在初級照護 胸痛表現與診斷有性別上的差異
作者：Laurie Barclay, MD
出處：WebMD醫學新聞
January 5, 2010 — 根據一項線上發表於2009年12月14日BMC家庭醫學執業期刊的研究結果，初級照護時，胸痛表現與診斷有性別上的差異。
德國馬爾堡馬爾堡大學的Stefan Bosner醫師與其同事們寫到，胸痛是初級照護中一個常見的抱怨以及會診的原因。在冠狀動脈疾病（CHD）方面，目前已有許多與性別差異有關的研究，但並沒有相關的初級照護研究。我們想要分析胸痛的病因學與臨床特徵在性別上的差異，並提供與性別相關的CHD症狀和病徵。
這項研究樣本包括1,212位連續的、年齡35歲以上，在74個一般執業醫師診間因胸痛就診的病患，這些執業醫師記錄每位病患的症狀與後續追蹤數據。在收納病患的時候，由獨立多專業徵詢團隊檢閱臨床資訊，並決定每位病患的胸痛原因。以多變項迴歸分析，研究者們決定協助確認或是排除女性與男性CHD的臨床預測因子。
相較於男性，女性被診斷有精神異常的機率較高（11.2%相較於7.3%；P=0.02）。然而，男性比較容易被診斷罹患CHD（17.2%相較於13.0%；P=0.04）、外傷（5.1%相較於1.8%；P<0.001）、肺炎/肋膜刺痛（3.0%相較於1.3%；P=0.04），且胸痛比較常發生在胸部右側（25.0%相較於9.1%；P=0.01）。
不論性別，與CHD正面有關的因子包括年齡、已知臨床心血管疾病、以及運動加劇疼痛。疼痛時間超過1個小時與女性CHD有關，但疼痛時間較短與男性CHD有關。女性的刺痛以及疼痛會受到吸氣影響，男性局部肌肉痠痛負面地與CHD有關。
這項研究的限制包括提供給諮詢團隊的臨床資訊有限、以及與最終診斷有關之可能的合併誤差。
研究作者們寫到，我們發現，初級照護時因胸痛就診的病患中，病因學、CHD與症狀及病徵之間關係、特定臨床特徵有性別上的差異。未來需要研究來釐清這些差異是否將支持根據病患性別使用不同診斷方法的建議。
其中一位試驗作者中擔任MSD與ESSEX的科學顧問。
Sex Differences Noted in Presentation, Diagnosis of Chest Pain in Primary Care
By Laurie Barclay, MD
Medscape Medical News
January 5, 2010 — There are sex differences in presentation and diagnosis of chest pain in primary care, according to the results of a study reported online in the December 14, 2009, issue of BMC Family Practice.
"Chest pain is a common complaint and reason for consultation in primary care," write Stefan Bosner, MD, MPH, from the University of Marburg in Marburg, Germany, and colleagues. "Research related to gender differences in regard to Coronary Heart Disease (CHD) has been mainly conducted in hospital but not in primary care settings. We aimed to analyse gender differences in aetiology and clinical characteristics of chest pain and to provide gender related symptoms and signs associated with CHD."
The study sample consisted of 1212 consecutive patients 35 years and older with chest pain seen at offices of 74 general practitioners, who recorded symptoms, findings, and follow-up data for each patient. At the time of patient recruitment, an independent interdisciplinary reference panel reviewed the clinical information and determined the cause of chest pain for each patient. Using multivariable regression analysis, the investigators determined clinical predictors helping to confirm or exclude CHD in women and men.
Compared with men, women were diagnosed with more psychogenic disorders (11.2% vs 7.3%; P = .02). However, men were more likely to have CHD (17.2% vs 13.0%; P = .04), trauma (5.1% vs 1.8%; P < .001), and pneumonia/pleurisy (3.0% vs 1.3%; P = .04), and chest pain was more often localized on the right side of the chest (25.0% vs 9.1%; P = .01).
Factors positively associated with CHD in both sexes were age, known clinical vascular disease, and pain worse with exercise. Pain duration of more than 1 hour was positively associated with CHD in women, whereas shorter pain durations were associated with CHD in men. There were negative associations for stinging pain in women and for pain affected by inspiration and localized muscle tension in men.
Limitations of this study include only limited clinical data available to the reference panel and possible incorporation bias regarding the final diagnoses.
"We found gender differences in regard to aetiology, selected clinical characteristics and association of symptoms and signs with CHD in patients presenting with chest pain in a primary care setting," the study authors write. "Further research is necessary to elucidate whether these differences would support recommendations for different diagnostic approaches for CHD according to a patient's gender."
One of the study authors acts as scientific advisor for MSD and ESSEX.
BMC Fam Pract. Published online December 14, 2009.
