Typical and Atypical Symptoms of Myocardial Infarction Among African-Americans, Whites, and Koreans

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Typical and Atypical Symptoms of Myocardial Infarction Among African-Americans, Whites, and Koreans Haeok Lee, DNSc, RN, Robert Bahler, MD, Oh-Jang Park, PhD, RN, Cho-Ja Kim, PhD, RN, Hyang Yeon Lee, PhD, RN, and Yoo-Jung Kim, MSN, RN

Mortality from corona1y heart disease (CHD) in the United States has been declining for men and women and for minorities and whites since the early 1980s. 50 In the last two decades, major efforts and dollars have been applied to develop effective pharmacologic and percutaneous therapies for acute myocardial infarction (MI) . Reperfusion therapy seems to be the most effective method of limiting myocardial damage, and it has significantly reduced the morbidity and mortality of MI.2· 13 • 15 Nevertheless, the success of this thrombolic therapy is highly time-dependent, and only a fraction of pa-

This study was supported by a grant from the Ame rican Heart Association and a research gra nt from Chonnan National University for Professors' Research Year. From the School of Nursing, University of Colorado Health Sc iences Center, Denver, Colorado (HL), MetroHealth Medical Center, Cleveland, Ohio (RB); and College of Nursing, Chonnan National University, Kwangju, (0-JP, Y-JK), College of Nursing, Yonsei University, Seoul (C-JK), and Department of Nursing, Kyung Hee Un iversity, Seoul (HYL), Korea

tients eligible for reperfusion therapy receive it, primarily because of delays in hospital arrival. 11 · 19- 21 • 35 • 47 · 53 There are a variety of reasons for delays in seeking treatment. Patients may fail to recognize that their symptoms represent a significant medical problem requiring immediate attention, the symptoms they experience may differ from those they expect to have, or they may encounter financial and organizational barriers to seeking treatment. Clinical symptoms at the onset of MI are important because they lead patients to seek professional therapy and assist health care professionals in diagnosing ML Furthermore, atypical clinical symptoms (i.e., symptoms other than chest pain) may lead health care professionals to an incorrect or delayed diagnosis and delayed intervention.5. 28 • 51 Experiencing the typical clinical symptom of chest pain, experiencing severe symptoms, and perceiving symptoms as a serious problem have predicted reduced delay time.9, 12 • 16 • 23, 3 1 In addition, when symptoms begin suddenly rather than progressing slowly and when

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symptoms are not resolved, patients come to the emergency room earlier. 1• 9 • 10 Longer delays occur more frequently in those w ho present with the atypica l clinical symptoms of dyspnea, shortness of breath, or syncope or in those with slow symptom progression. 8 · 30 · 38· 43 Several studies have found that atypical clinical symptoms of dyspnea or shortness of breath are reported more frequently by elderly, female, and African-American (AA) MI patients. 3· 6~9 . 26 · 36· 40 Perkoff 40 found that white MI patients were much more likely to complain of chest pain (64%) than were AA MI patients ( 40%). Dyspnea was t:V\rice as likely to be the presenting symptom of MI in AA patients compared with white patients (31 % vs 12%). Clark et al 6 found that although chest pain was the presenting symptom in 85% of patients (n = 304) admitted to the critical care unit of an inner city hospital , AA patients presented significantly more often without chest pain than did Hispanic or white patients (22.7%, 9.1%, and 4.9%, respectively; P < 0.001). Patients without chest pain more often had congestive heart failure (P < 0.01) and a history of hypertension (P < 0.06). Although several studies focused on the symptoms of MI, the studies only tested whether AAs experienced chest pain at the onset of MI but did not explore the full range of types of MI symptoms. Moreover, no research has been conducted to explore types of MI symptoms and treatment-seeking behavior of Asian-Americans. Health care professionals and patients have been sensitized to the importance of chest pain as a marker for MI. Indeed, public education has essentially said, "For chest pain, dial 911 and call for an ambulance." 18· 32· 34 Our knowledge of chest pain as the classic symptom of MI is based largely on data gathered from middle-class white men, however. 17 Unfortunately, researchers and health care providers have generalized the findings to nonwhites, women, and the elderly by assuming that they would experience the same symptoms of MI that midclleaged white men experience . As a result, the content of public education campaigns in the United States has possibly misguided people who may experience symptoms other than chest pain when they develop MI.

A part of the National Institute of Health's mission is "science in pursuit of knowledge to improve human health." There is some question about whether the health of AAs, Hispanic-Americans, and Asian-Americans or Pacific Islander-Americans (AAPis) is being improved specifically by research, however. A lack of data has hampered efforts to make the US health care system more responsive to the needs of an ever more racially and ethnically diverse population. Data are particularly unavailable for Hispanic-Americans and Asian-Americans. Studying MI in KoreanAmericans, a subgroup of Asian-Americans, is difficult because of the challenge of recruiting an adequate sample. In Korea , the incidence of CHD and associated mortality rates have steadily increased since the 1980s, possibly as a result of Western influences, including changes in nutrition and an increasingly sedentary lifestyle. 24 • 25 We developed an international study to describe MI symptoms among AAs, white Americans, and Koreans. Specifically, the study compared the types of MI symptoms reported by AA, white, and Korean MI survivors.

Method Sample A consecutive series of 128 AA and white MI patients who had survived at least 2 clays after admission were recruited at two inner city university teaching hospitals and two community hospitals in the United States. A consecutive series of 89 Korean MI patients who had survived at least 2 clays were recruited at one university hospital located in the capital city of a southern province of Korea. Identica l variables were used in the United States and Korea, including a standard diagnosis of MI. Acute MI was diagnosed when two or more of the following existed : the characteristic clinical presentation, pathologic Q waves in electrocardiographic or serial ST-segment and T-wave changes, and an increase in serum creatine phosphokinase and creatine phosphokinase-myocarclial band (MB) fraction above normal. Patients were excluded if they were unable to be interviewed because of severity of illness, presence of delirium or dementia, or other cognitive or language

MYOCARDIAL INFARCTION AMONG AFRICAN-AMERICANS, WHITES, AND KOREANS

problems. Informed consent was obtained from all subjects in the United States.

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1neclical record was examined for risk factors and other clinical variables.

Data Collection

Results

Subjects were approached and interviewed 2 to 3 clays after admission to the hospital. A semistructured interview was conducted with trained nurse interviewers. The same data collection form was used , although the English version was translated into Korean. During the interview, the nurse interviewer asked about the types of symptoms experienced, the onset of symptoms, and how the patient perceived the symptoms. The emphasis in the interviews was on enabling survivors to give spontaneous accounts of their assessment of symptoms at the onset of the heart attack. Open-ended questions and questions with "yes/no" answers were used. Although the interview guide had no prior reliability testing, content validity was established through review of the current literature and consultation with experts in treatmentseeking behavior and clinical cardiology. The

Table 1

Sample Description The demograph ic characteristics of AA, white, and Korean MI patients are presented in Table 1 and Table 2. Of the 128 subjects in the United States, 45% were women and 55% were men; 32% were AAs , and 68% were white. Nine percent were under 50 years of age, and 44% were over 70 years of age. Thirty percent of the Korean subjects were women. Twenty percent of Korean MI patients were under 50 years of age, and only 28% were over 70 years of age. Women accounted for significantly more AA patients than white and Korean patients (63% vs 39% vs 30%, respectively). AAs had significantly more Medicaid health insurance (40% vs 13%), although significantly more whites had combined private and Medicare health

DEMOGRAPHIC CHARACTERISTICS OF AFRICAN-AMERICAN AND WHITE MYOCARDIAL INFARCTION PATIENTS

Variables Age (y) <50 50- 59 60-70 > 70 Gender* Female Male Marital status Married Widowed Divorced/separated Living alone Monthly income* < $1000 < $2000 < $5000 >$5000 Health insurance* Medicaid Private Med icare Medicare + private No insurance

Total (N

= 128)

African-Americans (n

= 41)

Whites (n = 87)

9 21 26 44

7 24 32 37

9 20 23 48

45.1 54.9

63.4 36.6

39 .1 60.9

51.1 34.6 10.5 31.6

43.9 34 .8 12.2 29.3

52.9 34.5 9.1 34 .5

41.0 26.5 21.4 111

61.8 20.6 8.8 8.8

32 .9 26.6 27.8 12.7

21.9 35.9 12.5 25.0 4.6

40.0 32.5 12.5 7.5 5.0

13.0 37.7 12.0 34 .9 2.4

'P< 0.05. Al l variab les are percentages, except for the age variable: mean

± SD

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LEE et al

Table 2

DEMOGRAPHIC CHARACTERISTICS OF KOREAN MYOCARDIAL INFARCTION PATIENTS

Variables Age (y) <50 50-59 60- 70 > 70 Health insuranc e Medicaid Group insurance Monthly income (Won) < 1 million 1 million to > 2 million 2-3 million > 3 million

Total (N = 89)

Men (n = 62)

Women (n = 27)

20 45 24 11

20 45 25

8

21 44 22 15

7 93

6 94

92

33 39 19 9

34 31 22 13

30 59 1 0

8

All variables are percentages.

insurance (34% vs 8%). In Korea, most of the patients (94%) held socialized group insurance, and a few p atients (7%) were on a government-subsidized health insurance program similar to Medicaid. Significantly more AAs than whites had low monthly incomes ( P < 0.05) . The incomes of Koreans w ere measured in Korean currency; when their incomes were converted into dollars, they were found to be in the range of middle-class incomes. Corona1y risk factors are shown in Table 3 and Table 4. The most prevalent risk factors in the AA group were hypertension (80%), cholesterolemia (73%), diabetes (47%), and smoking (42%). In the w hite group, the majo r risk facto rs were cholesterolemia (58%), hyp ertension (57%), smoking (31%), and diabetes (23%), and in the Korean group, hypertension (65%) , smoking (60%) , and diabetes (11 %) were the major risk factors (cholesterol was not measured in the Korean group) . A significantly greater number of AA p atients than white p atients had a histo1y of hyperten-

Table 3

sion , left ventricular hypertrophy, diabetes, or cholesteremia and were current smokers (P < 0.05) . The Korean group showed a significantly higher incidence of smoking and a lower incidence of diabetes than the AA and white groups. Typical and Atypical Symptoms of Myocardial Infarction

Table 5 shows the symptoms of MI in AA, white, and Korean subjects. When AAs and whites were compared , chest pain was the most frequent symptom in AAs and whites (77%); however, many MI patients presented with atypical symptoms, including pain in the shoulder, neck, and jaw (39%); dyspnea (33%); perspiration (32%); nausea and vo miting (28%); fatigue (21%); and palpitations (6%). Seventy percent of patients had more than two clinical symptoms, but 4% had no symptoms. Although the frequency of chest pain was similar in the two groups, whites presented w ith p ain in the shoulder,

RISK FACTORS OF AFRICAN-AMERICAN AND WHITE MYOCARDIAL INFARCTION PATIENTS

Risk Factors(%)

Total (N = 128)

Hypertension* Diabetes mellitus* Current smoker* Family history of coronary heart disease Left ventric ular hypertrophy* History of myocardial infarc tion Cholesterol (mg/d L)*

62.8 31 .3 33.8 66.1 20.5 24.1 224 ± 59

* P < 0.05. Categorical variables are percentages; continuous variables are mean

African-Americans (n 80.0 47.5 41 .5 65.8 34. 2 29. 3 25 1 ± 58

±

SD.

= 41)

Whites (n

= 87)

57.1 22.9 31.0 67.1 12.7 23.0 211± 54

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MYOCARDIAL INFARCTION AMONG AFRICAN-AMERICANS, WHITES, AND KOREANS

Table 4

RISK FACTORS OF KOREAN MYOCARDIAL INFARCTION PATIENTS

Risk Factors(%) Hypertension Cu rrent smoker* Diabetes mellitus Family history of coronary heart disease

Total (N = 89)

Men (n = 62)

Women (n = 27) 55 13 11 26

65

69

60

83

11 35

10 35

'P< 0.05. All variables are percentages.

neck, and jaw more frequently than AAs ( 44% vs 29%; P < 0.07). More than twice as many AAs as whites presented with dyspnea (56% vs 24%) and fatigue (32% vs 17%); these differences were statistically significant (P < 0.05). Chest pain (98%) was the most frequent symptom for Koreans, followed by dyspnea (82%); pain in the shoulder, neck, and jaw (67%); and perspiration (52%). More Koreans than whites experienced atypical symptoms of dyspnea (82% vs 24%), perspiration (52% vs 29%), and palpitation (26% vs 5%).

Discussion This study provides a detailed comparison of the clinical characteristics and types of clinical symptoms of MI in AAs, whites, and Koreans. Over 60% of the AA patients and almost 40% of the white patients were women, which is in line with our understanding of race and gender differences in the rates of MI in the United States. The larger number of women among AA MI patients might re-

fleet the excessive early death rate among AA men. Thirty percent of the Koreans were women, which is the lowest rate, but this is in agreement with the findings of other investigators, who have reported that the incidence of MI among Korean women ranges from 30% to 37%. 19, 53 The lower rate of MI in female patients may suggest that early onset of MI, a low rate of smoking, and a low rate of diabetes might function as protectors of women in Korea. The classic CHD risk factors of hypertension, high cholesterol, diabetes, and smoking were more prevalent in AA patients than in white MI patients, which is consistent with previous reports. 37 , 45 The high prevalence of risk factors among AAs indicates that health care providers need to treat these risk factors aggressively. The increased presence of CHD risk factors in AAs would bring an increased risk of recurrent coronary events and, eventually, death. Cardiovascular disease accounts for 35% of all deaths in AAPis and for 36% in all AAPI women. 49 Among the Koreans in the current study, the major risk factors for men

Table 5 TYPICAL AND ATYPICAL CLINICAL SYMPTOMS OF MYOCARDIAL INFARCTION AMONG AFRICAN-AMERICAN, WHITE, AND KOREAN PATIENTS Symptoms

African-Americans (n = 41)

Chest pain Pain in shoulder, neck, and jaw* Dyspnea* Perspiration Nausea/vomiting Fatigue* Palpitation * Shock No symptoms

78.0

'P< 0.05. All variables are percentages.

29.3 56.1 41.5

24.4 317 9.8 0.0 0.0

Whites (n 76.5 43.5 23.5

29.4 30.6 16.5 4.7 0.0 5.9

= 87)

Koreans (n = 89)

97.8 67.4 82.1 5 1.7 23.6 19.1 25 .8 1.1

2.2

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LEE et al

were smoking (83%), hypertension (69%), and diabetes 00%); for women, the major risk factors were hypertension (55%) and diabetes 01 %). Similarly, previous studies in Korea reported that the major risk factors for CHD were smoking and hypertension; diabetes, high cholesterol, and obesity were less important. 21 · 39 Park et al, 39 who compared risk factors between an MI group (n = 167) and a healthy control group (n = 137) in Korea, found that the major risk factors for men with coronary artery disease were smoking (79%) , hypertension (35%), diabetes 09%), obesity 08%), and high cholesterol 0 7%), although for control men, the major risk factors were smoking (33%), hypertension (25%) , high cholesterol 02%), and diabetes (8%). For women with coronary artery disease , the major risk factors were hypertension (56%), diabetes (26%), obesity (23%), smoking (22%) , and high cholesterol 03%), and for control women, the risk factors were hypertension (25%), high cholesterol 09%), smoking (9%), and diabetes (9%). Although CHD is the leading cause of death in Korea and other developing countries in Asia, most health care providers in the United States think that CHD is not an Asian-American disease. In this study, the major risk factors for CHD were similar in all three groups, and the differences between the races were minimal: cigarette smoking was significantly higher in Korean men than in other groups, the hypertension rate was higher in AAs and Korean men than in white men, and the diabetes rate was significantly lower in the Korean group than in the AA and white groups. An especially high prevalence of smoking in Korean men may contribute substantially to future CHD among Korean men as well as to other smokingrelated illness. Unfortunately, smoking is also prevalent among Korean-American men. According to a Korean-American community health survey, 52 the current smoking rate among Korean-American men is close to 40%. By comparison, Korean-American men showed a higher smoking rate than other racial groups: AAPis 05%), Hispanics/ Latinos 09%), w hites (26%) , andAAs (27%). 49 Smoking among Koreans and KoreanAmericans is a serious problem because it is not only a major risk factor for CHD but may also interfere with treatment by altering the

metabolism of standard antianginal drugs such as beta-blockers. 4• 29 Cessation of smoking may be one of the most effective means to prevent acute MI and its recurrence in Korean and Korean-American men. As in previous studies, 6· 8 · 40 in this study of MI patients, we found a significantly greater incidence of the atypical symptoms of dyspnea and fatigue in AAs (P < 0.01) and a greater incidence of pain in the shoulder, neck, and jaw in whites, although the latter difference was not significant. The incidence of chest pain or discomfort was almost the same in the two groups in the United States. All the Korean patients except one experienced chest pain, and, overall, more Korean patients experienced multiple symptoms of MI than did AA or white patients. Some investigators have suggested that the typical symptom of chest pain occurs more frequently in whites than in AAs. 6· 8· 40 Because their studies did not categorize pain in the shoulder, neck, and jaw and data were collected through medical record review from inner city hospitals, it is not possible to make direct comparisons with our study. Other studies have reported that the rate of chest pain was between 68% and 90% in whites and 60% to 85% in AAs; our findings are in line with those figures. 6, 8, 9 , 16, 22 , 3140, 44 Nevertheless, it should be emphasized that our patients all had a diagnosis of MI. The true incidence of atypical clinical symptoms of MI is not known, because many patients without chest pain may not seek medical attention. Most patients in all three groups experienced more than two symptoms of MI. It is important to note that MI may manifest the typical symptom of chest pain combined with atypical symptoms rather than solely chest pain or solely atypical symptoms. As we have reported elsewhere,27 the interaction between type of symptoms and race significantly influences delay time; having chest pain helped white patients promptly seek medical attention, but there was no beneficial effect in AAs. Interestingly, among AAs, dyspnea had a beneficial effect in causing early treatment seeking. In a population-based study, the Edgecombe County study, 46 nearly half of all AAs but only 27% of w hites with reported chest pain had never discussed this pain with a doctor.

MYOCARDIAL INFARCTION AMONG AFRICAN-AMERICANS, WHITES, AND KOREANS

Several hospital and community-based studies 11 · 16·'18 found that AAs took longer than

537

whites to seek medical attention for chest pain.

SUMMARY Most public education about the clinical symptoms of MI and the appropriate response to those symptoms has been designed to reach educated segments of the white population based on data gathered from white men. 12• 15- 17 • 30 As a result, AAs and Korean-Americans may be less alert to chest pain, less likely to relate this symptom to heart attack, and less likely to seek treatment promptly. Our findings provide a race-specific database on CHD risk factors and types of MI symptoms, which should be of pa1ticular interest to the trauma and emergency care nurse as well as to the coronary care nurse. AAs and Koreans experienced chest pain as frequently as whites, but AAs experienced the atypical symptoms of dyspnea and fatigue more often, and Koreans experienced dyspnea, perspiration, and fatigue more often than whites. This information can be helpful in developing public education programs on MI that are sensitive to our increasingly diverse population. In the acute and critical care setting, these data assist the nurse to recognize that "classic" signs and symptoms of acute MI may not be classic for all racial and ethnic groups. This awareness can lead to more culturally sensitive assessment tools and educational interventions, earlier recognition of acute MI with more appropriate triage decisions, more aggressive treatment, and a reduction in morbidity and mortality of these high-risk groups.

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