1. McSweeney, Jean C. PhD, RN, FAHA, FAAN
  2. O'Sullivan, Patricia EdD
  3. Cody, Marisue PhD, RN
  4. Crane, Patricia B. PhD, RN


Background/Objectives: Coronary heart disease (CHD) is the number one cause of death in women, yet, little is known about women's symptoms. Early symptom recognition of CHD in women is essential but most instruments do not assess both prodromal and acute CHD symptoms. Our aims were to develop an instrument validly describing women's prodromal and acute symptoms of myocardial infarction and to establish reliability of the instrument, the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS).


Methods: Four studies contributed to the content validity and reliability of this instrument. Two qualitative studies provided the list of symptoms that were confirmed in study 3. The resulting instrument assesses 37 acute and 33 prodromal symptoms. In study 4, 90 women were retested 7 to 14 days after their initial survey. We used the kappa statistic to assess agreement across administrations.


Results: The women added no new symptoms to the MAPMISS. The average kappa of acute symptoms was 0.52 and 0.49 for prodromal. Next we calculated a weighted score. The mean acute score for time 1 was 19.4 (SD = 14.43); time 2 was 12.4 (SD = 8.79) with Pearson correlation indicating stability (r = .84; P < .01). The mean prodromal score at time 1 was 23.80 (SD = 24.24); time 2 was 26.79 (SD = 30.52) with a Pearson correlation of r = .72; P < .01.


Conclusions: The tool is comprehensive, has high content validity, and acceptable test-retest reliability. Low kappas were related to few women having those symptoms. The symptom scores remained stable across administrations.


Although researchers have focused on cardiovascular disease for the previous 50 years, it remains the number one cause of death in men and women. 1 Cardiovascular disease has retained this ranking in part because health care professionals do not recognize and subsequently treat early warning or prodromal symptoms of coronary heart disease (CHD). 2-4 Prodromal symptoms, those symptoms that come and go prior to and change after a myocardial infarction (MI), are especially important to identify in women since they experience both higher morbidity and disability than men do after a MI. 1 However, only 7% of women identify CHD as women's greatest health threat. 5,6 Because most women are unaware of their risk for CHD or do not believe their symptoms indicate heart problems, they often ignore prodromal symptoms. Likewise, since health care providers learn the symptoms indicative of CHD from studies predominately of men whose symptoms often differ from women's symptoms, they have difficulty recognizing and treating women's symptoms appropriately. 5-8


Limited studies, primarily with men, have addressed variability of acute MI symptomatology, but consensus is growing that women's symptoms of MI vary from men's. 8-14 Although larger MI studies included women, they often did not differentiate women's symptoms from men's, 15-18 or used tools that excluded some important symptoms frequently reported by women, according to our preliminary work. 11,12,19-21 Further, no large-scale study has investigated both prodromal and acute symptoms in women. Therefore, development of a symptom instrument was warranted for earlier diagnosis of CHD in women.


This article discusses 4 studies that contributed to the development and establishment of validity and reliability for the symptom portion of an instrument to describe the full range of prodromal and acute symptoms: the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS). This article will describe the content development of the symptom portion of the instrument by summarizing 2 qualitative studies (1 and 2). Then, it will describe tool development, validity, and reliability by summarizing 2 quantitative studies (3 and 4). The University Human Research Advisory Committee approved all studies.