Sex Differences in Acute Chest Pain Care in a US ED Cohort

Key Takeaways

• Lower 30-day death or myocardial infarction was observed in women than men, and adjusted odds remained lower after accounting for cardiovascular disease confounders and initial hs-cTn.
• Women also had lower 30-day hospitalization and lower use of objective cardiac testing, and both remained modestly lower after adjustment.
• This observational cohort included 40,979 adults seen across 25 emergency departments in 2021, with sex defined by the legal sex electronic health record variable and outcomes assessed at 30 days.

In a multisite U.S. emergency department cohort managed under a standardized high-sensitivity troponin pathway, women had lower 30-day rates of death or myocardial infarction than men after presenting with chest pain. Rates were 2.4% in women, or 552 of 23,188, versus 5.2% in men, or 917 of 17,791. The difference remained after adjustment, with an adjusted odds ratio of 0.65 and a 95% confidence interval of 0.57 to 0.74, in a 30-day comparison that also assessed hospitalization and downstream utilization after ED presentation.

The cohort included adults aged 18 years and older who presented with chest pain from January through December 2021 across 25 emergency departments, totaling 40,979 patients. Women accounted for 56.6% of the cohort, with 23,188 women and 17,791 men, and the mean age was 52 years. Sex was based on the legal sex field in the electronic health record, and outcomes were assessed at 30 days. The primary safety outcome was all-cause death or myocardial infarction, the primary utilization outcome was hospitalization, and objective cardiac testing, including stress testing, coronary computed tomography angiography, or invasive coronary angiography, was the secondary utilization measure. Comparisons used chi-squared testing and logistic regression, with adjusted models accounting for cardiovascular disease confounders and initial hs-cTn.

Hospitalization within 30 days occurred in 30.2% of women, or 6,998 of 23,188, compared with 36.0% of men, or 6,411 of 17,791. After adjustment, women still had lower odds of hospitalization, with an adjusted odds ratio of 0.93 and a 95% confidence interval of 0.88 to 0.98. Objective cardiac testing within 30 days occurred in 14.9% of women, or 3,452 of 23,188, versus 19.6% of men, or 3,488 of 17,791. Adjusted odds were also lower for women on this measure, with an adjusted odds ratio of 0.93 and a 95% confidence interval of 0.87 to 0.98. Together, the findings show lower downstream utilization among women in this cohort.

Across the reported outcomes, unadjusted differences favored women for death or myocardial infarction, hospitalization, and objective cardiac testing. Adjusted analyses also remained lower for women across all three outcomes after accounting for cardiovascular disease confounders and initial hs-cTn. Investigators concluded that 30-day rates of death or myocardial infarction, hospitalization, and objective cardiac testing were lower in women than in men in this cohort. The abstract does not specify additional covariates beyond cardiovascular disease confounders and initial hs-cTn. The 30-day comparisons were consistent across both safety and utilization measures.