Heart attack often underdiagnosed in women vs men

Chest pain is often dismissed as nonserious events in women presented to an emergency department (ED), leading to real acute coronary syndrome (ACS) diagnosis being missed more frequently in women than men, according to a study presented at the ESC Acute CardioVascular Care (ACVC) 2021 Meeting.

Moreover, women themselves were also more likely to delay seeking medical help than men when having chest pain.  

“Our findings suggest a gender gap in the first evaluation of chest pain, with the likelihood of heart attack being underestimated in women,” highlighted lead author Dr Gemma Martinez-Nadal from the Hospital Clinic of Barcelona, Spain. “The low suspicion of heart attack occurs in both women themselves and in physicians, leading to higher risks of late diagnosis and misdiagnosis.”

Among 41,828 patients (42 percent female) presenting with chest pain at an ED, significantly more women than men waited for ≥12 hours after symptom onset before presenting to the hospital (41 percent vs 37 percent; p<0.001). [ESC ACVC 2021, abstract 20071]

“This is worrying since chest pain is the main symptom of reduced blood flow to the heart [ie, ischaemia] because an artery has narrowed,” said Martinez-Nadal. “It can lead to a myocardial infarction which needs rapid treatment.”

In the initial diagnosis based on clinical history, physical examination, and ECG* (before complementary tests such as on biomarker like troponin were done), physicians were more likely suspect ACS in men than in women presenting with chest pain (2.5 percent vs 1 percent; p<0.001 for STEMI** and 5.4 percent vs 4.3 percent; p<0.001 for non-STEMI).  

Among the 93 percent of patients with non-diagnostic ECG, physicians’ suspicion of probable ACS was again significantly lower in women than in men (39 percent vs 44.5 percent; p<0.001). This persisted even in the presence of ≥3 cardiovascular risk factors, with women being 28 percent less likely to be diagnosed as having ACS than men (odds ratio, 0.72, 95 percent confidence interval [CI], 0.63–0.83).   

“Risk factors like hypertension and smoking should instil a higher suspicion of possible ischaemia in patients with chest pain. But we observed that women with risk factors were still less likely than men to be classified as probable ischaemia,” noted Martinez-Nadal.

After these patients with initially non-diagnostic ECG completed the necessary work-up in the chest pain unit, 14 percent were eventually diagnosed with an ACS — of which 3 percent were initially misdiagnosed.

When stratified by sex, women were more likely to be misdiagnosed initially compared with men (5 percent vs 3 percent; p<0.001). The researchers found that the female gender emerged as an independent risk factor for lower suspicion of ACS in the initial evaluation, based on a multivariate analysis.

“There is a gender gap in the first evaluation of chest pain with an underestimation of risk in women, not only by the patients who are more often late presenters, but also by the physicians, which entails a higher risk of being misdiagnosed or late diagnosed,” observed the researchers.

“Heart attack has traditionally been considered a male disease, and has been understudied, underdiagnosed, and undertreated in women, who may attribute symptoms to stress or anxiety. Both women and men with chest pain should seek medical help urgently,” said Martinez-Nadal.

*ECG: electrocardiogram
**STEMI: ST-Elevation Myocardial Infarction