Gender gap in the evaluation of chest pain: heart attack diagnosis missed in women more often than in men

Posted: 26/07/2021

The differences and inequalities in the treatment of women’s chest pain or cardiac symptoms have been the subject of scrutiny on a number of occasions. However, it appears from a study undertaken in Spain and reported recently at the European Society of Cardiology, that this inequality sadly still persists and is also common in other countries, not just the UK.

Acute coronary syndrome or ACS occurs when there is a sudden reduced blood flow to the arteries that supply the heart muscle (often referred to as ischemia). This can leave the heart muscle unable to function property or can result in part of the heart muscle dying. ACS is an emergency that can cause a number of conditions, for example, a heart attack, also called a myocardial infarction or MI.

In this study of 41,828 patients admitted to hospital with chest pain (42% of whom were women), the researchers recorded the doctor’s initial diagnosis after the first evaluation of each patient. This was based on clinical history, physical examination and ECG, ie before other examinations like blood tests, were carried out. The study therefore looked at the treating doctor’s first impression as to whether the chest pain had a coronary cause or other origin, such as anxiety or a musculoskeletal complaint.

The author discovered that ‘in the doctor’s first impression, women were more likely than men to be suspected of a non-ischaemic problem’, ie a problem not associated with ACS. She found:

• in the initial diagnosis, ACS was more likely to be considered the cause of chest pain in men compared to women;
• where an ECG did not provide a definitive diagnosis for ACS (this was in 93% of the patients reviewed) there was a statistically significant difference in the percentage of women (39%) as compared to men (44.5%) who were suspected of having ACS;   
• the significantly lower suspicion of ACS in women was maintained regardless of the number of risk factors or the presence of typical chest pain;
• in women, 5% of those subsequently confirmed as having ACS were initially misdiagnosed, compared to 3% of men, again a difference that was highly statistically significant.

Women are also more likely to present late to hospital

The study also found that women with chest pain were significantly more likely to present late to hospital (defined as waiting 12 hours or longer after symptom onset): this occurred in 41% of women compared to 37% of men. The delay is particularly worrying as chest pain is the main symptom of reduced blood flow to the heart which can lead to a heart attack.

The author said: “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.”

UK A&E treatment for suspected ACS

It is worth noting that in the UK, NICE guidelines recommend that where a patient presents to A&E with suspected ACS, an ECG and a blood test for a hormone called troponin I are carried out on arrival at hospital (troponin can signal that the heart muscle is under stress). However as this study shows, if women are less likely to be suspected of ACS when attending A&E, such investigations may not be carried out promptly.

Elizabeth Maloney, associate in Penningtons Manches Cooper’s clinical negligence team, commented: “We act for families where a heart attack has been overlooked and the patient has become seriously ill or even died. It is alarming that this gender gap in diagnosis still persists and that some women are being misdiagnosed and their symptoms interpreted as stress, anxiety or even indigestion. Prompt, accurate diagnosis is vital to avoid longer term cardiac problems, such as heart failure or arrhythmias, or unnecessary deaths.”

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