher, developed through the experiences of years of acute care nursing, were potential validity threats as were the biases arising from preliminary chart reviews and discussions with the charge nurse prior to each interview. These potential biases were explored and bracketed (Polit & Hungler, 1999). Reliability was also addressed by consulting with an expert in phenomenology who reviewed the audit trail and independently coded themes and subthemes within selected interviews to provide comparative analysis.
The transcribed interviews were thematically analyzed using the strategies outlined by Colaizzi (1978). Data were analyzed within male and female cohorts. The transcribed interviews were coded for themes and subthemes. Subthemes were labeled on the interview transcriptions and were organized around the indicators, quotations from the transcribed interviews. The subthemes were then clustered according to meanings and organized under themes. The themes were compared between sexes to explore commonalties and differences in the symptom experience. Themes were organized to reflect the meaning of the symptom experience and to create a detailed description of the symptom experience.
The themes were ordered from most to least common significant symptom experience from the perspective of the women and men.
Table 2 compares the themes between women and men.
Female Symptom Experience
The women’s symptom experiences were grouped into themes with clustered subthemes.
Feeling fatigued. Fatigue was an important symptom. Women described sleep disturbances, increased sleepiness, weakness, and tiredness as aspects of fatigue. They felt washed out, tired, and without ambition. Acknowledging that they were “sleeping more than usual” and “just feeling really tired,” women recognized that their weakness and fatigue were different than usual. “I haven’t been feeling well for a while. I haven’t felt like myself, very drained.” They found themselves sitting or lying down because the weak feeling was overwhelming. “I couldn’t move. I was just so weak that he had to practically carry me to the car.”
Some found themselves sleeping more than usual. Others had difficulty getting a good night’s rest. “I didn’t get a good night sleep. I didn’t sleep at all!”
Feeling breathing distress.
I. Shortness of breath. Women breathed differently during their AMI. They described being short of breath as “I don’t feel the air going down in my lungs.” Their shortness of breath was extremely uncomfortable. The women were singularly focused on the act of breathing. One said, “I wasn’t thinking about whether or not I’m getting enough air. You’re just aware that you have shortness of breath!”
II. Being unable to breathe. Women were unable to take a deep breath or to talk as they were having their MI. “It was as if I couldn’t take a deep breath!” This was a different feeling than the feeling of shortness of breath. One said she had “no significant distress other than difficulty trying to talk–which is distress enough in itself!” The women felt that there was not enough air moving into their lungs and they were unable to deeply fill their lungs despite the need for air.
III. Having dyspnea on exertion. Women did not tolerate their usual activities. They had dyspnea on exertion. For example, one noted, “I had to stop three times walking across the hotel.” The women were unable to tolerate their usual activities. “I was winded for just about the stupidest things.”
Having chest symptoms. Chest pain with breathing, pressure in the chest, and tightness in the chest focused women’s attention to what was going on in their chest cavity. “It wasn’t a pain. It was sort of a tearing feeling and a little pressure right in between my breasts.” One observed that her symptom experience included the sensation of “a ton of bricks were falling on my chest.” Chest pains were variously described as “a nasty little pain,” “a mediocre pain,” and “a hard pain … it squeezes, then it pounds, and then it burns.” Chest pressure was different from chest pain. Women felt “heaviness in the chest” as though “something was lying across my chest” or “like somebody was sitting on my chest.”
Having back and arm pain. Women complained of having pain in their necks that radiated to their temples, having a slight headache, and tooth pain. One said, “I had a slight headache and that was it.” The pain in their teeth was different from that of a typical toothache. The pain was severe and aching. “My teeth started to hurt–real bad.”
Women also complained of aches and pains in their backs. The backaches were pronounced, sometimes in conjunction with chest pain and sometimes radiating across the back. “My back was aching too but most of the pain stayed in the front.” They did not see a relationship between their back pain and their heart.
Women described weakness and pain in their arms. One said, “I went over and sat down on the chaise lounge and that’s when my arms started feeling weak.” Another said, “When the ambulance driver came over to me in the chair, he was picking them (arms) up. I remember it was just like jelly.” Some women felt pain in either one or both arms. The sensations in their arms felt like a combination of numbness, soreness, or cramping.
Feeling body temperature changes. When they were having their AMI, women noticed that their body temperature was changing. Some knew that they were sweating, felt clammy, or had a cold feeling. One woman said, “I broke out in a cold sweat. It was profuse … my hair was soaked and wet.” For some, there was a difference between feeling cold and having a cold feeling. Women who felt cold were appreciative of additional blankets while those with a “cold feeling” felt a “funny feeling” that was “frightening.”
Having distressing gastrointestinal symptoms. Gastrointestinal symptoms were distressing and uncomfortable. The women had a significant loss of appetite. They did not want to eat. “I didn’t eat anything. I just didn’t have an appetite.” Nausea was noticed with an “upset stomach.” One described this upset feeling as “I wanted to throw up and I couldn’t.” Some women noticed gaseous feelings like a “gas bubble in my chest” and “excessive burping.” One vomited during her AMI.
Being unaware. Women were aware that they were not fully alert at all times during their AMI symptoms. They did not remember what was going on around them. One said, “I thought I was conscious the whole time. I didn’t believe them when they told me I wasn’t.” Another asserted, “don’t ask me to remember anything else after that cause for some crazy reason, I can’t remember a thing until I ended up here!”
Being fearful. A few women were scared, worried, upset, and felt out of control during their heart attack. Some were afraid of dying. They felt that they were not going to survive their AMI. “I’m thinking that it’s the last breath.” They wondered if they were going to live. “You don’t know if you’re going to make it.” Women were afraid of not seeing their children. Some keenly felt this fear of death and recognized that they were not yet ready to die. One declared, “I had no time to die. I had things to do, and I wasn’t ready!”
Feeling calm. In contrast to those women who reported being fearful, others were calm, unafraid, and reassured during the event. They did not panic. “You know, I was scared but in the cath lab, I wasn’t. Something was lifted over me telling me not to be afraid anymore.” Some women remained calm and were stoic throughout the AMI. “I was alone and it was nothing exciting.”
Relying on the direction of key people in their lives. Women were often compelled to seek medical care by their family members and friends as the AMI symptoms unfolded. The key people in their lives, husbands and children, urged them to go to the hospital or call their physicians. “My husband said, `you’re going to the hospital today if I have to drag you!'” On the other hand, some friends and family members convinced the women to delay medical intervention. The reactions of family and friends were important to the women and their decision making was greatly influenced by these reactions. Hearing comments such as “you don’t look too serious” and “don’t worry” encouraged them to disregard or deny the importance of their feelings and symptoms.
Noticing symptom changes. Women felt fluctuating symptoms that varied in intensity, onset, persistence, progression, and resolution. Some were impressed by the sudden onset of their symptoms. “It came on rapidly, and it was pronounced and in my little experience with shortness of breath … it was dramatic!” Others felt a gradual onset of a constellation of symptoms. “The symptoms happened a couple of hours after I first felt washed out.” In contrast, one was unimpressed by her symptoms saying, “it wasn’t anything drastic at any time.”
Some women lived with symptoms for a few days, although they did not realize the origin of their symptoms. “I had that feeling for a couple of days. I’ve had it before that I can remember and it goes away.” The symptoms were often persistent, lasting for hours or for days. Most did not experience complete symptom relief until they received medical intervention. Women noticed that, at times, their symptoms changed. “The chest hurt first and then the nausea came.”
Managing symptoms. Once symptoms presented, women tried to relieve them using interventions to help them relax. One used warm baths to relieve her aches. Women believed that rest and sleep would rid them of symptoms. “I thought, `now all I need is a good night’s sleep.'” One tried to induce vomiting to relieve her upset stomach.
Trying to make sense of symptoms. Women tried to make sense of their symptoms by attempting to interpret them within the context of past experiences or based upon their preconceived ideas about heart attack symptoms. Those with particularly distressing gastrointestinal symptoms believed that they had developed food poisoning or gallbladder disease. Aching feelings were explained away as muscle pain or arthritic pain. “I have arthritis so I thought maybe the back pain was from arthritis but evidently, I guess it wasn’t.” Depending upon their past health experiences, the women tried to relate their AMI symptoms to familiar conditions. “I’d had walking pneumonia and I thought it would be pneumonia because of the extreme tiredness and pain in the chest.” Women who had a history of angina associated their pain with an anginal episode rather than a heart attack. “I would get angina and I thought maybe it was one of those attacks coming on.”
Women with a family history of heart disease or with a previous history of AMI were concerned that they were experiencing a heart attack. “I was afraid it was a heart attack because it’s in the family.” Some recognized that although their symptoms were unfamiliar and new to them, there was a possibility that they were experiencing an infarction. “I wasn’t sure but I thought maybe it was a heart attack because I never felt like that before.” Women who had a history of AMI recognized their symptoms as heart symptoms. “I had a silent heart attack earlier this year. I had an echocardiogram which showed that I had some damaged heart muscle due to a heart attack which had produced those symptoms.”
Women recognized their risk factors for AMI. One spoke to herself during her symptoms and said, “You had some real warning signs here. You’re a heavy smoker. You’re overweight. It’s in the family. You’re not taking care of yourself and you certainly don’t feel well!” For some, interpreting their symptoms was particularly difficult given other chronic medical problems. “I have asthma and most of the time, if anything goes on, I just think it’s asthma.”
I. Seeking immediate treatment Some women knew that their symptoms reflected a life-threatening problem. They realized that they needed help. “It’s funny because in about 5 minutes I recognized the fact that I needed help.” These women did not take time to consider their symptoms–they simply reacted. “I didn’t have any thoughts at all–just to get help!”
II. Wrapping up home responsibilities. Alternatively, other women fulfilled obligations prior to seeking care. These women prioritized meeting their role obligations over seeking medical evaluation. They were concerned about taking care of their husbands and their homes. “I stayed home and I laid on the couch. I got up and walked around and did some cleaning. I made dinner.” The women juggled their symptoms with their activities. “I fried the steak, but while I’m frying, I’m sitting down at the same time cause I feel I’m getting tired.” They were conscious of not interrupting the normal household routines. “I’m not telling my husband yet because he’s eating real good.”
III. Wanting to avoid hospitalization. Women did not want to be admitted to the hospital, particularly if it was not the hospital of their choice. One stated, “I knew I wanted to be home!” At times, they delayed seeking medical care simply because they were reluctant to become a patient. “He wanted to bring me in Friday or Saturday and I wouldn’t go. I don’t like hospitals!” Some chose to stick out the pain rather than go to a hospital that they did not prefer. “But I thought, if it is a coronary, they’re going to ship me right across the street to–Hospital and I didn’t want to go there. So, I said, `oh well, I’ll see if I can stick it out until morning.'”
Being surprised. Some women were surprised that they were diagnosed with a heart attack. “I didn’t know I had a heart attack.” They were astounded that a heart attack could happen despite regular medical examinations. “I really don’t know how. It’s not that we don’t go to the doctors. We get checked up all the time!” One was surprised that she had not recognized her symptoms as related to the heart given her past exposure to the medical field. “I should have known what it was. I should have known cause I had been a nurses’ trainer once.”
Male Symptom Experience
The men’s symptom experiences were grouped into themes with clustered subthemes and arranged beginning with the most frequently cited significant symptom experiences.
Feeling chest sensations. Men had chest sensations that were “heavy.” Chest heaviness was “a caved-in feeling … uncomfortable.” The men noticed tightness in the chest area. They felt “chest pressure” similar to “an intense feeling where you feel like maybe somebody is squeezing you. There’s no relief. It just doesn’t go away.” Some men experienced pain in their chests rather than pressure. “When I woke up out of bed, I had a sharp pain right in the chest. A sharp, deep, stabbing pain just straight in the chest.” They noticed that the pain they felt was different from a pressure sensation. This pain was centered in the middle of the chest region. “The pain was in the very center of the chest.”
Changing breathing patterns. Men noticed changes in the way that they usually breathed. Several felt that they could not breathe and were “blocked from oxygen.” They were very distressed by their inability to catch their breath. “There was no satisfaction. I was constantly gasping for air!”
Men found themselves breathing heavily during their AMI and felt short of breath. “I had an uncomfortable time trying to get air into me. I was huffing and puffing.” Some men particularly noticed this shortness of breath during activities and intermittently throughout the day. The shortness of breath scared the men. “Shortness of breath is the scariest. You just seem like you can’t get enough air in your lungs and you fight it as hard as you can to get that damn air in your lungs!” In contrast, a few did not notice any changes in their breathing and were not troubled by shortness of breath.
Having upper limb pain and numbness. The men noticed pain in either one or both arms. The pain was “sharp” or “tingling.” Their arms hurt. “I woke up with pains in my arm Saturday morning from the elbow on down in both arms. They were very sharp pains all day long.” The pain was relentless and never completely went away throughout the AMI. Some men had arm pressure or heaviness in either the left arm or both arms. “It was very hard to bring my arms up. They felt very heavy like somebody is just pulling on you … squeezing on you.” Arm pain was different than arm heaviness. One man had pain in his left wrist that was “a real sharp pain” that was “burning” and “almost felt like it was drawing my fingers together.” The arm heaviness was like “you just got done swimming a marathon and you had absolutely no more strength left in your arms and when you just picked them up, they just fell.”
Some felt hand numbness. The numbness prevented them from controlling their hand and using it in the way in which they were accustomed. “My left hand went completely numb. I was trying to hold onto the wall and there was no control.” This numbness was concerning to the men as they were unable to determine its cause. “All day Saturday I was saying, `what’s going on here?'”
Noticing head and neck symptoms. The men had pulling, tightness, pressure, and tingling feelings in their jaws that were so subtle that they did not notice them until after their AMI event. “I never realized I had jaw tingling until a couple days later when somebody mentioned it.” One noticed minor pain in his neck and throat.
Having gastrointestinal distress. Men were distressed by gastrointestinal disturbances. They felt stomach upset and were uncomfortable with significant indigestion. “I guess it was like somebody punching me in the stomach. It doubled me over and just felt like indigestion.” The men needed to burp and noticed that their discomfort felt like gas. “It felt like my abdomen was full of gas and it wasn’t allowing my chest to expand.” Some believed that if they could only burp, some of their distress would be alleviated. “It just felt like it was another burp to come out. So, that’s why I thought it was indigestion.” One vomited during his AMI and after a single event of emesis, the feeling of needing to vomit was gone.
Feeling changes in consciousness. Men felt lightheaded and dizzy during their AMI. These two feelings were often experienced simultaneously. Some were concerned that they were going to lose consciousness. “I thought I was going to lose consciousness but I didn’t reach that point.” One did lose consciousness and experienced a loss of bowel control and a seizure during his AMI.
Noticing sleep disturbances. Several men had restless or interrupted sleep. “I was up all night laying down. I’d lie down and the indigestion would hit me or whatever the heck it was and I’d get up again, walk around, and watch TV.” At times, their symptoms abruptly woke them from a sound sleep. “About 4 o’clock, suddenly I got up.” Once they were awakened, they were unable to fall back to restful sleep.
Responding emotionally and spiritually. As their heart attack symptoms persisted, the men were afraid and scared. “I was frightened. I was absolutely frightened because the one fear that I had was that I was going to have to come here to the hospital.” Men with a previous history of heart problems were upset and fearful when they recognized that their symptoms were related to another heart attack, particularly when they had undergone previous procedures to correct their heart disease. “I knew what it was but it scared me more this time.” One man had visions during his AMI and was moved to begin praying for fear that he might not see his mother and wife again.
Some viewed their heart symptoms as bothersome and inconvenient events. “I was calm, I guess, but felt like, `there goes my weekend!’ I had plans for the holiday and I don’t know if I can still make them. So, it wasn’t that I was afraid that I was going to die or expire or anything else.” One regarded his symptoms as aggravating and bothersome saying, “It’s bothersome. I wasn’t scared. I was just kind of aggravated that I couldn’t catch my breath.”
One man was uncertain and “dazed” about the events going on around him while others felt confident and assured that they would survive the heart attack. They believed that they would overcome their health problems. They found new determination to address and correct their poor health habits. “It left me all the more challenged to get going and get off the cigarettes and beer.”
Feeling warm and sweaty. Men were diaphoretic during their heart attacks. They felt warm and noticed sweat on their foreheads and, at times, soaking through their shirts. For some men, the sweat was profuse. “I started to perspire and my undershirt was completely soaked. It only lasted about 5 seconds but I could tell that my whole shirt was wet!” The men experienced thermal symptoms including feeling warm. Their symptoms varied from “I was sweaty a little bit. My forehead was sweaty a little bit” to “I was soaked and wet–wringing wet!” The men were impressed by their amount of sweating. One said that he “broke out into a sweat like I was covered in water.”
Being warned during activities. Men had difficulty participating in their usual physical activities. “I was working outdoors and I noticed that every time I overexerted myself, I would fall and gasp for breath with pain.” Routine chores and enjoyable activities became difficult. Men found that climbing stairs, walking up hill, or activities after meals triggered worsening symptoms. “The walk up the stairs was a bit much. I never did recover from that.” Those who were familiar with angina symptoms noticed that their chest pain and shortness of breath came during activities that were previously tolerable.
Having no warning. Conversely, some of the men had no warning signs. One said that his symptoms “just hit me” while another noticed that “I didn’t feel real good but I did wake up like I normally do and I started my normal Saturday routine.”
Noticing that pain travels. Men’s heart attack symptoms varied in their pattern of radiation and degree of pain. Men noticed pain pathways. “It started under the breast bone, mostly under the breast bone, and into the jaw, right to the back of the neck, and then down the left arm.” They were interested in the sequence of their pains. “The arm and chest pain started right at the same time. Then, the jaw pain started.” The men noticed the changing qualities of their pains. “It was a very sharp pain, very sharp.”
Responding to medical treatment. Men responded to the medications and interventions made available on the ambulance and in the emergency department. “They took care of everything there and put me on different medications and within an hour, I felt better.” They were impressed by the effectiveness of the medicines. “They started putting nitroglycerin into me and within about 10 or 15 minutes, the pain was gone and I haven’t had any since then.”
Trying to make sense of symptoms. Some men realized that their symptoms were related to their heart while others were confused by co-existing medical problems that complicated their symptom interpretation. “I finally came here even though the doctor told me in February that I was just having an epiglottis problem.” Men recognized that they were experiencing an emergency and sensed that they needed immediate treatment. Once they realized this fact, they quickly sought care. “She was talking to our family doctor and I said, `No, let’s go right to the hospital. I think its worse than what I thought it was.’ She drove me down here and that was it.” Men realized that they had to get help. “Getting to the hospital was the uppermost thing in my mind. I didn’t care what I was wearing or how I was dressed. I wanted to get to the hospital because I knew that was my only chance.”
Men interpreted their symptoms based upon previous experiences. “I kind of felt like I was having a heart attack again because it felt similar to the one I had before.” At times, they thought that their symptoms had nothing to do with their hearts. As a result, they tried a variety of ways to get rid of their discomforts. “I first thought it might have been a reflux thing or something like that.” One thought he had “twisted a muscle in my arm” while another attributed his difficulties to temperature differences from air conditioning.
Self-managing symptoms. Men tried to control their symptoms using a variety of strategies including breathing techniques, fresh air, and relaxation. “I just laid all day thinking that whatever was wrong would go away.” Breathing deeply and rhythmically helped some men deal with their pain. “I just kept taking deep breaths and eventually it went away.” Some men denied the reality of their symptoms or refused to acknowledge the importance of their symptoms. “Even when it became clear that from this institution’s point of view, I had a heart attack, I wasn’t going to accept it.” One pointed out that, “I’m a survivor so I tend to close my eyes, grit my teeth, and endure.” At times, Maalox[R] or ibuprofen was used to treat the stomach upset or aches and pains associated with the heart attack.
I. Seeking help from others. Married men shared concerns about symptoms with their wives who directed them to seek medical care. “That was when my wife said, `Enough is enough!'” If men were not in the company of their wives, they told people who were near and convenient to them. “I went to work and I told the checker and she says, `You know, it might be something else’ I said `No, its just indigestion. I’ll get a bottle of Maalox’.”
II. Accessing medical care. Men contacted emergency services for ambulance transportation to the hospital. “I called the ambulance right away as soon as I realized something was going wrong.” One asked his son to bring him to the hospital since “we only lived about two, three hundred yards from the hospital.”
Teaching others based upon personal experiences. Men wanted to talk about the factual information that they had learned about medical care and heart attacks. “I felt tightness and a certain amount of discomfort which may be due to the lack of circulation when the angina pain started.” They were interested in the mechanical aspects of their heart. “I understand from the doctors that the way to tell whether there is angina, upset stomach, or indigestion is to use the nitroglycerine and, after about 2 or 3 minutes, if the pain subsides after you place the pill under the tongue, then you have a heart problem.”
Men considered their risk factors for heart attack and blamed their heart disease on smoking, diet, weight, and stress. “I was under stress because I was trying to pick out a new vehicle and we had gone to McDonalds. I had my fries and my hamburger and then we came back to deal with the salesman again. We got in the parking lot and that’s when it just hit me.” As a result of their new insights, they offered suggestions for other people to heed in order to prevent heart damage. “Just get those symptoms checked out before you have one.” Men believed that seeing a doctor as soon as pains present could decrease the chances of a heart attack.
Acquiring information about heart attacks.
I. Hearing about heart attack symptoms. Some men had heard about heart attack symptoms from other people. “Everybody says it’s a pain in your arm and your jaw could go numb.” They recognized that heart attack symptoms could be individualized and unique. “When you experience it, it’s totally different than what you’ve heard about.” Men compared and contrasted their symptoms to those shared by others. “It was not as if somebody was sitting on my chest and I didn’t have pains down my arm. My fingers weren’t numb as would describe a major heart attack.”
II. Being misinformed. Men were surprised at the misinformation they had heard about AMI. “Having some indigestion really was having a heart attack. I’ve never heard of anybody saying that this is a possible sign of a heart attack.” Because they were uninformed or misinformed, the men had trouble accurately interpreting their symptoms. “A couple of times when I had sex it really bothered me in the chest. I never thought that it was the heart.” One man was surprised that despite reading about heart attacks, it “never even dawned on me that having pain from the elbows down was from a heart problem.”
Gender-Based Differences And Similarities in AMI Symptom Experiences
There were similarities and differences between the men and women with respect to their AMI symptom experience. Women felt overwhelmingly fatigued and tired prior to and during their AMI. Men did not notice a similar feeling of extreme fatigue. Often, women attended to their role responsibilities as wife, mother, and homemaker prior to actively seeking out medical intervention. They were sensitive to the suggestions and advice of the people who were dear to them. Men solicited input from their wives and acquaintances; yet, they were more directive once they realized the urgency of their symptoms. The men were focused on the need for care once their symptoms were identified as emergent. The women paid attention to their symptoms but simultaneously continued to be solicitous and aware of the perceived expectations and opinions of the people around them.
While both men and women noticed changes in the temperature of their bodies, men perspired heavily compared to the women. Also different, women had back pain during their AMI. Both men and women were distressed by changes in their breathing; however, some of the women felt like they could not breathe deeply and could not fill their lungs with air. The men did not notice this same feeling. Rather, the men felt deprived or short of air.
Women and men were frightened by their symptoms but the women did not always prioritize this fear over the inconvenience or aversion to admission to a hospital that they viewed as undesirable. Men did not have these same concerns. Once the acuity of their symptoms was recognized, the men sought medical care. They were not concerned about the particular hospital that would be involved in providing this care.
Some women had felt tooth pain during their heart attack. In contrast, men noticed tingling or pain in their jaws or necks but they did not notice pain in their teeth. While both men and women felt pain, numbness, and weakness in their arms, the men felt numbness to a greater extent than that felt by the women.
Men were curious about the facts and details of their heart disease and their AMI. They were intrigued by the various medications and invasive therapies used by the medical team. Women were less interested in the science of their AMI event. They knew how they felt and how they were feeling. The women did not analyze their circumstances as did the men and were less active in seeking the details of their plan of care.
Study findings reveal some intriguing similarities and dissimilarities in the AMI symptom experiences of men and women.
The findings supported the conclusions of other researchers who have suggested that the most frequent acute myocardial infarction symptoms experienced by women include chest sensations, shortness of breath, feeling hot and flushed, and unusual fatigue (McSweeney & Crane, 2000). In a grounded theory study (Dempsey et al., 1995), researchers described the psychological processes by which women experiencing AMI symptoms determined whether or not to seek medical treatment. Their findings suggested that the basic structure of these psychological processes involved two fundamental categories: maintaining control and relinquishing control. Dempsey et al. (1995) concluded that women’s decision making during AMI symptom experiences was influenced by multiple factors which included: symptom awareness, perceived symptom insignificance, beliefs about AMI and CAD, past symptom experience, denial, commitments, concern for others, and outcome uncertainty.
The decision-making influences identified by Dempsey et al. (1995) were consistent with the themes and subthemes described in this study’s results. Additionally, the grounded study findings indicated that once women acknowledged the severity of their symptoms and began to relinquish control, they consulted lay people for advice. The advice of lay people either encouraged the women to immediately seek care or encouraged the women to delay seeking medical intervention. These conclusions were supported by the findings of this phenomenologic study.
The symptom experience of these white men was consistent with the findings of other published studies (Zucker et al., 1997) and reports (Halm & Penque, 1999). The men noticed chest sensations of heaviness, tightness, pressure, squeezing, and pain. They also described changing breathing patterns, having upper limb pain and numbness, noticing head and neck symptoms, and having gastrointestinal distress as significant symptom experiences associated with their AMI. The American Heart Association identifies the most common heart attack warning signs as pain or discomfort in the center of the chest; discomfort in one or both arms, back, neck, jaw, or stomach; shortness of breath; and other signs including a cold sweat, nausea, and lightheadedness (AHA, 2001). Interestingly, the male participants described these same classic signs as significantly important.
Generalizability refers to “the extent to which one can extend the account of a particular situation or population to other persons, times, or settings than those directly studied” (Maxwell, 1992, p. 293). The intent of this study was to provide a description of the symptoms associated with myocardial infarction as described by the white men and women experiencing AMI. The intent of a qualitative, phenomenological study is to provide a richly detailed descriptive account of the particular experience as it is lived by the participants. The findings should not be generalized to all men and white women who have had an AMI. Rather, the results of this study may be used to enhance the current understanding of AMI and to develop a more informed awareness of the symptom experience as lived by some Caucasian men and women. Qualitative methodology is not used to infer findings to a larger population.
Demographic variables for this study included age, sex, type of AMI, presenting signs and symptoms as recorded in the medical record, and a previous history of AMI. Socioeconomic status information was not collected as a demographic variable given the lack of support in the literature for this particular variable as an influence on AMI symptomatology.
While its limited scope precludes wide generalizabilty, this study has several implications for practicing nurses. Many of the participants had some type of pre-existing knowledge concerning the symptoms of a heart attack, and they interpreted this information as factual and exact. The men and women did not appreciate the possible nuances of symptoms associated with an AMI. Those with some understanding of AMI tended to look for “classic” signs and symptoms or previously experienced symptoms. They were unaware that people experience symptoms differently and uniquely. It may be that the individuality of the symptom experience should be stressed when teaching about AMIs. When discussing the classic signs and symptoms of a heart attack, nurses should include information about the possible ambiguity and individuality of symptoms. Incorporating possible gender-specific symptom experience information into teaching materials and public information campaigns may be helpful to support efforts directed towards reducing the amount of time between symptom recognition and health care system access.
Study findings emphasize the importance of primary and secondary prevention initiatives to combat CAD. The National Institutes of Health (NIH) National Institute of Heart, Lung, & Blood initiative, “Act in Time to Heart Attack Signs,” is a joint endeavor with the American Heart Association designed to raise awareness about the need for a fast response to AMI signs and symptoms on the part of patients, the general public, and health care professionals. Although there have been many life-saving advances in heart attack treatment options, only a small number of patients are getting into the health care system within the first hour of symptoms. As a result, many patients are unable to reap the full benefits of AMI therapy (NIH, 2001).
One barrier to early AMI intervention is the incongruence between the symptoms people actually experience with AMI and the symptoms that they expect to experience with AMI. People tend to believe that AMI presents as a dramatic event rather than anticipating AMI as an occasionally subtle and quiet constellation of symptoms or as a singular symptom presentation (NIH, 2001). Increasing awareness of the variety of symptoms experienced during AMI is a critical component of any effort targeted toward reducing the delay between symptom presentation and health care intervention response.
The findings suggest that AMI assessment accuracy may be enhanced when sex-specific information is included in nursing and physician assessments. Symptom experience study findings could be used to develop emergency department AMI assessment checklists that are sex specific. Additionally, and very importantly, future studies are needed that explore the AMI symptom experiences of diverse patient populations.
Sex Type of AMI Age Presenting Signs Previous MI
Female Anteroseptal 73 Chest pain (CP); Shortness No
of breath (SOB)
Female Inferior Wall 44 Substernal CP; SOB, Nausea; No
Female Inferior Wall 46 Substernal CP Yes
Female Non-Q wave 88 SOB; Chest discomfort No
Female Anterior 85 SOB; Increased lethargy No
Female Non-Q wave 90 SOB No
Female Anterolateral 77 Nonradiating CP; Nausea No
Female Anterolateral 82 CP Yes
Female Anterior 76 SOB; Weakness No
Female Septal 80 CP; SOB No
Male Anterior 79 SOB; Nausea No
Male Anterior 56 CP; SOB; Diaphoresis Yes
Male Inferior 40 Substernal CP; Left arm No
pain; SOB; Nausea
Male Inferior 65 CP; Left arm numbness; No
Male Inferior 60 CP No
Male Subendocardial 44 Chest tightness; SOB No
Male Inferior 55 Sob; Nausea; Diaphoresis No
Male Subendocardial 50 CP; Diaphoresis; Jaw pain; Yes
Male Subendocardial 83 Chest pressure; SOB Yes
Male Inferior 41 CP; SOB; Diaphoresis No
Note. Myocardial infarction type described by area of involved
Sex-Based Comparison of AMI Symptom Experience Themes
Female Symptom Experience Male Symptom Experience
Feeling Fatigued Feeling Chest Sensations
Feeling Breathing Distress Changing Breathing Patterns
Having Chest Symptoms Having Upper Limb Pain and Numbness
Having Back and Arm Pain Noticing Head and Neck Symptoms
Feeling Body Temperature Changes Having Gastrointestinal Distress
Gastrointestinal Symptoms Feeling Changes in Consciousness
Being Unaware Noticing Sleep Disturbances
Being Fearful Responding Emotionally and
Feeling Calm Feeling Warm and Sweaty
Relying on the Direction of Key
People in their Lives Being Warned During Activities
Noticing Symptom Changes Having No Warning
Managing Symptoms Noticing that Pain Travels
Trying to Make Sense of Symptoms Responding to Medical Treatment
Setting Priorities Trying to Make Sense of Symptoms
Being Surprised Self-Managing Symptoms
Teaching Others Based upon Personal
Acquiring Information About Heart
Note. Themes are listed from the most to least common significant
symptom experiences as described by the women and men.
Acknowledgments: The author acknowledges the contributions of Suzanne Chase, BSN, RN, Assistant Researcher, who participated in the literature review and data analysis as a senior student while enrolled in La Salle University, School of Nursing. The study was funded by the Kappa Delta chapter, Sigma Theta Tau, International; La Salle University. Additionally, funds were made available through the Institute for the Advancement of Mathematics, Science and Technology Research Fellowship program of La Salle University to support literature review activities.
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Patti Rager Zuzelo, EdD, RN, CS, is Assistant Professor and Clinical Nurse Specialist Track Coordinator, La Salle University; and Associate Director of Nursing for Research, Albert Einstein Medical Center, Philadelphia, PA. She practices as a Per Diem Nurse, Emergency Trauma Care Unit, Abington Memorial Hospital, Abington, PA.
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