The purpose of the study was to determine whether older (≥65 years) and younger (<65 years) women presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome (ACS) varied on risk factors, comorbid conditions, functional status, and symptoms that have implications for emergent cardiac care. Women admitted to five EDs were enrolled. The ACS Symptom Checklist was used to measure symptoms. Comorbid conditions and functional status were measured with the Charlson Comorbidity Index and Duke Activity Status Index. Logistic regression models were used to evaluate symptom differences in older and younger women adjusting for ACS diagnosis, functional status, body mass index (BMI), and comorbid conditions. Analyses were stratified by age, and interaction of symptom by age was tested. Four hundred women were enrolled. Mean age was 61.3 years (range 21-98). Older women (n = 163) were more likely to have hypertension, hypercholesterolemia, never smoked, lower BMI, more comorbid conditions, and lower functional status. Younger women (n = 237) were more likely to be members of minority groups, be college-educated, and have a non-ACS discharge diagnosis. Younger women had higher odds of experiencing chest discomfort, chest pain, chest pressure, shortness of breath, nausea, sweating, and palpitations. Lack of chest symptoms and shortness of breath (key symptoms triggering a decision to seek emergency care) may cause older women to delay seeking treatment, placing them at risk for poorer outcomes. Younger African American women may require more comprehensive risk reduction strategies and symptom management.

Objective

The aims of this systematic review were to determine the magnitude and impact of multimorbidity (≥2 chronic conditions) on mortality, length of stay, and rates of coronary intervention in patients with acute coronary syndrome (ACS) and to compare the prevalence of cardiovascular versus noncardiovascular multimorbidities.

Methods

MEDLINE, PubMed, MedlinePlus, EMBASE, OVID, and CINAHL databases were searched for studies published between 2009 and 2019. Eight original studies enrolling patients with ACS and assessing cardiovascular and noncardiovascular comorbid conditions met the inclusion criteria. Study quality was evaluated using the Crowe Critical Appraisal Tool.

Results

The most frequently examined cardiovascular multimorbidities included hypertension, diabetes, heart failure, atrial fibrillation, stroke/transient ischemic attack, coronary heart disease, and peripheral vascular disease; the most frequently examined noncardiovascular multimorbidities included cancer, anemia, chronic obstructive pulmonary disease, renal disease, liver disease, and depression. The prevalence of multimorbidity in the population with ACS is high (25%-95%). Patients with multimorbidities receive fewer evidence-based treatments, including coronary intervention and high-dose statins. Patients with multimorbidities experience higher in-hospital mortality (5%-13.9% vs 2.6%-6.1%), greater average length of stay (5-9 vs 3-4 days), and lower rates of revascularization (9%-14% vs 39%-42%) than nonmultimorbid patients. Women, despite being the minority in all sample populations, exhibited greater levels of multimorbidity than men.

Conclusions

Multimorbid patients with ACS are at a greater risk for worse outcomes than their nonmultimorbid counterparts. Lack of consistent measurement makes interpretation of the impact of multimorbidity challenging and emphasizes the need for more research on multimorbidity's effects on postdischarge healthcare utilization.