An analysis based on sex&gender in the chest pain unit of an emergency department during the last 12 years

Abstract

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Josep Font 2019 Grant from Hospital Clinic de Barcelona Background Differences between female (F) and male (M) with coronary disease (CD) are related to time delays in detriment of women such as: hospital presentation, recognition of symptoms or an appropriate treatment. Further research based on sex and gender (S&G) is at important to confront the interplay of factors that shape health inequities. Purpose To do an analysis based on S&G of the admissions in the chest pain unit (CPU) of an emergency department (ED), comparing clinical features and also the physician’s initial diagnostic orientation after the first evaluation of the patients (FEoP) . Methods This is an observational descriptive unicentric study of consecutive cases. We retrospectively analysed all the cases admitted in a CPU from 2008-2019 and recorded the cardiovascular risk factors (cvrf), and the clinical and electrocardiographic (ECG) features. We also recorded the final diagnostic after all the management in the CPU and the FEoP [based on the clinical history, physical examination and ECG; before other complementary examinations like troponins (Tnc)]. The characteristics were compared according to sex (F or M). Results 41828 patients were included (42% F), with an older median age in F [Md (RIC) [65 (47-78) vs 59 (43-73)] y.o.; p < 0,001]. We found a significant greater number of late presenters (≥12hours from symptoms onset) in F (41%vs37%;p < 0,001). F were associated to greater rates of obesity, hypertension and previous heart failure; M had greater rates of diabetes mellitus, previous known coronary disease and smoke or cocaine use. When we considered the patients with typical chest pain (TCP), no significant differences based on S&G were found. Women’s ECG were more often interpreted as not having significant changes of ischemia. After the FEoP, the patients were classified as having an STEMI(♀1%vs♂2,5%;p < 0,001), non-STEMI (♀4,3%vs♂5,4%;p < 0,001) or non-diagnostic-ECG(93%). Among patients with non-diagnostic ECG, the physician’s initial diagnostic was a probable acute coronary syndrome (ACS) in 42% of cases. F were less likely to be considered as having an ACS (♀39%vs♂44,5%;p < 0,001). This significant differences were maintained when:1) patients had ≥3cvrf [♀OR0,72; IC95%(0,63-0,83)]; 2)patients had ≥2cvrf [♀OR0,79; IC95% (0,74-0,86)]; 3)patients had TCP [♀OR 0,69; IC95% (0,64-0,74)]; 4)patients had ≥2cvrf and TCP [♀OR 0,72; IC95% (0,63-0,82)]. After the management in the CPU, a 14% of patients with non-diagnostic ECG were finally diagnosed with an ACS (36% if≥2cvrf and TCP). 3% of ACS were initially misdiagnosed (♀5%vs♂3% ;p < 0,001). After a multivariate analysis F is an independent risk factor for an initial impression of non-ACS. Conclusions There is a gender gap in the first evaluation of chest pain with an underestimation of risk in women, not only by the patients who are more often late presenters, but also by the physicians, which entails a higher risk of being misdiagnosed or late diagnosed.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review

“…An extensive malpractice claims database analysis showed that most patients in cardiovascular outpatient general medicine malpractice cases have at least one risk factor suggestive of ischemic heart disease, such as hypertension, tobacco use, or prior cardiovascular disease [36]. Furthermore, the evidence shows that chest pain and ACS are more commonly misdiagnosed in women, with 5% of ACS misdiagnosed in women versus 3% in men (p < 0.001) [37]. As probable ACS was noted in 39% of women and 44.5% of men (p < 0.001), myocardial infarction is likely underestimated in women [37].…”

“…Furthermore, the evidence shows that chest pain and ACS are more commonly misdiagnosed in women, with 5% of ACS misdiagnosed in women versus 3% in men (p < 0.001) [37]. As probable ACS was noted in 39% of women and 44.5% of men (p < 0.001), myocardial infarction is likely underestimated in women [37].…”

Managing patients with sex-, race-, or ethnicity-based cardiovascular health inequities

“…Compared with cisgender men, cisgender women presenting with ACS are 37% more likely to receive an initial misdiagnosis of an ST-segment elevation myocardial infarction (STEMI) and 29% more likely to receive a misdiagnosis of a non-ST-segment elevation myocardial infarction (NSTEMI) 16. This may be partly due to lower suspicion of ACS by both the affected cisgender women and their clinicians; it also could be due to the lower sensitivity of common diagnostic tests in cisgender women 13,17-21…”

“…16 This may be partly due to lower suspicion of ACS by both the affected cisgender women and their clinicians; it also could be due to the lower sensitivity of common diagnostic tests in cisgender women. 13,[17][18][19][20][21] Time from symptom onset to hospital arrival The first step in reducing disparities in the diagnosis of ACS for cisgender women is to educate patients on specific symptoms most commonly associated with sex traits and the importance of seeking care promptly at symptom onset. In a study across 41 hospitals of patients presenting with ACS, cisgender men were found to present to the hospital, on average, 30 minutes closer to the time of symptom onset than cisgender women.…”

Chest Pain in Women: Gender- and Sex-based Differences in the Presentation and Diagnosis of Heart Disease

“…A Spanish study of 41,828 women concluded that, upon initial evaluation, the diagnosis of AMI was underestimated in women presenting with chest pain leading to late and missed diagnosis, further elevating diagnostic costs. 49 Future studies are also needed to comprehensively evaluate the differences between the cost of chest pain in men and women, as well as the economic impact of chest pain misdiagnosis in women.…”