Highlights
- •Race, ethnicity, age, sex, and socioeconomic factors are intertwined with acute coronary syndrome burden, presentation, and outcomes.
- •Nurse practitioners should maintain a high index of suspicion as acute coronary syndrome has diverse presentations.
- •Absence of chest pain does not rule out acute coronary syndrome.
- •Standard electrocardiograms should be considered with ambiguous presentations in high-risk patient populations.
- •Tailor approach to acute coronary syndrome in ethnic, female, and elderly patient populations by requiring a lower threshold for workup.
Abstract
Acute coronary syndrome (ACS) remains one of the leading causes of death in the United States. With its heightened prevalence, considerable variabilities in the disease process exist across ethnicities, sex, and age. This creates substantial disparities in the recognition and management of ACS, which consequently contributes to poor outcomes. It is of utmost importance that nurse practitioners remain vigilant, cognizant, and maintain a high index of suspicion to accurately identify ACS presentations and thus efficaciously intervene to successfully manage the disease process.
Keywords
Introduction
Acute coronary syndrome (ACS) is a manifestation of coronary artery disease that results in compromised blood flow to the coronary vasculature. ACS comprises 3 disease processes: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).
1
,2
Unstable angina is associated with a plaque formation disrupting blood flow to the heart which can result in cardiac tissue hypoxia.3
NSTEMI occurs with the rupture of an atherosclerotic plaque that partially occludes coronary blood flow, resulting in cardiac tissue ischemia.3
Conversely, STEMI develops from a ruptured plaque that causes an acute complete obstruction in coronary blood flow resulting in myocardial tissue injury and necrosis.3
Unstable angina, NSTEMI, and STEMI are all regarded as an acute crisis that requires emergency services.ACS remains ubiquitous as a pervasive disease responsible for significant morbidity and mortality. Data from the American Heart Association reveal that an estimated 805,000 Americans will experience an ACS event annually.
4
Of those cases, 605,000 will be new attacks, and 200,000 are recurrent attacks.4
Additionally, incidence data from the American Heart Association indicate that an American will suffer from an ACS event nearly every 40 seconds.4
With that staggering prevalence, prevention, identification, and management are essential to mitigate the detrimental consequence of ACS. In the frontlines, clinician assessment focuses on classical presentations of ACS for timely diagnosis and treatment. However, nonclassical presentations persist, causing missed diagnoses and further hindering ACS outcomes. Growing literature challenges the notion of typical symptoms due to the overwhelming data on the variability of ACS presentation that is influenced by ethnicity, sex, and age. To accurately recognize ACS, clinicians must remain on high alert and widen the net of suspicion as patients from different circumstances may differ in ACS presentation.
Pathophysiology
ACS originates from the formation of an atherosclerotic plaque that involves various dynamic processes, including immunologic response, inflammatory mediators, endothelial dysfunction, and dyslipidemia.
2
,3
Initially, chronic elevations in blood pressure from hypertension cause increased hydrostatic pressure and shear stress to the vasculature, which stimulates compensatory vessel thickening, endothelial injury, and the release of inflammatory cytokines.3
This facilitates low-density lipoprotein to gather around the area of endothelial injury and the exposed intima of the blood vessel.3
,5
The resulting inflammatory process recruits monocytes which upregulate into macrophages that ingest low-density lipoproteins, resulting in foam cell formation.3
,5
As foam cells coalesce, they form a fatty streak.2
,3
The pathologic progression is continued by the production of reactive oxygen species and cytokines.
3
Platelets, dendritic cells, and mast cells are activated and gather in the developing plaque.3
Smooth muscle cells then proliferate and produce an extracellular matrix that contributes to the formation of a fibrous cap.2
,3
This fibrous cap becomes the outer layer that extrudes into the vessel lining. As the complex plaque continues to grow, endothelial cells deplete their antiplatelet properties, which allow for thrombus formation.3
The gradual progression of atherosclerotic plaque leads to significant vessel narrowing and arterial obstruction resulting in tissue ischemia.1
,3
The subsequent rupture of the fibrous cap and thrombus formation results in an acute occlusion of the coronary vessel that precipitates ACS.3
Risk and Prevalence
Risk factors associated with ACS are frequently separated into 2 categories: nonmodifiable and modifiable risk factors. Nonmodifiable risk factors include sex, age, race/ethnicity, and genetics.
2
,3
,6
In contrast, modifiable risk factors include hypertension, dyslipidemia, diabetes, lifestyle, obesity, diet, stress, and cigarette smoking.2
,3
,6
Collectively, these elements contribute to the development of atherosclerosis and significantly increase the likelihood of ACS.The prevalence of ACS does not discriminate by race, ethnicity, or sex as it transcends those barriers. Data from the Centers for Disease Control and Prevention indicate that between 2015 and 2018, 8.8 million Americans older than age 20 years were diagnosed with acute myocardial infarction (AMI).
7
Across sex, men have a higher prevalence of AMI compared with women in all age groups, except ages 20 to 39 years.4
However, women have higher in-hospital mortality rates.4
,8
In ethnic groups, White males have a higher prevalence of AMI, whereas African American women lead in the prevalence of AMI.4
Conversely, age-adjusted death rates for AMI are higher in African American men and women compared with Whites and Hispanics.4
ACS Across Race and Ethnicities
Population sizes of ethnic groups in the United States continue to dramatically increase as the US Census Bureau projects that more than 50% of the US population will belong to an underrepresented group by the year 2044.
9
Unfortunately, at the present time, the lack of inclusion of underrepresented groups, including Asian Americans, has been observed in research publications. With the projected population growth and scarce data on ethnic ACS influences, it is vital to include these groups to achieve a better understanding of the ACS contributions of race and ethnicity. Additionally, while there has been a reduction in ACS incidence across all ethnic and racial groups, crucial differences remain in the rate of decline among the groups.10
, - Chi G.C.
- Kanter M.H.
- Li B.H.
- et al.
Trends in acute myocardial infarction by race and ethnicity.
J Am Heart Assoc. 2020; 9e013542https://doi.org/10.1161/JAHA.119.013542
11
, 12
Over past decades, a substantial number of publications depicted the stark differences in ACS presentation among different ethnicities and consequently contributing to health disparities. The significance of that data contributes to a more robust collection of fundamental information necessary for patient care and the inclusion of underrepresented patient populations. In the more recent literature, while the focus of research has shifted from ethnicity differences to sex and risk factors, variances in ACS presentation continue to be reported between race and ethnicity.
Across all ethnic groups, midsternal chest pain remains the most commonly reported symptom in ACS presentations; however, prevalent symptoms among ethnic groups also include shortness of breath (SOB), diaphoresis, dizziness, and nausea and vomiting.
13
Many current publications are investigating genetic variations through genome-wide association studies that may help elucidate the variations in ACS presentation among ethnic and racial groups.- King-Shier K.
- Quan H.
- Kapral M.K.
- et al.
Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.
BMJ Open. 2019; 9e022479https://doi.org/10.1136/bmjopen-2018-022479
14
,15
African American Population
Risk Factors Comorbidities are frequently present in the African American (AA) population, which include obesity, diabetes, insulin resistance, and dyslipidemia.
16
,17
Additionally, there is a higher incidence of cardiovascular disease in the AA population compared with their White counterparts.16
Surprisingly, when compared with other ethnic groups, AAs were least likely to present with STEMI despite the prevalence of comorbid conditions.18
Presentation In the AA population, the presentation of diaphoresis was highly associated with ACS in men, whereas diaphoresis, left arm radiation, and palpitations were associated with ACS in women.
19
Conversely, the presentation of left anterior chest pain and pleuritic pain were less associated with ACS in AA women.19
,20
AA women notably experience a higher symptom burden and report more symptoms after an ACS event compared with White women.11
,19
,20
Moreover, AAs presenting with fatigue are highly likely to be diagnosed with ACS.20
Outcomes This population experiences longer delays in door-to-balloon times and door-to-drug times compared with Whites.
16
,18
Additionally, AA patients are less likely to receive percutaneous coronary intervention, angiography, drug-eluting stents, and coronary artery bypass grafting.12
,18
,21
,- Graham G.N.
- Jones P.G.
- Chan P.S.
- Arnold S.V.
- Krumholz H.M.
- Spertus J.A.
Racial disparities in patient characteristics and survival after acute myocardial infarction.
JAMA Netw Open. 2018; 1e184240https://doi.org/10.1001/jamanetworkopen.2018.4240
22
Multiple explanations have been postulated; in part, this may be due to misdiagnosis of ACS owing to higher comorbidities or lack of resources resulting in slower referral for procedures, deliberate refusal of angiography interventions,12
and limitations to access with deterrence from associated costs of seeking care.18
Moreover, causes for the gaps in procedural rates may extend beyond health care systems and be rooted in personal motivations, including trust level, hesitancies, and preferences.16
This reluctance in receiving care may be associated with the poorer outcomes observed, including repeat hospitalization and mortality rates.While conflicting evidence continues to be observed, remarkably, some studies have found that despite the dwindling rates of timely procedures, AA patients had lower in-hospital mortality rates compared with other underrepresented groups.
18
,22
However, once discharged, AA patients report extensively more adverse symptoms resulting in more clinic visits 1 month after an ACS admission.12
,16
Consequently, repeat hospitalization rates after ACS events are significantly higher in AA patients.12
Within 5 years after a first MI, AAs have higher rates of death, recurrence of ACS, and heart failure in all age groups except for those >75 years old compared with Whites.4
Asian American Population
Risk Factors While the literature is limited in Asian American patients in Western cultures, this population represents a vast number of diverse groups. Asian Americans often have lower mean body mass index (BMI); however, despite lower BMIs, South Asians, Japanese, and Filipinos have substantially higher rates of diabetes and metabolic syndrome compared with Whites.
16
,23
Moreover, Filipinos present with high risks for hypertension, diabetes, and dyslipidemia.16
,23
South Asians frequently have lower levels of high-density lipoproteins.16
Overall, Asian Americans have a high prevalence of comorbidities, including diabetes, hypertension, and kidney failure compared with Whites.22
,24
Collectively, Asian Americans represent the highest proportion of STEMI hospitalizations.18
,22
Presentation In presentations, Chinese Canadian patients were less likely to endorse experiencing moderate-intensity midsternal pain with radiation symptoms to the neck, shoulder, or arms; however, they do tend to report more central and less back or extremity discomfort in a pictographic analysis of torsos.
13
Further, while the more common characteristic of chest pain is described as pressure, burning, or squeezing, those of South Asian descent reported considerably more stabbing pain in nature and midsternal pain in more moderate to intense severity.- King-Shier K.
- Quan H.
- Kapral M.K.
- et al.
Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.
BMJ Open. 2019; 9e022479https://doi.org/10.1136/bmjopen-2018-022479
13
- King-Shier K.
- Quan H.
- Kapral M.K.
- et al.
Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.
BMJ Open. 2019; 9e022479https://doi.org/10.1136/bmjopen-2018-022479
Outcomes South Asians exhibiting atypical symptoms frequently had longer delays in presenting for emergency care, longer door-to-drug time,
16
and were less likely to receive percutaneous coronary intervention.13
Asian Americans receive drug-eluting stents and angiography at higher rates than other underrepresented groups; however, unfortunately, they have the highest in-hospital mortality rates and worst in-hospital outcomes in ACS.- King-Shier K.
- Quan H.
- Kapral M.K.
- et al.
Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.
BMJ Open. 2019; 9e022479https://doi.org/10.1136/bmjopen-2018-022479
12
,18
,22
Further, Asian Americans had the longest hospital lengths of stay compared with other ethnic groups.18
Hispanic Population
Risk Factors Overall, Hispanic patients have notably higher incidences of peripheral vascular disease and diabetes compared with Whites.
16
,18
In the community, higher rates of hypercholesterolemia were found in Central Americans, incidences of obesity were found to be increased in Puerto Ricans, and higher cases of hypertension were associated with Mexican Americans.16
,25
These preexisting conditions further contribute to poor outcomes for this population.Presentation In Hispanics, reported ACS symptoms are described as asphyxiating or difficulty breathing, having less energy, gradually worsening chest pressure, and arm pain with radiation to the shoulder.
25
More importantly, the terms used to describe ACS symptoms, including asphyxiating and less energy, differ from those previously reported as typical ACS symptoms.25
Outcomes Hispanic patients also experience long delays in reperfusion, door-to-drug, and door-to-balloon times in ACS events compared with Whites.
16
Analogous to AAs, Hispanics are also less likely to undergo cardiac procedures12
and therefore have higher ACS mortality rates compared with Whites.22
Additionally, Hispanics experience extended hospital admissions compared with Whites.16
ACS Across Sex
Risk Factors In the past, considerable effort on ACS research was concentrated on men. Currently, the attention has shifted to women due to the profound differences associated with ACS. AMI has a higher prevalence in men,
4
but overall, women have higher rates of cardiovascular risk factors, including diabetes, hypertension, dyslipidemia, and obesity.11
,26
,27
Women also have an increased likelihood of having microvascular disease that results from endothelial dysfunction and abnormalities in vascular smooth muscles spasticity.3
This results in inconsistencies in coronary artery narrowing and cardiac ischemia, where some female patients have no angiographic signs of vessel narrowing or lesions despite severe myocardial ischemia.3
,27
Additionally, risk factors associated with pregnancy, including gestational diabetes and pregnancy-induced hypertension, are added lifetime risks for developing ACS in women.11
,28
Presentation Women with cardiovascular disease have an increased likelihood of experiencing more prodromal symptoms, including fatigue, chest pressure, sleep disturbances, SOB, and leg pain than men.
25
,29
Moreover, although both sexes often experience chest discomfort with ACS, women have a decreased probability of presenting with chest pain and diaphoresis and instead present with nausea or vomiting, shoulder pain, back pain, and SOB.11
,30
Unfortunately, women often delay seeking care when their symptoms do not meet their preconceived understanding of typical ACS symptoms.- van Oosterhout R.E.M.
- de Boer A.R.
- Maas A.H.E.M.
- Rutten F.H.
- Bots M.L.
- Peters S.A.E.
Sex differences in symptom presentation in acute coronary syndromes: A systematic review and meta-analysis.
J Am Heart Assoc. 2020; 9e014733https://doi.org/10.1161/JAHA.119.014733
8
,25
Subsequently, ACS symptoms are commonly attributed to other disease processes that are noncardiac in origin, including stress, aging, and comorbid conditions.25
Outcomes More concerning are the hospital and postdischarge outcomes of women with ACS as they have higher in-hospital mortality.
4
,8
Irrespective of age, women have considerably higher rates of readmissions within 1 year after an ACS event26
,31
and a recurrent MI.26
,32
Additionally, women have higher mortality rates at 1 year and 5 years after a first MI, increased incidence of stroke within 5 years of their first MI, and shorter median survival time after a first MI.4
A recent study of young women 1 year after MI reported decreased levels of physical capabilities, lower levels of health status improvement, and higher levels of inflammation.8
Furthermore, the researchers reported that upon hospital discharge, these women had lower rates of referral to cardiac rehabilitation.8
ACS in the Aging Population
Risk Factors The prevalence of concomitant chronic illness increases with aging where the elderly population often presents with a myriad of comorbidities. Common risk factors, including hypercholesterolemia, hypertension, diabetes, and limitations in functional status place this population at extreme risk.
28
Presentation With the increased prevalence of risk factors and comorbid conditions, the elderly have a decreased likelihood of reporting chest pain, which obscures the presentation of ACS.
11
For instance, the elderly, who have a higher propensity for diabetes, can experience a silent MI due to the resulting neuropathy that can nullify the sensation of chest pain.11
Further, while younger adults have higher odds of exhibiting classic ACS symptoms, the elderly have been shown to present with fewer and more ambiguous symptoms, including nausea, dyspnea, and the absence of chest pain.29
Alarmingly, only approximately 40% of ACS patients older than 85 years present with chest pain.33
Typical symptoms exhibited in the elderly include nausea and vomiting, diaphoresis, dyspnea, and syncope.33
These place the elderly at a great disadvantage as they may attribute their ACS symptoms to current afflictions or the aging process.28
Outcomes The presence of comorbid conditions and risk factors that result in vague presentations contribute to unfavorable outcomes in the aging population. These circumstances inevitably lead to longer delays in seeking care due to misinterpretation of symptoms, missed ACS diagnosis due to failure to obtain electrocardiograms, and mismanagement due to delays in urgent interventions.
28
Furthermore, due to associations of aging, including frailty, disability, and comorbidities, the elderly experience worse outcomes because of the high risk for complications from limited cardiovascular reserve and complexity of late heart disease.33
Influence of Socioeconomic Factors
When considering the contributions of ethnicity, sex, and age in ACS disparities, the influence of socioeconomic factors that inevitably coexist must also be examined. Current literature has illustrated that a correlation exists between socioeconomic factors with ACS incidence and outcomes.
21
,- Graham G.N.
- Jones P.G.
- Chan P.S.
- Arnold S.V.
- Krumholz H.M.
- Spertus J.A.
Racial disparities in patient characteristics and survival after acute myocardial infarction.
JAMA Netw Open. 2018; 1e184240https://doi.org/10.1001/jamanetworkopen.2018.4240
34
,35
Research has found that health status, socioeconomic, and psychosocial characteristics extensively contribute to disparities in ACS outcomes and, more importantly, significantly influence mortality rates.21
This is further echoed by later studies that found that low socioeconomic factors, such as housing, income, education, occupation, and insurance, were associated with an increase in MI and cardiovascular death.- Graham G.N.
- Jones P.G.
- Chan P.S.
- Arnold S.V.
- Krumholz H.M.
- Spertus J.A.
Racial disparities in patient characteristics and survival after acute myocardial infarction.
JAMA Netw Open. 2018; 1e184240https://doi.org/10.1001/jamanetworkopen.2018.4240
35
Geographic location has also been associated with worse outcomes as rural areas experience higher mortality rates from in-hospital AMI compared with urban areas.34
Implications for NPs
NPs have the unique opportunity to interact directly with patients during ACS encounters to influence positive outcomes. In the frontlines, NPs are presented with these challenges as they witness ACS incidences firsthand. Given the evidence, a high index of suspicion must be maintained by NPs, who are often the first providers to see these patients. NPs must conduct astute observations and tailor their approach to ACS based on ethnicity, sex, age, and risk factors.
The absence of classical symptoms, including chest pain, does not rule out ACS. Therefore, obtaining standard electrocardiograms should be considered in patients with ambiguous presentations and associated risk factors. Knowledge of ethnic, sex, and age-associated differences in the clinical presentation of ACS will prevent crucial missed diagnoses and delays in urgent treatment. Developing the understanding and awareness of the obscurities of ACS can lead NPs to an accurate diagnosis and efficacious interventions to improve ACS outcomes. Thus, ethnicity, sex, age, and risk factors should be considered with the accompanying clinical presentation when determining an ACS diagnosis.
In caring for populations at risk for ambiguous presentations, including ethnic, female, and elderly patients, NPs are in a favorable position to advocate for these patients in all levels of health care. Given the evidence, teaching and education are essential components to spread awareness of ACS disparities. During patient interactions, NPs have the opportunity to inform and educate on the variabilities in ACS presentation that may not fit the widely accepted perceptions of ACS and the populations at risk. The dissemination of fundamental information will reduce misinterpretation of symptoms that frequently result in the delays in seeking care observed in populations at risk. Additionally, creating this key dialogue will help to foster a sense of trust and communication in the hopes of alleviating reluctance in care and gaps in treatment rates observed in these populations.
In practice, NPs caring for populations at risk are in a position to advocate for them by acting on evidence to tailor their approach to ACS. The ambiguity in presentation means that populations at risk require a lower threshold for workup. In doing so, NPs may promote a culture of change among other providers to adopt inclusive practices and ultimately improve ACS outcomes in populations at risk.
In diverse populations, NPs must remain cognizant of the intersectionality between religiosity, culture, perceived discrimination, and level of acculturation as these may influence acceptance of care and health-seeking behaviors. Reluctance in seeking care may be exhibited due to culturally determined gender roles, comfort level with mainstream health care, and preferences for providers (eg, sex and racial/cultural congruence). A level of sensitivity is required as careful consideration must be made to provide appropriate care aligned with the patient’s religious and cultural beliefs. As such, the implications of the social, cultural, and religious context must be considered and incorporated into care planning. NPs must be aware of these factors as they assist in tailoring a plan of care that emphasizes cultural competence and inclusivity among diverse patient populations.
In public health, NPs are in a promising position to raise awareness, cultivate knowledge, and empower patients to take necessary actions. Current research demonstrates that awareness of common ACS symptoms differed by race and ethnicity as underrepresented groups, including Asian Americans, Hispanics, and AAs, had lower knowledge of symptoms compared with Whites.
36
,37
Additionally, socioeconomic factors carry a heavy influence as populations with low education, low income, and lack of insurance had significantly decreased levels of symptom awareness.- Mahajan S.
- Valero-Elizondo J.
- Khera R.
- et al.
Variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.
JAMA Netw Open. 2019; 2e1917885https://doi.org/10.1001/jamanetworkopen.2019.17885
37
- Mahajan S.
- Valero-Elizondo J.
- Khera R.
- et al.
Variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.
JAMA Netw Open. 2019; 2e1917885https://doi.org/10.1001/jamanetworkopen.2019.17885
These data sets reveal the existing disparities that hinder public health where the inability to identify ACS symptoms contributes to drastically poorer outcomes in ethnic and underserved communities. NPs must recognize these knowledge deficits and highlight the importance of an educational focus for patients to better understand their risks and conditions. Because of the high prevalence and profound health impact of ACS, continued public health efforts are critical to systematically improve awareness, knowledge, and understanding of ACS.
Lastly, while research is ongoing, NPs must remain current with emerging literature. This is especially important as studies continue to examine genetic determinants that may influence ACS presentation and outcomes as these may dictate changes in standard of care practices among different racial and ethnic groups.
Conclusion
ACS exhibits a vast array of clinical symptoms that can be influenced by race, ethnicity, sex, and age. Due to the high prevalence and mortality of ACS, it is imperative that ACS presentations be accurately diagnosed and, more importantly, time-sensitive interventions are undertaken to improve outcomes. Frontline clinicians require a high degree of suspicion and must remain mindful of the variabilities in ACS presentations.
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Biography
Kristofer De Leon, BSN, RN, CCRN is an acute care nurse practitioner student at California State University Los Angeles and a transplant-surgical intensive care unit nurse at Ronald Reagan UCLA Medical Center, Los Angeles, CA, and can be contacted at [email protected]
Elizabeth J. Winokur, PhD, RN, CEN, is associate director and associate professor, California State University Los Angeles, and nurse researcher at St. Joseph Hospital, Orange, CA.
Article info
Publication history
Published online: November 18, 2021
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In compliance with standard ethical guidelines, the authors reports no relationships with business or industry that would pose a conflict of interest
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