Acute MI Workup in Emergency Departments Varies by Sex and Race

Young women with chest pain who present to the emergency department (ED) are seen less quickly and are less likely to be admitted to hospital than men who present with similar symptoms, according to results of a new study.

Investigators observed racial differences in treatment, too, with people of color, mostly non-Hispanic Black individuals, waiting longer for a physician evaluation than white patients.

Senior investigator Harmony Reynolds, MD (NYU Langone Health, New York, NY), said that previous studies, including the VIRGO study, have also demonstrated differences in care between men and women. For example, chest pain in women is less likely to be recognized as a symptom of acute MI compared with men.

“That’s consistent with my clinical experience,” Reynolds told TCTMD. “I take care of young women with myocardial infarction, and I have heard many stories of the initial encounter where the healthcare provider did recognize immediately that this might be a heart attack.”

It’s known that women are less likely to undergo cardiac testing when presenting with chest pain and less likely to undergo coronary revascularization or be prescribed guideline-recommended medical therapy once acute MI is diagnosed, she said. “It runs the gamut from the initial presentation with chest pain all the way to sex-based differences in the ISCHEMIA trial where everyone was known to have obstructive coronary artery disease and women received less intensive care,” said Reynolds.

The same trends hold true for people of color, with Black adults having poorer outcomes than white adults with acute MI and also being less likely to receive an ECG or troponin testing when presenting with chest pain. Black patients are also less likely to be undergo coronary revascularization compared with white adults.

The difference in the evaluation and treatment of men and women, as well as across race/ethnic lines, is an old refrain, according to C. Noel Bairey Merz, MD (Cedars-Sinai Medical Center, Los Angeles). Roughly 30 years ago, in fact, psychology experiments using case vignettes revealed cardiologists would provide different care depending on the sex and race of the patient.

“It’s kind of old news, unfortunately,” Merz told TCTMD. “It’s not a hypothetical anymore.”

More Than 4,000 ED Visits

For the new analysis, which was published May 4, 2022, in the Journal of the American Heart Association, investigators evaluated 4,152 ED visits for adults aged 18 to 55 years presenting with chest pain between 2014 and 2018 who were included in the National Hospital Ambulatory Medical Care Survey. Women accounted for 56.8% of the chest-pain ED visits and people of color—89% who identified as non-Hispanic Black—comprised 34.9% of the study population. The mean age of the female was 37.6 years, and for male patients it was 38.8 years.

I have heard many stories of the initial encounter where the healthcare provider did recognize immediately that this might be a heart attack. Harmony Reynolds

Overall, women presenting to the ED with chest pain were less likely to be triaged as requiring immediate/emergent care compared with men (19.1% vs 23.3%; P = 0.001), waited longer to be seen by a healthcare provider (48.1 vs 37.2 minutes; P < 0.001), and were less likely to be given an ECG (74.2% vs 78.8%; P = 0.024). During the ED visit, women were less likely to be treated with antiplatelet agents than men and were less likely to receive antianginal medications.

After multivariate adjustment, which accounted for a range of clinical features, there was no difference in the use of ECG or emergent triage, but men were significantly more likely to be seen than women at any time point and were more likely to be admitted to hospital or the observation unit.

Women of color waited longer than white women for their initial evaluation (57.8 vs 42.7 minutes; P = 0.006), as did men of color compared with white men (44.0 vs 34.0 minutes; P =0.006). Women of color were less likely to be prescribed antiplatelets, while men of color were less likely to receive antianginal medications, although they were more likely to be given an NSAID.

In multivariable regression analysis, people of color were significantly less likely to be seen by a provider at any time point compared with white patients, but there were no other differences observed, including differences in triage, use of ECG, or cardiac troponin testing between people of color and white adults.

‘Needle in the Haystack’

Overall, acute MI was diagnosed in 1.4% of all adults in the ED and in 6.5% of those admitted to hospital. The database contained too few details to evaluate differences by race and sex in the diagnosis of acute MI, say investigators.

“We recognize that most people who come to the emergency room don’t have a myocardial infarction,” said Reynolds. “That makes it a particular challenge for ED providers—they’re essentially trying to find the needle in the haystack.”

Maybe our awareness campaigns are actually working. Other than that, it’s an example of how things change but they don’t change enough. C. Noel Bairey Merz

Merz, who is the scientific advisor to the Women’s Heart Alliance (WHA) and wasn’t involved in this study, said there are snippets of good news from the new analysis. For example, men and women with chest pain were equally likely to arrive at hospital by ambulance, a contrast with previous data showing that women weren’t calling emergency medical services. Additionally, of the ED visits, women were in the majority (n = 2,319).

“It’s possibly progress,” said Merz. “Maybe our awareness campaigns are actually working. Other than that, it’s an example of how things change but they don’t change enough.”

Merz pointed out that the new analysis doesn’t include data on the outcomes of these ED patients, including those with acute MI. While women did wait longer to be seen by physicians, as did people of color, that increase might be clinically justified. “It’s an ambulatory data set and, as [the researchers] acknowledge up front, they don’t have the outcomes,” said Merz. “Without the outcomes, it might have been appropriate care. It’s what physicians do all the time—they triage and strategize.”

That said, however, the delay in treating Black males compared with white males doesn’t appear appropriate. “Black men are at a higher risk than white men for heart attacks,” said Merz. “That would lead you believe that at least some of this care wasn’t appropriately triaged.”

Comes Down to Education

In terms of why care differed for women and people of color, Reynolds stressed that the study can’t get at the underlying reasons, underscoring that ED physicians and staff have a challenging job in identifying patients with acute MI. Reynolds speculated these younger patients, particularly women, might not be the typical demographic for MI, which may lead them to be overlooked. Studies have also shown that women may articulate their symptoms differently than men, which may make it difficult for providers to recognize patterns.

“It might not be a textbook description of chest pain, particularly in women, which might make it difficult to identify rapidly that this might be a concerning chest-pain story,” she said. There might even be a perception that women are at lower risk for MI than men, even though women have worse outcomes after MI diagnosis than men.”

Regarding the racial differences, Reynolds said it might be the result of resource availability, although that is just a hypothesis.

To TCTMD, Merz emphasized the importance of education. The WHA, which is continuing to raise awareness about the risks of cardiovascular disease in young women, has initiated work with the Association of American Medical Colleges as part of their equity, diversity, and inclusion initiatives to develop physician leaders aware of these risks.

An additional limitation of the analysis is its lack of information on the sex of the providers, said Merz. In 2019, researchers published data in PNAS on patient-physician gender concordance and higher risks of mortality among female MI patients. That study showed men and women had similar mortality risks when treated by female ED physicians, but that women had a higher risk of death when treated by male doctors. It also showed that the presence of female physicians on staff influenced the outcomes of patients treated by male ED doctors.

“It really is about education,” said Merz. There are similar trends suggesting there are benefits of patient/physician race/ethnicity concordance, she said.