Diagnosis of chest pain in the emergency room: is the approach different for men and women?

Objective: To assess whether the diagnosis of chest pain is approached differently in

men and women attending hospital emergency services.

Method: Patients who were treated consecutively in the chest pain unit of a hospital

emergency department over a period of 16 months were studied. After the preliminary

examination and electrocardiogram (ECG), patient assessment followed 1 of 4 protocols:

P1, acute coronary syndrome (ACS) with ST elevation; P2, ACS with ST depression; P3,

chest pain with probable ACS but a normal or inconclusive ECG; and P4, chest pain

unrelated to ACS. Gender was the dependent variable. The independent variables were

time from arrival at the door of the emergency room until the first ECG (t1) for each

protocol; the admitting department for P1 and P2 patients; and the percentage of

patients in whom troponin was measured twice and a stress test was ordered, door

arrival to discharge time (t2), and door arrival to stress test time (t3) for P3 patients.

Variables that were significantly different between genders were studied further with the

population stratified by age and risk score for thrombosis in myocardial infarction (TIMI).

Results: A total of 4568 patients were attended (5% P1, 8% P2, 46% P3, 41% P4). Fortyfive

percent were women. The mean (SD) ages were 74 (18) years for women and 58

(18) years for men (p<.001). Sixty-three percent of women and 47% of men had a TIMI risk score less than 2 (p<.001). The median t1 was longer for women than men in all protocols (P1, 7 minutes vs. 5 minutes, respectively, p=.06; P2, 12 vs. 9 minutes, p=.15; P3, 15 vs. 13 minutes, p<.01; P4, 21 vs. 19 minutes, p=.25). Women were admitted to intensive or intermediate care units less often than men (36% vs. 62%, p<.001) and stress tests were less often ordered for them (33% vs. 39%, p<.01). The only difference that remained after stratifying by age was a lower percentage of intensive or intermediate care unit admission for women between 71 and 80 years of age and fewer stress tests for women between 81 and 90 years old. Many differences also disappeared after stratifying by TIMI risk score. Women with TIMI risk scores less than 2 were less often admitted to intensive or intermediate care units than men (15% vs. 43%, p<.01); those with scores between 3 and 4 were less often scheduled for stress tests (23% vs. 33%, p=.04). Conclusions: The diagnosis of chest pain in this hospital emergency department seems to be less energetically pursued in women; however, many of the differences initially observed disappear when the population is stratified by age and TIMI risk score.