女性冠心病患者所表现的症状影响其诊断

In Women, Diagnosis Influenced by How CHD Symptoms Are Presented

（阜外心血管病医院 高立建 翻译）

关键点：女性冠心病患者+紧张和焦虑=医生误诊

根据美国纽约Weill Cornell医学院的Gabrielle R. Chiaramonte博士领导的研究小组的研究结果：女性冠心病患者，在紧张和焦虑状态下，当表现出典型的冠心病症状，医生更有可能误诊。而男性，当表现出类似的症状时，则更有可能得到正确的诊断。

Chiaramonte医生在接受采访时说“假定女性冠心病症状和焦虑症状重叠…，而且女性的焦虑和功能紊乱症状较发生率更高，医生需要注意到不同性别冠心病所表现出来的症状上的差异，对于女性患者来说，焦虑是一种常见的状态、在无意识当中影响着医疗上的判断。”

假说检验

Chiaramonte和他的同事们创立了一个假想的有冠心病的典型症状的患者模型，并且这些患者伴有与冠心病发病相关的常见危险因素。他们创立了四种变化方式，仅仅通过改变性别变量和紧张是否作为冠心病的一种因素进行变化。此外，因为女性较男性冠心病发病晚大约10年，因此根据性别对年龄进行调整。参与者当中，初级护理医师包括87名经验丰富的内科医师和143名家庭医生，让他们阅读四种变化方式中的一种，然后让他们下诊断，并推荐一种治疗，同时要指出是器质性的还是自然状态下的心理症状。

在包括紧张因素的模式中，较少数的女性患者被诊断为冠心病（18%女性与57%男性，P<0.001），或介绍到心脏病专家处就诊（35%与76%，P<0.001）和给予脏疾病药物进行治疗（9%与43%, P≤0.001）。

研究者说：在有紧张因素时，医生对女性患者的症状如胸痛，呼吸急促，心律不规则认为是心理性的，而对相同症状的男性患者，不论是否存在紧张因素，则认为是器质性的，Chiaramonte医生说：“对以紧张或焦虑为表现的女性患者，促使医生更多的对其伴随症状给予解释，以至于对主要症状如胸痛或者气短的注意力被转移，给医生的印象为紧张或焦虑，并不是冠心病的表现。”然而，对男性患者，医生倾向于认为紧张和焦虑是冠心病的危险因素的观点，当男性患者描述这些心理上的症状时，医生则更高的可能性被诊断为冠心病或者推荐到心内科专家就诊。

典型症状

研究者也检测了是否冠心病的不典型表现，如胃肠道不适，会影响到女性冠心病患者的诊断。他们另外对142名家庭医生进行了研究，在这个研究中他们改变了患者模型为包括不典型症状在内的冠心病患者。

Chiaramonte医生说道：“在这种条件下，结果显示出不同的态势，女性较男性有更高的诊断为胃肠道疾病的可能性，而较少的诊断为冠心病。然而，附加表现为紧张和焦虑的不典型冠心病症状的患者，无论男性还是女性，均增加了胃肠道疾病的诊断。”

意外的发现

Chiaramonte说令她和她的同事感到惊奇的是：当紧张作为一个研究变量时，女性患者诊断为充血性心力衰竭的可能性很小，她说：在我们的研究当中，不止一项研究得到患者性别因素的差别，显示为女性心脏病患者有着较低的诊断率。

另外一项意想不到的发现是：医生的经验水平及其性别都对诊断没有太大的影响。医生的性别仅仅影响到家庭医生这个群体的结果。

Chiaramonte医生说：“当患者在紧张的状态下表现为冠心病时，女家庭医生对男性和女性冠心病患者有着同样低的诊断率。”

（来源：www.tctmd.com）

In Women, Diagnosis Influenced by How CHD Symptoms Are Presented 

Key Points:
• Female gender combined with stress and anxiety equals misdiagnosis by physicians.

By TCT Daily Staff

Physicians are more likely to misdiagnose CHD in women when they present with typical heart disease symptoms in the context of stress and anxiety. In addition, women with atypical CHD symptoms are also less likely to be diagnosed with heart disease.

Men, however, when presenting with either of these scenarios are more likely to be correctly diagnosed, according to a study presented here by a team of investigators led by Gabrielle R. Chiaramonte, PhD, of Weill Cornell Medical College in New York, New York.

"Given the overlap of CHD and anxiety symptoms . . . and given the higher prevalence of anxiety symptoms and disorders in women, physicians need to be aware of sex differences in symptom presentation," Chiaramonte said in an interview. "In the case of women, anxiety has a pervasive, unconscious influence on medical judgments."

Testing the hypothesis

Chiaramonte and colleagues created a fictional patient vignette presenting typical CHD symptoms accompanied by risk factors commonly associated with CHD. They created four variations, altering only the patient’s sex and whether stress was a factor. In addition, age was adjusted according to sex because women tend to develop CHD about a decade later than men.
The participants, primary care physicians including 87 experienced internists and 143 family physicians, read one of the four vignettes and were asked to make a diagnosis, suggest a treatment referral, and indicate whether the symptoms were organic or psychogenic in nature.
When stress was present in the vignette, fewer women received a CHD diagnosis (18% of women vs. 57% of men, P < .001), fewer received a referral to a cardiologist (35% vs. 76%, P < .001) and fewer were prescribed cardiac medications (9% vs. 43%, P =< .0001).

Physicians perceived symptoms such as chest pain, shortness of breath, and irregular heart rate in women as psychogenic when stress was present, whereas the same symptoms were perceived as organic in men regardless of whether stress was a factor, researchers said.

"For women, the presence of stress [or] anxiety drives the interpretation of accompanying symptoms, so that symptoms such as chest pain or shortness of breath undergo a ‘meaning shift,’ [being] perceived as a manifestation of the stress [or] anxiety and not as CHD symptoms," Chiaramonte said.

In men, however, physicians tend to view anxiety and stress as a risk factor for CHD. When men describe these psychological conditions, physicians are more likely to make a CHD diagnosis or referral to a specialist, the researchers found.

Atypical symptoms

The investigators also tested whether the presence of atypical symptoms such as gastrointestinal discomfort would affect the diagnosis in women. They conducted an additional study of 142 family physicians in which they altered the patient vignette to include atypical symptoms.

"Results showed a different dynamic in this case. Women were more likely than men to receive a [gastrointestinal diagnosis] rather than a CHD diagnosis," Chiaramonte said. "However, the addition of anxiety and stress to atypical symptoms increased the gastrointestinal diagnosis in both men and women."

Unexpected findings

Chiaramonte said she and her associates were surprised to find that women were less likely to be given a CHF diagnosis when stress was a variable. "In not one of our studies has the presentation of patient sex alone shown that women will be underdiagnosed with heart disease," she said.

Another unexpected finding was that neither the experience level nor the gender of the physician appeared to have much impact. The physician’s gender only influenced outcomes in the cohort of family physicians.

"When patients presented CHD in the context of stress, female family physicians underdiagnosed CHD in female patients as well as in male patients," Chiaramonte said.

Disclosures:
• Dr. Chiaramonte reports no conflicts of interest with regard to this study.