Differences in Presenting Symptoms of Acute Coronary Syndrome Among Various Race and Ethnic Groups: A Literature Review
Senior Honors Thesis School of Nursing
University of North Carolina at Chapel Hill April 13, 2020
Cardiovascular disease (CVD) is the leading cause of death in the United States (World Health Organization [WHO], 2020). Disproportionately, minorities are at a greater risk for CVD and worse outcomes (Devon et al., 2014; Benjamin et al., 2019) compared to Whites. Various barriers such as socioeconomic status, healthcare access and education contribute to these negative health outcomes. Prior studies have shown that minorities have longer prehospital delay but there is a lack of research that provides information on acute coronary syndrome (ACS) presenting symptoms in ethnically and racially diverse populations (Wechkunanukul et al., 2016). Early recognition of symptoms may lead to improved outcomes for all individuals suffering from ACS. The aim of this review is to investigate early presenting symptoms of ACS among various race and ethnic groups. The review was conducted using PubMed, CINAHL and Scopus databases. All articles were published between 2010-2019 in addition to a 2002 seminal study. The search resulted in 12 observational studies and one systematic review that met the inclusion and exclusion criteria. Evidence from the literature review revealed that Black individuals with suspected ACS symptoms usually present with less typical symptoms such as palpitations, diaphoresis and stomach discomfort. Individuals with an Asian background usually present with typical ACS symptoms such as chest pain. Most studies were limited by an
3 Key words: Acute coronary syndrome, disparities, ACS presenting symptoms, emergency cardiac care, prehospital delay, literature review
Cardiovascular disease (CVD) is the leading cause of death globally and each year, about 17.9 million people die from CVD (World Health Organization [WHO], 2020). Therefore, there is a dire need to address this problem. There have been multiple interventions and campaigns implemented to combat CVD, but it still prevails (O’Gara et al., 2013). Disproportionately, the incidence of CVD in minority groups is higher. Factors such as health disparities and fewer resources may contribute to this disadvantage (Devon et al., 2014; Benjamin et al., 2019). Research studies have been done to investigate presenting symptoms associated with acute coronary syndrome (ACS) to help manage, diagnose and understand its influence on race (Leigh et al., 2016). Knowledge and recognition of presenting symptoms can help patients and providers act fast when an ACS event occurs. According to Allabban et al. (2018), many ethnic and
4 that ethnic and culturally diverse groups have a significantly longer prehospital delay time. The American College of Cardiology Foundation/American Heart Association (ACCF/AHA)
recommends that reperfusion therapy be administered within 12 hours of the onset of symptoms (O’Gara et al., 2013).
The purpose of this literature review is to describe disparities in emergency cardiac care. This review specifically analyzes the differences associated with early presenting symptoms of ACS among various race and ethnic groups.
Methods Search Strategy
An integrative literature search was conducted using PubMed, CINAHL and Scopus databases to identify articles about early ACS symptoms in different ethnic and cultural groups. Before developing the search terms, PubMed was used to identify Medical Subject Headings. A consultation was made with the health science librarian to construct search terms and identify relevant articles. Keywords were used alone and in combination by using “AND” and “OR” in the search engine. The search was limited to articles published in the last 10 years and the following terms were used: ((Race factors OR Racial OR Race OR ethnicity OR ethnicities OR Culture)) AND ((("Acute Coronary Syndrome"[Mesh] OR Acute Coronary Syndrome OR Acute Coronary Syndromes)) AND ("Emergency Medical Services"[Mesh] OR "Emergency
5 paramedic OR paramedics)). This search resulted in 81 articles in PubMed and 45 articles in CINAHL.
Inclusion and Exclusion Criteria
Articles were included in the review based on the following inclusion criteria: (1) published between 2010 to 2019 in addition to a seminal study by Klingler et al. from 2002; (2) written in the English language; (3) included participants admitted to the hospital for ACS symptoms; and (4) included individuals from different ethnic and cultural groups in their sample.
Table of Evidence
Author (S) & Year
Title Number of
Participants Sample Characteristics Study Design Level of Evidence
Measures Major Findings
Devon et al.
(2014) Disparities in patients presenting to the emergency department with potential acute coronary syndrome: It matters if you are Black or White
663 Patients presenting to the ED with
symptoms triggering a cardiac evaluation
Cohort study IV ●Acute Coronary Syndrome (ACS) symptom checklist (shoulder pain, chest pain, sweating, etc.) ●ACS Patient Information Questionnaire that measured patient reported information such as Prehospital delay
●Froelicher’s Health Services Utilization Questionnaire-revised which measured clinic visits, calls to 911, admissions to hospital, MI, stroke and death ●Medical record review form
●Blacks reported more symptom severity and more symptom distress. ●Blacks who presented with palpitations, unusual fatigue and chest pain were 3-4X more likely to be confirmed for ACS.
●Blacks were more likely to report chest pressure, palpitations, and chest pain compared to Whites.
(2013) Anginal Symptoms, Coronary Artery Disease, and Adverse Outcomes in Black and White Women: The NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study
466 Women who were older than 18 undergoing physician referred coronary angiography for suspected coronary artery disease (CAD).
Cohort study IV ●Questionnaire to assess presence of typical angina ●Quantitative angiographic assessment of CAD
●Black women reported more symptoms and a greater variety of symptoms.
●Upper and typical symptoms did not differ significantly between Black and White women. Deshmukh et al.
(2011) Acute Coronary Syndrome: Factors Affecting Time to Arrival in a Diverse Urban Setting
423 Culturally and socio-economically diverse patients (Haitians, Caribbeans, Hispanics and African
Americans) presenting with ACS symptoms to EDs in Central Brooklyn
study IV ●A validated questionnaire that focused on perception of signs and symptoms of ACS
●Kruskal-Wallis test which measured statistically significant differences in delay times across groups
●Symptom perception varied among the different cultural groups.
●More African Americans attributed their symptoms to the heart compared to the other groups. ●All groups delayed significantly longer than the recommende d 3h for reperfusion therapy. Allabban et al.
(2017) Gender, race and the presentation of acute coronary syndrome and serious cardiopulmonary diagnoses in ED patients with chest pain
4162 Patients (Black males/ females and White males/females) Evaluated in the ED with chest pain symptoms
Secondary analysis of data from a prospectively collected, observational cohort study
IV ●Questionnaire of 24 characteristics of chest pain and associated symptoms
●Cardiac history ●Basic demographic information
●The various groups presented slightly different with ACS symptoms.
●Black males had a higher risk of ACS if they presented with diaphoresis
they presented with diaphoresis, palpitations and left arm radiation and less likely with pleuritic chest pain and left anterior chest pain. King-Shier et
al. (2019) Acute coronary syndromes presentations and care outcomes in White, South Asian and Chinese patients: a cohort study
1334 Patients (White, SouthAsian, and Chinese men) admitted to the hospital with a confirmed ACS diagnose
Cohort study IV ●Validated questionnaire to asses typical and less typical ACS symptoms ●Pain/discomfort severity
●South Asians were significantly more likely to report having midsternal
pain/discomfort of moderate to severe intensity
●Chinese patients were less likely to report having radiating ACS symptoms as well as moderate to severe intensity
Klingler et al. (2002)
Perceptions of chest pain differ by race
215 Patients (White and Black clients) admitted to the hospital with the primary diagnosis of unstable angina, chest pain, rule out MI, AMI, or any derivative
Cohort study IV ●Validated
questionnaire to assess the contextual, emotional and behavioral factors that lead the patient to seek medical care.
●African American patients were more likely to perceive their symptom onset as serious
al. (2010) Racial differences in women’s prodromal and acute symptoms of myocardial infarction
1,270 Ethnically diverse (Black, Hispanic and White) women who had experienced an AMI
study IV The McSweeney Acuteand Prodromal Myocardial Infarction Symptom Survey which included 33 prodromal and 37 acute symptoms
●Black and Hispanic women reported more prodromal symptoms than White women. ● Black women reported significantly greater intensity and/or frequency of prodromal symptoms ●Hispanic women reported more pain/discomfort in multiple locations Devon et al.
What’s the Risk? Older Women Report Fewer Symptoms for Suspected Acute Coronary
than Younger Women
237 Women and men presenting to the ED with suspected ACS symptoms
IV ●General demographics ●ACS patient information questionnaire ●ACS symptom checklist that measured the symptoms of ACS (chest discomfort, chest pain, chest pressure, shortness of breath, unusual fatigue, lightheadednes s) ●Charlson comorbidity which measures disability and ●Younger women were more likely to experience chest discomfort, chest pressure, shortness of breath, nausea and sweating and palpitations. ●They were also more likely to be members of minority groups; college educated and have
death predictions after ischemic stroke and heart disease. ●Duke Activity Status Index that measures functional capacity Allana et al.
(2018) Sex differences in symptoms experienced, knowledge about symptoms, symptom attribution, and perceived urgency for treatment seeking among acute coronary syndrome patients in Karachi Pakistan
249 Patients hospitalized for a confirmed ACS event in Karachi Pakistan
IV ●Validated response to symptoms
questionnaire (RSQ) which collected ACS symptom (chest pain, arm pain, dyspnea, sweating, jaw pain etc.) data
● Less typical symptoms were experienced more often by women who thought these symptoms did not require treatment. ●More women experienced nausea, vomiting, backache, palpitations, epigastric pain and dyspnea more frequently than men. Wechkunanukul
et al. (2016) The association between ethnicity and delay in seeking medical care for chest pain: a systematic review
10 studies Culturally and linguistically diverse (CALD) populations presenting with ACS symptoms
All 10 studies that met the inclusion criteria were observational studies. (5 prospective cohort studies and 5 retrospective
cross-IV ●Different ethnic groups (White, Black, Hispanic, Asian, South Asian, Southeastern Asian and Chinese) and delay in seeking medical care
●Culturally and linguistically diverse populations have a significant longer delay time.
studies) (United States, UnitedKingdom and Canada).
al. (2012) Examining the signs and symptoms experienced by individuals with suspected acute coronary syndrome in the Asia-pacific region: A prospective
1868 Patients presenting with suspected ACS to the ED in the Asia-Pacific region.
Cohort study IV ●customized case report form
●Patient standardized interviews with validated questionnaire
●Chinese, Indian and Korean patients were more likely to report typical symptoms than White patients. ●White patients were more likely to report nausea, diaphoresis, and shortness of breath
●Diaphoresis was associated with significantly
increased risk of acute coronary syndrome Body et al.
The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes
796 Patients who presented to the ED with suspected cardiac chest pain
Cohort study IV ●Custom-designed case report form (CRF) to assess symptoms
●Several typical symptoms were found to have no significant diagnostic or
prognostic value of predicting AMI. ●Diaphoresis observed by the ED provider was the strongest predictor of AMI
●Reported vomiting was a strong predictor of AMI
Frisch et al.
(2019) Prevalence and Predictors of Delay in Seeking Emergency Care in
743 Patients who were transported to the hospital for the chief
Secondary analysis of an observational
IV ●Predictors of delay in
Patients who Call 9-1-1
for Chest Pain complaint of chest pain or equivalent cohort study ●Prevalence of delay inseeking care care.
●Symptoms of palpitations were found to decrease wait times. Note. Level I: Systematic review or meta-analysis of randomized controlled trial studies (RCT)
Level II: RCT
Level III: Quasi-experimental
13 Literature Review
The purpose of this literature review is to describe differences in ACS symptoms
presentation in various ethnic and racial groups. Based on the findings, individuals from diverse populations were divided into three groups (Black, Hispanic and Asian). Further dissection of the various groups could not be made due to the lack of research on this topic.
Symptoms Among Diverse Populations
ACS Symptoms in Black Patients
A significant finding from the literature review is that Blacks report more symptoms and greater symptom severity compared to other cultural and ethnic groups when experiencing ACS symptoms (Eastwood et al., 2013; Klingler et al., 2002; McSweeney et al., 2010). These findings were consistent with findings from Devon et al. (2014). This study examined the differences in ACS symptoms with patients who presented to the ED with potential ACS. The sample consisted of 781 patients (Black n=116, White n=547, Hispanic n=37, Asian n=24, multi-racial n=21, American Indian/Alaskan Native n=15, and n=21 unknown ethnicities). The final analyses included only Black and White patients (n =663) due to the small sample size of the other racial groups. The study found that in patients with confirmed ACS and non-ACS, Black patients reported more symptom distress (ACS: Black (2.1) White (2.7) P= .005 ; non-ACS: Black (2.1) White (2.5) P= .009 ) and a greater number of symptoms (ACS: Black (3.7) White (2.7)
14 greater symptom severity. These two studies assessed the acute symptoms of ACS and they resulted in similar findings. Increased symptom severity and reporting a greater number of symptoms could be influenced by differences in expression of symptoms across different cultures. An individual’s culture can influence how they express pain duration and intensity (Peacock et al., 2008).
15 ACS symptoms. In a more recent study by Deshmukh et al. (2011), most African American patients attributed their ACS symptoms to cardiac related origins. This sample consisted of culturally diverse patients (n=384) who presented to the ED with ACS symptoms. The sample included of Carribeans (61.2%), Haitians (4.2%), Hispanics (9.4%) and African Americans (25.3%). It is also important to note that most Haitians attributed their symptoms to gas pain and indigestion.
Current evidence suggests that Black patients with suspected ACS usually present with less typical symptoms. Although a summary of these studies does not result in an exact symptom or a cluster of symptoms that could lead to an ACS diagnosis, there is evidence that Blacks present with symptoms other than chest pain. Other less typical symptoms that warrant further study include, but are not limited to: palpitations, diaphoresis and stomach discomfort. These symptoms need more in-depth exploration because several studies have identified them as predictive of ACS. Continual research about different ACS symptoms other than chest pain could increase early diagnosis and treatment. This is vital information for providers and patients when recognizing and diagnosing ACS.
ACS Symptoms in Hispanic Patients
In a study looking at women’s prodromal and acute symptoms of myocardial infarction, McSweeney et al. (2010), found that Hispanic women reported, unusual fatigue (58.6%),
ACS Symptoms in Asian Patients
Greenslade et al. (2012) conducted a study with Asia-pacific patients presenting to the ED with suspected ACS. The sample included 1,868 patients (Chinese n=730, Indian n=100, Korean n=181 and White n=857) and data were prospectively collected. The researchers found that Chinese, Indian, and Korean patients were more likely to present with typical ACS
symptoms compared to White patients. White patients were more likely compared to other ethnic groups to present with nausea, shortness of breath and diaphoresis. This finding conflicts with previous research that reported minorities are more likely to present with less typical symptoms (Wechkunanukul et al., 2016). The study also discovered that Chinese and White patients that presented with diaphoresis had an increased risk of ACS. The study done by King-Shier et al. (2019), resulted in similar results. Patients (White n=630, South Asian n=488, and Chinese n=216) admitted to the ED with confirmed ACS were analyzed with a validated questionnaire. The majority of the patients across the different ethnic groups presented with chest pain
symptoms. Midsternal discomfort was the most reported symptom and Whites were more likely to report nausea or vomiting. Although the different ethnic groups were more likely to present with chest discomfort, the location of the pain/discomfort varied between the different groups. A study done by Allana et al. (2017), in Karachi Pakistan resulted in similar results. The three most common reported symptoms were chest pain, chest heaviness and fidgetiness.
17 study done by Deshmukh et al. (2011), found that patients from different racial/ethnic groups reported delay that was longer than the recommended 3 hours after the initial recognition of ACS symptoms. Patient delay was attributed to factors such as mode of transportation. Participants were more likely to use their private vehicles to get to the hospital due to their economic and insurance situation. More than 40% of the participants in this study decided to seek help because of unbearable chest pain. The only exception were Haitians who sought help due to shortness of breath. Symptom perception in different racial and ethnic groups may be a factor in prehospital delay. A systematic review done by Wechkunanukul et al. (2016) revealed that ethnicity is a factor in prehospital delay. Nine of the 10 studies found that there was a significant difference in delay between different ethnic groups and the majority group. Factors associated with longer delay were differences in symptom perception/ presentation, atypical symptoms, underuse of the ambulance, socioeconomic status and language barriers. Some of these findings are similar to the factors associated to prehospital delay in the former study.
A study done by Allana et al. (2017), showed that lack of education on the urgency of thrombolytic therapy affected prehospital delay negatively. There were 249 Pakistani
participants in this study, including 53.4% men and 46.6% women. Less than 50% of the participants had prior knowledge of ACS symptoms. More women than men thought symptoms such as dyspnea, sweating, nausea/vomiting and palpitations were no at all urgent to seek medical services. Prior knowledge of the importance of timely reperfusion therapy and recognition of ACS symptoms may decrease prehospital delays
18 also showed that the non-Caucasian race was the only independent predictor to result in a delay greater than 12 hours in seeking medical services. Non-chest pain symptoms and delay in seeking medical services is reoccurring theme in the literature. This finding may be related to patients having difficulty differentiating symptoms related to their chronic comorbidities. Exclusion of Non-English Speakers
Half of the inclusion criteria in the reviewed articles required participants to speak English. Three of the 12 articles did not specify if there was a language requirement to
participate. There was only one article that included participants who spoke English or Spanish. This study also accommodated participants with different Spanish dialects. The other 2 studies that included participants who spoke languages other than English were done outside of the United States.
These findings highlight the need to include non-English speakers, particularly Spanish speaking individuals in emergency cardiac care research. Although it is evident that a need exists, patients who are not able to speak English are continuously excluded from major studies. According to Brodeur et al. (2017), from 2004 to 2014 exclusion of non-English speakers from two emergency medicine journals increased from 6.4% to 16.2%. The lack of inclusion of this growing population in important research studies is concerning and researchers should work towards including this population.
19 diaphoresis, palpitations and stomach discomfort. Asians were more likely to present with typical ACS symptoms in comparison to White individuals. There was a lack of articles about
presentation of ACS symptoms in the Hispanic population, therefore a trend could not be
determined. This problem highlights the need for inclusion of the Hispanic population in current research studies about presenting symptoms of ACS.
Emergency nurses are on the forefront when receiving and caring for patients with cardiac events. The ability to recognize typical and less typical ACS symptoms is critical when advocating and caring for patients. Comprehensive nursing assessments that identify ACS signs/symptoms could aid in early diagnosis and decreased reperfusion therapy time. Nurses are also responsible for teaching patients the most up-to-date evidence-based findings. Implications for nurse investigators are to include different ethnic groups in their research, especially the Hispanic population. The findings of this literature review display the need to consider presenting ACS symptoms in different races and ethnic groups.
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