Original Contribution
Inequalities in the early treatment of women and men with acute chest pain?

https://doi.org/10.1016/j.ajem.2011.12.020Get rights and content

Abstract

Purpose

The aim of this study was to identify sex differences in the early chain of care for patients with chest pain.

Design

This is a retrospective study performed at 3 centers including all patients admitted to the emergency department because of chest pain, during a 3-month period in 2008, in the municipality of Göteborg. Chest pain or discomfort in the chest was the only inclusion criterion. There were no exclusion criteria.

Data Sources

Data were retrospectively collected from ambulance and medical records and electrocardiogram (ECG), echocardiography, and laboratory databases.

Main Findings

A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included.

When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13).

Delay time to the first ECG recording did not differ significantly between women and men.

Principal Conclusions

Among patients hospitalized due to chest pain, when adjusting for differences at baseline, female sex was associated with a prolonged delay time until admission to a hospital ward, to administration of aspirin, and to performing a coronary angiography. There was no difference in delay to the first ECG recording.

Introduction

Cardiovascular disease is a major cause of death among women and men worldwide [1]. In Sweden, the incidence of acute myocardial infarction (AMI) in 2008 for men and women was 619 per 100 000 and year, and 440 per 100 000 and year, respectively [2]. This incidence is decreasing over time: as compared with 2001, age-standardized incidence was 20% lower for men and 15% lower for women in 2008 [2]. This change has been seen despite new definitions of myocardial infarction and the use of new sensitive biomarkers [3]. Mortality has also decreased considerably during the last decade, and for 2008, the 28-day mortality rate for myocardial infarction in Sweden was 29% among men and 32% among women [2]. Our experience indicates that sex differences in the treatment of acute coronary syndromes (ACSs) are minor or even nonexistent if the patient was admitted to a coronary care unit (CCU) [4], [5]. In contrast, recent scientific reports from China, France, Germany, and the United States still describe the underutilization of reperfusion therapy in ACS among women as compared with men [6], [7], [8], [9].

Sex discrepancies in patients with myocardial infarction do exist. Women are 4 to 10 years older than men when having their first myocardial infarction [10], [11]. They more often have a previous history of hypertension and diabetes but are less likely to have a history of previous myocardial infarction or revascularization [11]. Female coronary artery vessels have smaller dimensions, and the atherosclerosis is often more diffuse than in men. Chest pain due to spasm in the coronary arteries and cardiac syndrome X seem to be more common in women, as is stress-induced or takotsubo cardiomyopathy [12], [13]. Among patients with AMI, women more frequently report nausea, vomiting, and dyspnea, and there is also a difference in localization of symptoms where women have more pain in the neck, back, and abdomen as compared with men [14], [15], [16], [17].

The purpose of this study was to identify differences in the chain of care for women and men with chest pain. Our primary hypothesis was that there is a difference in delay time to a hospital ward between men and women with chest pain. The secondary objective measures were delay time to (1) electrocardiogram (ECG) recording, (2) administration of aspirin, and (3) coronary angiography. Our primary objective reflects the capacity of the health care system in handling the large volumes of patients with chest pain in our community. The secondary objective measurements are chosen because of their diagnostic and therapeutic importance to reduce myocardial damage when given early in the ACS event.

We also wanted to descriptively compare investigations and treatments to highlight any differences between sexes, with the intention to generate future hypotheses for studies focusing on equitable cardiac care.

Section snippets

Study design

This is a retrospective chart review performed at 3 centers including all patients admitted to the emergency department (ED) because of chest pain, during a 3-month period in 2008, in the municipality of Gothenburg. This study was approved by the Göteborg Ethical Review Board.

Study population

From mid-September to mid-December in 2008, all patients with chest pain visiting one of the 3 hospitals (Sahlgrenska, Östra or Mölndal) in the Sahlgrenska University Hospital organization were included in this study. The

Results

A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included. Of these visits, 1350 resulted in hospitalization (in 1266 patients). Of all visits, 42% of women and 38% of men (P = .62) were transported by the EMS.

Discussion

In the Göteborg region, there are 3 hospitals that provide emergency and basic care to approximately 620 000 residents and also provide highly specialized care for 1.6 million inhabitants living in western Sweden (December 31, 2010). Patients with chest pain are common at the EDs, and these 3 hospitals are taking care of nearly 10 000 patients with chest pain every year. Therefore, it is of greatest importance to optimize and improve the quality of care for this group of patients.

Research on

Acknowledgments

Thanks to Eva Brändström, Sören Johansson, Henrik Eriksson, Åsa Axelsson, and Annika Odell for fruitful discussions and good ideas during this project. I also want to thank Eva-Sofie Andreen, Angela Synnero, Renee Palmnäs, Annika Dahllöf, Anneli Linner, and Carina Gustafsson for their great support during data collection. Last but not least, I want to express my gratefulness to Nguyen Dang Thang for great support in ECG analysis.

References (26)

Cited by (15)

  • The influence of age and gender on delay to treatment and its association with survival after out of hospital cardiac arrest

    2021, American Journal of Emergency Medicine
    Citation Excerpt :

    The clinical implication of this is questionable, and the observation that the difference was not even more pronounced, can most likely be attributed to the fact that defibrillation is mainly performed by healthcare professionals who are trained to perform rapid defibrillation regardless of age and gender. Previous reports have shown that women with various manifestations of cardiovascular disease are not treated as effectively as men [19-21]. Women have also been reported to less often undergo bystander CPR than men [22].

  • Differences in Presentation, Management and Outcomes in Women and Men Presenting to an Emergency Department With Possible Cardiac Chest Pain

    2017, Heart Lung and Circulation
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    Our finding that women spent a similar amount of time in the ED is also in contrast to previous studies of confirmed ACS patients [10–14]. Analysis of ED time in chest pain patients with possible ACS patients is lacking, although one such study did observe delayed time from ED presentation to ward admission for female patients [33]. Minimising the time from symptom onset to reperfusion is important as delays are associated with higher mortality, and it is possible that delayed time until reperfusion has contributed to the relatively poor prognosis historically observed in female ACS patients [34,35].

  • Prehospital ECG signs of acute coronary occlusion are associated with reduced one-year mortality

    2013, International Journal of Cardiology
    Citation Excerpt :

    Presence of ST-elevation on the initial ECG was associated with lower 1-year mortality. The chest pain patient is one of the most common visitors at our hospitals, and former studies have shown that about 50% of these patients are hospitalized after triage at the emergency department [7]. In the municipality of Göteborg (630,000 inhabitants in Dec. 2011) there are three hospitals offering emergency care for patients with presumed ACS.

  • Comparison of the performances of cardiac troponins, including sensitive assays, and copeptin in the diagnostic of acute myocardial infarction and long-term prognosis between women and men

    2013, American Heart Journal
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    Fourth, the prognostic accuracy offered by cTnT, hs-cTnT, and copeptin was similar in women and men, even when a different cutoff value based on the 99th percentile value in women and men was applied. These findings have important clinical implications and extend previous work on gender differences.3-10,16,23 The role of cardiac biomarkers may be even more prominent in women because they more likely than men report atypical symptoms, such as dyspnea, weakness, nausea, and backpain1; these unspecific complaints may delay accurate diagnosis or even lead to misdiagnosis of AMI or acute coronary syndrome.

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This study was supported by grants from the Laerdal Foundation in Acute Medicine in Norway and from the research program VINNVÅRD jointly funded by Vårdalstiftelsen, VINNOVA, Sveriges Kommuner och Landsting (SKL), and Social departementet.

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