1. Kamm-Steigleman, Lucia RN, MSN, MBA, PhD

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Welcome to Nursing2008 Critical Care's new regular column, Research Rounds. This column is compiled by critical care nursing professionals who meet regularly to critique recent articles in scientific literature.


This group aims to help readers with two crucial dilemmas: 1.) translating critical care research into practice techniques you can immediately put into place at the patient bedside, and 2.) saving you time and money by summarizing the key points in noteworthy research articles, which eliminates the need to for you to physically drive to meet your colleagues in a group that's often called a "journal club." In Research Rounds we'll learn the basics of nursing research, discover the research findings within a particular high-interest article, and critique the article.


Learn the basics of nursing research

The clinical question of our first discussion relates to acute myocardial infarction (AMI). Specifically, is there a difference in symptoms between male and female patients? One efficient way to explore this question is to read review articles on the topic. Here, we do the summary for you.


Chen, et al,1 wrote a review article that critically analyzes and evaluates studies comparing gender differences in symptoms of AMI. Part of the nursing research process can include searching for more recent articles on the topic such as Fukuoka, et al.2 Historically, the bulk of the research on AMI was performed on male participants in the 1960s. In the 1990s, the National Institutes of Health began funding research on women's experience of heart disease.


Discover the research findings

Over time, it became apparent that women's symptoms of AMI differ from men's in 10 of the 11 studies; however, the specific findings were inconsistent across studies. Inconsistent findings can result from the way the studies were conducted. For example, data can be collected from medical records that might not completely delineate the symptoms. The research studies can vary in the number of participants studied, called the sample size. If the sample sizes are small or the criteria used to select the participants differ from one study to another, inconsistencies in the findings can occur. The findings reported in this review article were: women were more likely to report shortness of breath (in 6/10 studies), nausea (in 5/6 studies), back pain (in 5/6 studies), vomiting (in 2/3 studies), neck pain (in 3/5 studies); men were more likely to report chest pain (in 3/8 studies) and sweating (in 4/8 studies). General public and healthcare providers need to be educated about gender differences in symptoms of AMI. Women need to be especially educated and to be aware of the variability of AMI symptoms.


Regardless of the inconsistencies of the specific research findings, a synthesis of the literature shows that our patient's symptoms may not be standardized and that severe chest pain may not be a reliable cue. For nurses in evidence-based practice, the common symptom of pain described as an "elephant sitting on my chest" should not be the only indicator of an AMI for women.


Critique the article

Does the article follow the usual format? Yes, it does. It begins with the abstract, which is a "cliff-notes" summary of what you will find within the article. The introduction includes a statement of purpose and how the search was conducted to review the literature. For example, in the article by Chen, et al,1 the authors reviewed the Medline and CINAHL databases looking for studies on AMI symptoms in men and women. They reviewed quantitative research studies that included both men and women. The goals of quantitative studies are to provide statistical information about research questions. In the summary section, the author pointed out the strengths of the research article that included a large number of participants, adjustment of important confounding variables (such as social and environmental factors that might have influenced the findings), and the use of a data collection form. The article is a valuable source of information because it critically reviewed the past 10 years of brand-new research on the differences of women's symptoms at the time of their AMIs. Their review included 39 studies-many of them full-text articles-all easily accessible to the reader.


The diagnostic criteria for AMI have changed since 2000. According to the 2007 ESC/ACCF/AHA/ WHF Expert Consensus Document, Universal Definition of Myocardial Infarction, in a clinical setting consistent with myocardial ischemia, diagnostic criteria include a rise or fall of cardiac biomarkers (preferably troponin) with at least one of the following: symptoms of ischemia, ECG changes consistent with new ischemia, the development of pathological Q-waves, or imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. Quantitative studies continue to enhance the knowledge of gender differences in cardiac symptoms. It was reported in the recent large study of 1,059 AMI patients across five countries (Australia, Japan, South Korea, England, and the United States) that women are twice as likely to attribute their cardiac symptoms to the flu. Women were less likely to recognize their symptoms as cardiac if they were single or had a recent marital status change.2 Research designs that include large sample sizes and use various nations from which to draw participants increase the power of the study. Power allows the researcher to detect differences or relationships that exist.


The process for gaining knowledge needs to continue. It would seem that once the data began demonstrating AMI differences in women, additional research studies should've been conducted until statistically significant correlations were uncovered. The last 10 years have shown that quantifying a woman's uniqueness is paramount to improving mortality outcomes in women following AMI. Seeking to uncover knowledge is like shooting at a moving target. Time marches on and the process is never static, so a measured moment in time has many different circumstances from another moment in time.


This Research Rounds' topic is as current today as it was in 2005 when the review article was published. The importance of reducing the time to treatment of a cardiac episode has been the focus of critical care nurses' attention for years. Failure to recognize a woman's unique presentation, coupled with the fact that women do not perceive themselves to be at risk for heart attack, seriously puts women at risk for poor outcomes.


Many ask why there are so many articles, so many researchers, so much time involved with a focus on the same topic. It's because research findings are still inconsistent, as shown in this article. This showcases the profound importance and global impact of the research process in expanding knowledge. As difficult as this process is, the necessity of saving human life demands probing gender differences and quantifying womens' unique responses to imbalances in their health. If you're well-versed in the latest AMI research findings, you'll be better prepared to educate the public about AMI recognition in women.




1. Chen W, Woods SL, Puntillo KA. Gender differences in symptoms associated with acute myocardial infarction: a review of the research. Heart Lung. 2005;34(4):240-247. [Context Link]


2. Fukuoka Y, Dracup K, Moser DK, et al. Is severity of chest pain a cue for women and men to recognize acute myocardial infarction symptoms as cardiac in origin? Prog Cardiovasc Nurs. 2007;22(3):132-137. [Context Link]