SCIENTIFIC
Gender Bias in Chest Pain Evaluation in the Emergency Department : A 25-Year Update
AUTHORS : Abigail Tolbert
Dipali Nemade , MD , MPH Jo Ann Raines , MA , C-TAGME Mitch Charles , MD Paulette Wehner , MD Franklin Shuler , MD , PhD *
Office of Graduate Medical Education , Marshall University
INTRODUCTION
Women often have an atypical presentation for cardiac conditions with nine women dying from heart disease and stroke every day in West Virginia ( WV ). 1 Cardiovascular conditions account for 29.7 % of all female deaths in WV . 2 Women often do not recognize that they are experiencing a cardiac event , making it less likely for them to seek medical help with delays in presentation leading to higher rates of complications and death . Data published 25 years ago revealed that women presented more than six hours after the onset of symptoms . 2
Women worldwide have a higher mortality from cardiovascular disease ( CVD ) despite a higher prevalence in men . Previous studies have described differences along gender lines regarding presenting symptoms and management . 2-6 For example , men are 2.5 times more likely to be referred to a cardiologist and receive more aggressive treatment . 2-6 Women may have more atypical presentations resulting in a less elaborate evaluation and treatment for positive non-invasive tests with resultant higher morbidity and mortality . 7 Differences in care along gender lines were described at a university affiliated hospital in WV in a 1996 study by Lehman and colleagues . 2 The purpose of this study is to determine if differences along gender lines in the care of patients with chest pain persist at the same university affiliated hospital 25 years later .
ABSTRACT
INTRODUCTION Due to having atypical presentations , women with potential cardiac disease may be approached and treated less aggressively than male patients . Differences in care along gender lines have been described at a university affiliated hospital in West Virginia ( WV ) in the past three decades . The purpose of this study is to determine if differences along gender lines in the care of patients with chest pain persists .
METHODS From July-December of 2015 , a retrospective chart review was performed at Cabell Huntington Hospital in WV . Data from 375 patients with a diagnosis of chest pain presenting to the emergency department ( ED ) was compared to data from 25 years prior . Symptoms , risk factors , medical history , medications , physical examination , laboratory and electrocardiogram results , treatment in the emergency department , and ultimate diagnoses were studied .
MATERIALS & METHODS
The Marshall University Institutional Review Board approved of this retrospective chart review ( IRB : 907588-6 ). Charts were reviewed from patients greater than 18 years of age presenting to the ED at Cabell Huntington Hospital ( CHH ) from July 1 , 2015 , to December 31 , 2015 , with the diagnosis of chest pain using ICD-9 / 10 codes . Three hundred seventy-five ( n = 375 ) patients were identified for this cohort . This retrospective chart review mirrored the 1996 study by Shanholzer and colleagues 1 and considered the following factors : presentation symptoms , risk factors , medical history , medications , physical examination , laboratory and electrocardiogram results , treatment in the ED , and diagnosis and outcome . 2 The variables that were studied are listed in Table 1 .
STATISTICS
Data was compiled and analyzed using the statistical software IBM SPSS-23 version .
RESULTS Women had less reproducible musculoskeletal pain and more use of over-the-counter medicines , hormones , and pulmonary medications before presenting to the ED . Treatment with nitroglycerin and gastrointestinal medications occurred more commonly in women . Regarding evaluations of symptoms , women received more electrocardiograms , cardiac monitoring , and laboratory testing in comparison to 25 years prior . Cardiology consultations and emergency catheterization as well as the use of aspirin , heparin , antibiotics , anxiolytics , and thrombolytic agents were more commonly used in the treatment of women in comparison to 25 years prior .
CONCLUSIONS In comparison to 25 years prior , there were documented improvements in the management of women presenting to the ED and experiencing new-onset , non-traumatic chest pain .
The following statistical tests were conducted : frequency percentage , mean , and standard deviation . Comparison of continuous variables between the two groups was conducted with t-test and Pearson ’ s chi-squared ( or Fisher ’ s exact ) test . Significance was established at p < 0.05 and the power of the study was 80 %.
RESULTS
The study group ( n = 375 ) consisted of 179 men and 196 women . The mean age was 48 years for men ( range from 31-98 years ) and 49 years for women ( range 28-89 years ). Men were more likely to claim musculoskeletal pain as compared to women ( p < 0.05 ). There was no significant difference between men and women for the location of pain , quality of pain , and related symptoms including diaphoresis and dyspnea ( Table 2 ).
One hundred eighty-three patients ( 49 %) were obese and 89 ( 24 %) were overweight .
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