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DOI: 10.1177/0145721706294262 © 2006 American Association of Diabetes Educators; Published by SAGE Publications
Symptom Interpretation in Women With Diabetes and Myocardial InfarctionA Qualitative StudyFrom the School of Nursing, Oregon Health & Science University, Portland (Ms Mayer, Dr Rosenfeld), and College of Nursing, Montana State University, Missoula (Ms Mayer). Correspondence to Dorothy "Dale" Mayer, APRN, BC, Montana State University College of Nursing, 32 Campus Drive 7416, Missoula, MT 59812-7416 (dmayer{at}montana.edu).
Purpose The purpose of this study was to describe the role of diabetes in acute myocardial infarction (MI) symptom interpretation. Methods This is a secondary data analysis of a study of treatment-seeking delay in women with acute MI (N = 52). This study included a subsample of those with diabetes (n = 16). Women were interviewed while hospitalized with MI about their actions, thoughts, and feelings from symptom onset to entry into the health care system. Qualitative description was the method of analysis. Results Three major themes were identified in the qualitative data: diabetes and decision making, presenting symptoms, and symptom attribution. Not all women included information about diabetes in their story, but those who checked blood sugars generally found it to be elevated. Diabetes was a factor in decision making for more than half of the sample. Presenting symptoms were variable but raised hypotheses about shortness of breath as a common presenting symptom for women with diabetes and MI. The third theme, symptom attribution, revealed confusion as to the cause of symptoms. Conclusions These results provide insight into symptom interpretation in women with diabetes and MI. Women with diabetesshould consider atypical symptoms such as shortness of breath, gastrointestinal symptoms, and fluctuating blood sugars as reasons to seek care. Education for women with diabetes should include action plans for how to recognize and respond to symptoms. More research on the influence of diabetes on MI symptom attribution and decision making is needed.
Cardiovascular disease is the most common complication of diabetes in women,1 and diabetes is the only condition that causes women to have rates of coronary heart disease (CHD) similar to those of men.2 Between 65% and 80% of patients with diabetes die of cardiovascular disease.3,4 Women with diabetes are 2 to 4 times more likely to be hospitalized for cardiovascular disease compared to women without diabetes, costing women's lives, well-being, and nearly $3.8 billion in direct inpatient costs in 2001.5 Mortality trends reveal that while heart disease mortality has declined 27% in women without diabetes, it has increased 23% in women with diabetes.6 Women with diabetes, however, may fail to recognize symptoms of the most common manifestations of CHD, especially acute myocardial infarction (MI). Failure to recognize the symptoms of MI may delay treatment and thus contribute to the high cardiovascular mortality and morbidity rates in women with diabetes.7 Such treatment-seeking delay for MI symptoms is dangerous; for therapies to be most effective, they must be administered within 2 hours of symptom onset.8 McSweeney et al's9 seminal description of women's prodromal and acute MI symptoms documented that only 57% of women with MI presented with acute chest pain and that women are likely to describe this chest pain as "tightness," "heaviness," and "aching." Ninety-five percent of women experienced prodromal symptoms prior to the development of acute MI symptoms, and these included unusual fatigue, sleep disturbances, shortness of breath, indigestion, and anxiety.9 Risk factors for MI without chest pain are female gender, older age, prior heart failure, and diabetes.10,11 Women with both diabetes and MI may experience symptoms other than chest pain, and the absence of chest pain may contribute to the difficulty in attributing their symptoms to a cardiac cause. It is generally accepted by clinicians that women with diabetes present with atypical symptoms or without ischemic symptoms,12 but a clearer understanding of the symptom experience of women with diabetes could serve as the basis for teaching women to recognize MI symptoms and to respond quickly. However, research to date on symptoms of MI in women with diabetes is limited and inconclusive. Five studies comparing MI symptoms in those with and without diabetes produced conflicting results about whether diabetes alters MI symptom presentation or affects treatment-seeking delay.13-17 Only 1 of these studies reported an analysis by gender.13 In that study, Culic and colleagues found that diabetes was a predictor of nonpain symptoms of MI in women but not in men. The purpose of this study was to describe the role of diabetes in MI symptom interpretation in a group of women with diabetes and acute MI. Using qualitative methodology, the researchers sought to describe unique aspects of the MI symptom experience in women with diabetes and to lay the foundation for future research related to symptoms and actions of women with diabetes and MI.
This study was a secondary analysis of data from a larger study of treatment-seeking delay in women with acute MI.18,19,29 In that study, women were interviewed while hospitalized and asked to describe their actions, thoughts, and feelings from the time their symptoms started until the time they reached the hospital. Then they completed a structured measure of MI symptoms. Diabetes diagnosis was determined by self-report and medical record review. This study was approved by the institutional review boards at the 3 hospitals used as recruitment and data collection sites.
Sample
Measures
MI Symptom Survey. The MI Symptom Survey was developed by
the second author (A.R.) based on a review of the literature for symptoms of
MI, providing evidence for its content
validity.21-25
In addition, 2 cardiac nurse experts judged the survey to be a complete list
of MI symptoms. The survey consists of 16 dichotomous items—15 symptoms
and an "other" category—and yields data regarding the
presence or absence of symptoms. Internal consistency reliability was
acceptable for this type of scale in the larger study (
Analysis In this study, a semistructured interview was used with the goal of discovering how women with diabetes described the MI symptoms they experienced. Initially, participants were asked to tell the story of what occurred before their admission to the hospital. Then participants were asked about the presence or absence of specific symptoms using the MI Symptom Survey discussed above. All interviews were audiotaped and transcribed verbatim. The qualitative description analysis plan used qualitative content analysis, in which the researcher focuses on summarizing content to generate patterns26 and then themes from the data. Qualitative content analysis is a dynamic and inductive method; data coding is a modifiable, iterative process. The first author (D.M.) read the interview transcripts, focusing on the identification of patterns in the data related to diabetes and symptom interpretation. On the first reading, general patterns were identified (such as symptoms, actions, and decisions). Repeated readings of the transcripts focused particular attention on participants' language and led to identification of more specific patterns. As specific patterns emerged, all analyzed transcripts were reexamined to verify the presence or absence of these patterns. Identified patterns were then grouped into themes. The goal was to provide an accurate summary of the participants' interpretation of their MI symptoms in the context of diabetes and their subsequent actions. The second author (A.R.) read the transcripts and the description of patterns and themes at each step, providing peer debriefing27 to ensure credibility of the findings. Through this process, both authors reached consensus about the findings.
Symptoms and Treatment-Seeking Delay Time Secondary analysis of the quantitative data revealed that the women with diabetes delayed seeking care for their MI symptoms longer than did those without diabetes (median delay time, 6.88 vs 4.25 hours). Table 1 lists the symptoms experienced by the women in this study. Women with diabetes reported more palpitations, shortness of breath, and fatigue but less chest discomfort and jaw pain than the women without diabetes in the larger sample.
Using qualitative description techniques, 3 major themes were identified. These were diabetes and decision making, presenting symptoms, and symptom attribution.
Diabetes and Decision Making Several women voiced frustration at not being able to get their blood sugar level down to normal. One woman said, "It was irritating me because of my blood sugars... because I couldn't get my blood sugars to go down." Another woman had measured her blood sugar and reported that her "blood sugar was actually 285" on the day of her admission for an acute MI. The same woman reported that in the days preceding her hospital admission, her blood sugar had been "300 to 350." Another woman stated, "I thought my blood sugar was going crazy."
Presenting Symptoms Several women mentioned extreme fatigue as a presenting symptom. One woman reported, "I felt very tired...I started feeling tired all the time...I could sleep the whole morning and part of the afternoon," and "I felt very, very tired." Another woman stated, "I slept most of the day on and off...I was very, very, tired." Five subjects reported initial respiratory symptoms such as the inability to catch their breath, breathing difficulties, or shortness of breath. For instance, 1 woman reported, "All at once I got this breathing difficulty...I could not breathe right and it got worse and it got worse and it got worse...I did not have chest pains...I had this difficulty breathing." An additional woman wondered, "Why can't I catch my breath?" Only 1 woman reported her presenting symptom as sweaty, clammy, and shaky, and as might be expected, this woman attributed these symptoms to her diabetes and a low blood sugar level. She stated, "I was feeling really weak so I made myself a peanut butter [sandwich]." Later, her daughter "came in and gave [me] a spoonful of sugar." This woman continued to feel "weak and just plain yucky" and eventually told her husband, "I think I'd better go to the hospital. This is not going away." As a result of their presenting symptoms, the women with diabetes often self-medicated. These women reported self-medicating with a variety of medications including antacids, benzimidazole, nonsalicyates or salicylates, H-2 receptor antagonists, opiates, and nonsteroidal anti-inflammatory medications. Three women self-treated for a low blood sugar level with candy, sugar, or chocolate. None of the women in the sample reported taking any cardiac medication such as nitroglycerine.
Symptom Attribution Five women attributed their initial symptoms to gastrointestinal disturbances including gas, heartburn, and indigestion. For example, 1 woman stated, "I thought it was all indigestion. So [my husband] was thinking heart attack the whole time I was thinking indigestion." Remarkably, only 1 woman in this sample thought she might be having a heart attack and called her physician's office. She described her symptoms as a vague nagging pain in her face, back, and shoulder. She obtained an appointment with her physician for later that day, at which time the diagnosis of MI was made. She later commented, "You know, you always hear about the big pain in your arm and the constriction of your chest and falling down on the golf course and stuff...I didn't realize that women could have a heart attack without having major pain."
The goal of this study was to explore how women with diabetes experience MI and thereby understand how they manage their symptoms. It provides an initial examination of how the presence of diabetes mellitus affects the decision making of women who experienced an MI. Three important themes emerged from this work: diabetes and decision making, presenting symptoms, and symptom attribution. Together, the results of this study provide insight into symptom interpretation in women with diabetes and MI, including the symptoms women with diabetes experience during MI and their response to those symptoms. The precise mechanisms underlying women's MI symptom manifestations are not clearly understood, but research points to gender differences in physiology. For example, the process leading to MI in women is plaque erosion, whereas in men, it is plaque explosion and rupture.28 In addition, although diabetic autonomic neuropathy has most often been offered as the explanation for nonchest pain or silent MI in people with diabetes, Airaksinen12 has challenged this hypothesis and suggested that complex mechanisms of silent cardiac ischemia are responsible. Not all women in the sample included information about diabetes in their story, and many of the participants did not check their blood sugar level during the time when they experienced symptoms prior to their MI. However, those women who did check their blood sugar level generally found it to be elevated. For more than half the women in the sample (56%), the presence of diabetes was a factor in their decision making. An elevated blood sugar level was usually frustrating and may have distracted the women's attention away from their other symptoms. However, for the rest of the sample, the presence of diabetes did not appear to influence their decision making. They did not think about their diabetes in relation to the symptoms they were experiencing and more often than not did not check their blood sugar level. Because there is little known about how women with diabetes interpret their cardiac symptoms in light of their illness, these findings highlight the need for research to explore the perception of symptoms in the context of diabetes. The second theme revealed that the presenting symptoms of MI in women with diabetes were variable, as they are in women in general. This is consistent with the work of Culic et al,13 Funk et al,15 and MacKenzie and Neibert.16 Many of the participants did not have chest pain or chest pressure. In fact, women often reported indistinct and atypical symptoms of pain. Women in the sample frequently cited respiratory symptoms. It is important to note that only 1 woman reported the symptoms of hypoglycemia, which she was not able to self-manage, thus precipitating her visit to the hospital. The findings of the study lead us to hypotheses about differences in cardiac symptom presentation and atypical symptoms in women with diabetes. The results suggest a possible role for shortness of breath as a presenting symptom for women with diabetes and MI. Funk et al15 and Culic et al13 reported a higher frequency of shortness of breath as a symptom of coronary heart disease in patients with diabetes compared to those without diabetes. In addition, MacKenzie and Neibert16 found that shortness of breath was a factor in the decision to seek care in men and women with diabetes. Further research is needed to confirm shortness of breath as a possible hallmark of MI in women with diabetes. The third theme, symptom attribution, revealed confusion as to the cause of the symptoms. Many women reported surprise when told they were having an MI. They often attributed their symptoms to other conditions, including respiratory distress or gastrointestinal disturbances. It appears that many women in the sample anticipated that an MI would present as a major episode of chest pain. In only a few instances were the presenting symptoms attributed to the women's diabetes. It is not uncommon for women to attribute their symptoms to factors other than MI,29 but the findings presented here point out the need for research to further describe the influence of diabetes on symptom attribution. For example, does relating symptoms to diabetes help or hinder in seeking immediate care for MI symptoms? This study is limited because it was a secondary data analysis, and thus, the researchers could not check back with the participants to determine if the analysis of their stories was accurate or to ask further questions related to their diabetes. However, the analysis techniques used were designed to ensure the credibility of the findings. Despite this limitation, this study provides direction for future research related to the symptom experience of women with diabetes and MI.
The findings can also guide practice. Cardiovascular disease is the most common complication of diabetes in women.1 Therefore, it is crucial that diabetes educators discuss the risks and symptoms of cardiovascular disease with their clients and emphasize the fact that cardiovascular disease is a common complication of diabetes.30 This study provides preliminary information that can help make those educational efforts more effective. Rather than just reviewing lists of symptoms, it is helpful to provide examples of how other women with diabetes experience their symptoms, what they think and do about them, and how they often delay seeking medical care. The findings suggest a potential role for elevated blood sugar levels as an MI prodromal symptom that could be recognized by women. Further research is needed to determine an existence of temporal relations between MI symptoms and blood sugar level changes. However, diabetes educators and other health care providers should encourage women with diabetes to check their blood sugar level when experiencing unusual, different, or vague symptoms. Medical care should be sought for elevated blood sugar levels, especially if other symptoms are also present. Women with diabetes should consider other symptoms, particularly shortness of breath but also including gastrointestinal disturbances, fatigue, and fluctuating blood sugar levels, as reasons to seek medical attention. It has been learned that it may be important to question women with diabetes with MI about the presence of atypical symptoms, including fatigue, respiratory and gastrointestinal symptoms, and typical symptoms such as chest pain or pressure. Education for women with diabetes should include self-management strategies, such as action plans for how to respond to symptoms and blood sugar measurements during symptoms. This in turn may facilitate a woman's decision to seek medical attention. Community education targeted for women with diabetes can also be developed. These educational programs should stress that women often do not experience the classic MI symptoms of severe chest pain. In sum, women with diabetes should be instructed to pay attention to vague and unusual symptoms and seek medical attention to determine if the symptoms might be cardiac.
Funding for this study came from the National Institute of Nursing Research, National Institutes of Health, R01 NR05268, Anne Rosenfeld, principal investigator, and Oregon Health & Science University School of Nursing intramural funding. The authors wish to acknowledge the editorial assistance of Rachel Dresbeck and Blair G. Darney.
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Abstract
Methods
= 65 years) was not
significantly different from those without diabetes (n = 36;
= .60). 
