Women with chest pain receive inferior care to men: study

Women presenting to emergency services with acute chest pain are less likely to receive standard care than men, a Victorian population-based study suggests. 

They are also more likely to die from ST-segment elevation myocardial infarction (STEMI) than men, but have better outcomes for other causes of chest pain.

A team of cardiologists and researchers, from institutions including Alfred Health, Monash University and the Baker Institute in Melbourne, examined sex differences in patients seeking emergency medical attention for undifferentiated acute chest pain in Victoria from January 2015 to June 2019. 

The observational cohort study included 256,901 emergency medical service attendances for chest pain, of which half were women and the mean age was 62. 

Findings, published in the Journal of the American College of Cardiology [link here], showed a cardiovascular disease diagnosis was less common in women than men, although the difference was less pronounced in the over-70 age group.

However, among specific diagnoses, pulmonary embolism and supraventricular tachycardia were more common in women across all ages, while arial fibrillation and heart failure were more common in women in the over-70 age group.

Meanwhile, acute and stable coronary syndromes, pericarditis, myocarditis and acute aortic syndromes were more common in men than women across all ages.

Women were less likely than men to receive guideline-directed prehospital care, including transport to hospital, prehospital aspirin or analgesia administration, 12-lead ECG, intravenous cannula insertion and review by ED staff within target times. 

Data also showed that women with acute coronary syndrome were less likely than men to undergo angiography or be admitted to a cardiac or intensive care unit. 

While 30-day and long-term mortality risk and readmission risk were lower among women than men overall (33%, 23% and 6% reduced risk respectively), among those who presented with STEMI, the risks were higher among women (24%, 22% and 48% increased risk respectively).

“Reducing these differences should be a priority for clinicians and health services, and policy changes such as sex-specific reporting of government key performance measures, including currently non-reported measures such as angiography rates for acute coronary syndrome, could be beneficial in highlighting whether improvements are occurring,” the researchers said.

Writing in an accompanying editorial [link here], US cardiologist Dr John Brush said the greater number and variation in symptoms experienced by women in the study – which included higher rates of nausea or vomiting, palpitations, dizziness and headache – might have contributed to the diagnostic errors and delays. 

The higher mortality and higher readmission rates for women with STEMI suggest that the differences in care had serious consequences,” said Dr Brush, from Sentara Healthcare and Eastern Virginia Medical School.

“Of all the diagnoses that the patients in this study experienced, STEMI is the diagnosis where outcomes are most time-sensitive and where the detrimental effect of time delay would be most evident.”

He added: “The delays in care and disparities in STEMI outcomes observed in this study are a call for the medical profession to act. 

“Prompt diagnosis, timely ECGs, and early treatment should be a top priority for all patients with undifferentiated chest pain, including women.”

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