Gender perspective in the care experience and in the results of patients who consult for chest pain in an emergency department

Introduction

Ischemic heart disease remains the leading cause of morbidity and mortality worldwide^1,2. As a typical clinical presentation, it manifests with chest pain, and for optimal diagnosis and treatment upon admission to an emergency department, specialized units were implemented, following criteria, recommendations, and definitions from scientific societies. The implementation of a chest pain unit (CPU) has improved the quality of care for patients with acute coronary syndrome (ACS)³.

These structured hospital procedures (which include algorithms, protocols, and well-defined recommendations based on updated clinical practice guidelines) increase community awareness among patients (for early recognition of symptoms) as well as among medical professionals and services (to shorten delays related to cardiology consultations, hemodynamics, or transfers), ensuring better workflow and improving performance^4,5.

Gender-specific medicine acknowledges that both men and women may experience diseases differently and that biological, hormonal, social, and behavioral factors may influence both health and response to treatments^6,7. Regarding cardiovascular disease, the so-called atypical manifestation in women has been known for many years^8-11. Similarly, it is more common for women to present with ACS without ST-segment elevation¹².

However, there are reports that highlight inequalities in medical care, such as: women experience longer delays in receiving medical attention and undergoing complementary tests¹³, greater delay in performing the first electrocardiogram (ECG), and a lower proportion of troponin tests¹⁴, which could impact not only therapeutic decisions but also clinical outcomes¹², leading to higher mortality in women after a coronary event^15,16.

In fact, despite seeking healthcare prior to hospitalization, 53% of women and 37% of men with similar clinical presentations reported that healthcare personnel ruled out the possibility of cardiac causes^14,17.

Currently, there is global interest in addressing this issue, aiming to reduce or mitigate gender disparities during the care process. However, data at the local level remain limited.

Since time and efficiency play a crucial role in mortality and morbidity in chest pain consultations, this observational and retrospective study aimed to compare, between men and women, the time to medical attention and to performing the first ECG from ER admission, as well as to describe the clinical evolution (e.g., time to case definition, complementary tests performed) and the hospitalization outcomes (in terms of door-to-balloon time, length of stay, and hospital mortality).

Method

This cross-sectional study included all unscheduled consultations that occurred during the year 2021 at the Adult ER of Hospital Italiano de Buenos Aires (Argentina), a high-complexity center located in the Autonomous City of Buenos Aires (Argentina), which has a service open 24 hours a day, 365 days a year, and typically attends to a mean of 350 consultations daily. Patients who, during triage, were assigned to the Chest Pain Unit (CPU) as the first area upon admission due to chest pain-related reasons were identified.

The variables of interest were captured retrospectively, using secondary high-quality databases from the electronic health records (EHR). The administrative variables collected were date and time of arrival at the ER, date and time of medical attention (which allowed calculation of delay time); date and time of episode closure (which allowed calculation of the total length of stay in the ER), and discharge condition (e.g., discharge to home, death, or hospitalization). The patient-related variables were age, sex, cardiovascular history and comorbidities, time to first ECG, other complementary tests requested, and/or treatments initiated in the ER.

Manual review of health records by cardiology specialists was conducted, restricted to the subgroup of hospitalized patients, to gather: the initial presumptive diagnosis and the final diagnosis at hospital discharge, times to revascularization, length of hospital stay, need for mechanical ventilation (MV), discharge medication regimen, and/or in-hospital mortality.

The STATA software was used for analysis. In descriptive statistics, numerical variables were expressed as mean and standard deviation (SD) or median and interquartile range, while categorical variables were expressed as relative numbers and percentages with their respective 95% confidence intervals (95%CI). In analytical statistics (to explore gender differences), chi-square or Fisher’s exact tests were used for dichotomous variables, and t-test or Wilcoxon test for numerical variables (after normality checks), considering statistical significance for p-values < 0.05. Additionally, logistic regression was used, and odds ratios (OR) with their respective 95%CI were reported.

The study protocol was presented and approved by the institutional committee (CEPI#6412) and developed following ethical principles in accordance with the regulatory standards for research involving human health at both the national and international levels. Informed consent was not required from participants due to the observational and retrospective design. The procedures followed adhered to the ethical standards of the responsible human experimentation committee and the World Medical Association and the Declaration of Helsinki.

Results

During the study period, there were a total of 133,607 consultations, mostly from women (59%). However, of the 1469 admitted to the CPU (1.09%), 774 were men (52.7%) and 695 were women (47.3%).

As shown in table 1, men were younger (mean of 60 years vs 65 years in women; p = 0.001) and a lower frequency of overweight (17.18% vs 22.16%, respectively; p = 0.016), though higher admissions to the coronary unit in the previous year (12% vs 7%; p = 0.004).

Table 1. Baseline characteristics of ER consultations, by gender

Regarding health care resources during the ER consultation, men underwent more biomarker tests: troponins (63% vs 55%; p = 0.004; OR, 1.35; 95%CI, 1.10-1.67) and creatine kinase (CPK) (24.8% vs 19.1%; p = 0.008). They also received treatment with aspirin (6.7% vs 3.1%; p = 0.002) and nitrates/nitrites (6% vs 3%; p = 0.004) more frequently.

No gender differences were found regarding the performance of at least one ECG during the initial evaluation (91% vs 90%; p = 0.646), nor in the time to perform it (median of 4.1 vs 4.5 minutes; p = 0.244), nor in the delay to medical care (median of 25 vs 26 minutes; p = 0.215) (Fig. 1).

Figure 1. Times of care, stratified by gender. ECG: electrocardiogram.

Differences were observed regarding clinical definition: men were hospitalized more than women (17.18% vs 10.50%; p = 0.001; OR, 1.76; 95%CI, 1.30-2.40).

However, as shown in table 2, during hospitalization, there were no statistically significant differences in terms of length of hospital stay (p = 0.265), the need for mechanical ventilation (MV) (p = 0.060), or in-hospital mortality (p = 0.913).

Table 2. Attention times and progression variables, by gender

Of the subgroup of 206 hospitalized patients, 172 were hospitalized for suspected coronary syndrome (109 men and 63 women), while 34 were hospitalized for alternative presumptive diagnoses (24 and 10, respectively). The non-coronary diagnoses upon admission were mainly arrhythmias (e.g., atrioventricular block, atrial fibrillation, atrial fibrillation with rapid ventricular response, bradycardia) and heart failure.

However, only 112 subjects were discharged with a final diagnosis of ACS (54%), with 81 men and 31 women (OR, 2.66; 95%CI, 1.75-4.05; p = 0.001) (Table 3).

Table 3. Incidence of ischemic heart disease in patients with chest pain in the er who are hospitalized, stratified by gender

Non-coronary diagnoses at discharge mainly involved cine coronary angiography with no significant lesions. There were no differences in the times to revascularization by gender (median of 29 minutes in men vs 31 in women).

Discussion

During the management of chest pain at the ER setting, gender was not associated with different times to evaluation (median delay time to the first ECG was 4.5 vs 4.2 minutes; median delay time to medical care was 26.3 vs 25.6 minutes), nor with differential initial diagnosis (90% and 91% of ECGs recorded in EHR). These findings represent an evaluation of process mapping and patient experience, metrics that are relevant to hospital quality. On the other hand, they are inconsistent with the gender disparities in cardiovascular care reported in the literature¹⁸. Quality improvement programs specifically aimed at addressing this important topic can promote continuous education among health care professionals through simple awareness.

Although women were the majority in all ER consultations (59%), men predominated in chest pain consultations (52.7%), leading us to reflect on the possibility that female patients with ACS may have been underestimated during the initial triage and thus did not reach the chest pain unit. This could be related to information or selection bias linked to initial triage classification. These findings are consistent with the epidemiology of cardiovascular disease, whose prevalence undoubtedly varies by gender, clinical setting, and the risk profile of the studied population¹⁹.

Regarding prehospital treatment, contrary to what is reported in the literature¹⁴, no differences were found in the complementary studies requested (ECG, chest X-ray, and echocardiogram). However, similarly, more requests for serological biomarkers¹⁴, administration of aspirin, and/or nitrates/nitrites were identified, which could also represent a difference in the diagnosis and treatment of female patients with chest pain, possibly reflecting information bias (or attention bias). The higher frequency of aspirin (6.7% vs 3.1%) and nitrates/nitrites (6% vs 3%) is consistent with the literature, as another study reported that women were less likely than men to receive aspirin (relative risk [RR]: 0.76; 95%CI, 0.59–0.96) and nitroglycerin (RR: 0.76; 95%CI, 0.60–0.96)²⁰.

In our study, women were somewhat older than men (65 vs 60 years), which can be explained by simple pathophysiology and hormonal protection during their reproductive years, delaying the onset of cardiovascular disease. Despite this, the balance likely shifted toward requesting studies in male patients.

In relation to the clinical definition of the ER consultation, men were hospitalized more often (17% vs 10% in women; p = 0.001). However, there were no differences in the times to revascularization (median of 29 vs 31 minutes, respectively), which suggests that gender was not associated with different treatment times.

As for the final diagnosis, it was found that almost a quarter of men (74%) and nearly half of women (49%) who were hospitalized with suspected ACS did not have it, highlighting the importance of accessibility to high-complexity diagnostic studies (e.g., cine coronary angiography) inside the hospital²¹.

A total of 60% of men and 42% of women experienced coronary events. This higher risk in men is consistent with what was reported by the Tromsø study²². However, it did not impact in-hospital mortality, with no evidence of gender differences, which contrasts with other studies^8-11.

A few limitations should be mentioned. First, as with all retrospective observational studies, it is prone to biases (as previously mentioned) and potential confounders (e.g., baseline cardiovascular risk). In this regard, since patients often present with multiple problems or reasons for consultation, the way data were collected (restricted to patients admitted to the CPU) can be controversial; other patients with chest pain or coronary origin may have been excluded due to misclassification in triage (e.g., false negatives assigned to other areas of care). Second, as a single-center study, it provides highly relevant local data, but with limited external validity. Third, it was not possible to collect other variables of interest (e.g., the number of previous visits to the ER, as evidence shows that women are often underestimated in repeated visits)¹⁷. Lastly, cases of MINOCA (myocardial infarction with non-obstructive coronary arteries) were not identified, nor was the specific etiology determined, as only patients with non-obstructive coronary lesions were diagnosed via cardiac catheterization²³.

The main strength lies in the lack of local or regional data on this topic, making the findings relevant at the institutional level from the perspective of management and care quality. Similarly, another important aspect was the consecutive sampling of all consultations, as this eliminated potential selection and information biases.

Future studies will be needed to explore the clinical evolution of non-hospitalized patients to evaluate longitudinal outpatient follow-up and/or follow-up after hospital discharge with mid- to long-term outcomes for those hospitalized.

Conclusions

Female sex was not associated with greater delays in prehospital or hospital times (in the times for ECG completion or medical attention in cases of chest pain in the ER), and there were no gender-specific differences in times to revascularization or in-hospital mortality (Fig. 2). The findings challenge gender stereotypes and emphasize hospital care quality as a key factor in equal medical treatment. There were differences in the use of biomarkers and hospitalization rates among men, but gender did not influence times for care, diagnosis, or treatment.

Figure 2. Variables related to chest pain care, stratified by gender. ECG: electrocardiogram; ACS: acute coronary syndrome.