Acute chest pain in women vs. men treated differently across the care spectrum

Women with acute chest pain are managed differently than men across the care spectrum, an Australian study found.

Researchers performed a population-based cohort study in Victoria, Australia, to assess sex differences in epidemiology and care pathways for acute chest pain from emergency medical services (EMS) contact through clinical outcomes after discharge. Consecutive adults treated by EMS for acute undifferentiated chest pain from Jan. 1, 2015, to June 30, 2019, were included in the study, and EMS clinical data were individually linked to ED and hospital data. Mortality and care quality and outcomes were assessed by using multivariable analyses. The study results were published March 6 by the Journal of the American College of Cardiology.

Among 256,901 EMS responses for chest pain, 129,096 (50.3%) were in women. Mean patient age was 61.6 years. Women were more likely to have additional and more diverse concurrent symptoms besides chest pain (≥2 other symptoms in 37.1% of women vs. 32.4% of men). They had higher rates of nausea or vomiting, palpitations, dizziness, and headache, and age-standardized incidence rates for chest pain were marginally higher for women than for men (1,191 vs. 1,135 per 100,000 person-years). Multivariable models found that women were less likely to receive guideline-directed care across most measures, including transport to the hospital, prehospital administration of aspirin or analgesia, 12-lead electrocardiogram, IV cannula insertion, and transfer from EMS or review by ED clinicians within target times. Women with acute coronary syndrome (ACS) were less likely to undergo angiography or to be admitted to a cardiac or intensive care unit. Thirty-day and long-term mortality were lower overall for women than for men, but higher for women diagnosed with ST-segment elevation myocardial infarction (STEMI). (Of note, another recent study, published Feb. 27 by the Journal of the American Heart Association, found that STEMI hospitalizations have increased among U.S. women ≤45 years of age from 2008 to 2019 and that in-hospital mortality rates for STEMI have not changed in this time period in women ≤55 years of age, in contrast to global trends in STEMI mortality.)

The researchers noted that their study looked only at patients who used EMS, among other limitations. “In this state-wide population-based study of acute chest pain presentations, women were less likely to receive guideline-directed care compared with men across most care quality measures in the prehospital, hospital, and ACS care settings. Women had higher mortality for STEMI, but better outcomes for other etiologies of chest pain compared with men,” they wrote. “These findings highlight a need to reduce substantial care discrepancies for women presenting with acute chest pain.”

An accompanying editorial said that the study shows “cascading delays” in prehospital and hospital care for women with acute chest pain and noted that such delays are particularly problematic in the case of STEMI. “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 [electrocardiograms], and early treatment should be a top priority for all patients with undifferentiated chest pain, including women,” the editorialist wrote. “An ECG is a quick and conclusive diagnostic test for a STEMI diagnosis and timely ECGs in all patients with chest pain might be an easy and inexpensive remedy for the implicit bias that appears to impede the diagnosis and care in women with STEMIs.”