An analysis based on sex&gender in the chest pain unit of an emergency department during the last 12 years

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Josep Font 2019 Grant from Hospital Clinic de Barcelona Background Differences between female (F) and male (M) with coronary disease (CD) are related to time delays in detriment of women such as: hospital presentation, recognition of symptoms or an appropriate treatment. Further research based on sex and gender (S&G) is at important to confront the interplay of factors that shape health inequities. Purpose To do an analysis based on S&G of the admissions in the chest pain unit (CPU) of an emergency department (ED), comparing clinical features and also the physician’s initial diagnostic orientation after the first evaluation of the patients (FEoP) . Methods This is an observational descriptive unicentric study of consecutive cases. We retrospectively analysed all the cases admitted in a CPU from 2008-2019 and recorded the cardiovascular risk factors (cvrf), and the clinical and electrocardiographic (ECG) features. We also recorded the final diagnostic after all the management in the CPU and the FEoP [based on the clinical history, physical examination and ECG; before other complementary examinations like troponins (Tnc)]. The characteristics were compared according to sex (F or M). Results 41828 patients were included (42% F), with an older median age in F [Md (RIC) [65 (47-78) vs 59 (43-73)] y.o.; p < 0,001]. We found a significant greater number of late presenters (≥12hours from symptoms onset) in F (41%vs37%;p < 0,001). F were associated to greater rates of obesity, hypertension and previous heart failure; M had greater rates of diabetes mellitus, previous known coronary disease and smoke or cocaine use. When we considered the patients with typical chest pain (TCP), no significant differences based on S&G were found. Women’s ECG were more often interpreted as not having significant changes of ischemia. After the FEoP, the patients were classified as having an STEMI(♀1%vs♂2,5%;p < 0,001), non-STEMI (♀4,3%vs♂5,4%;p < 0,001) or non-diagnostic-ECG(93%). Among patients with non-diagnostic ECG, the physician’s initial diagnostic was a probable acute coronary syndrome (ACS) in 42% of cases. F were less likely to be considered as having an ACS (♀39%vs♂44,5%;p < 0,001). This significant differences were maintained when:1) patients had ≥3cvrf [♀OR0,72; IC95%(0,63-0,83)]; 2)patients had ≥2cvrf [♀OR0,79; IC95% (0,74-0,86)]; 3)patients had TCP [♀OR 0,69; IC95% (0,64-0,74)]; 4)patients had ≥2cvrf and TCP [♀OR 0,72; IC95% (0,63-0,82)]. After the management in the CPU, a 14% of patients with non-diagnostic ECG were finally diagnosed with an ACS (36% if≥2cvrf and TCP). 3% of ACS were initially misdiagnosed (♀5%vs♂3% ;p < 0,001). After a multivariate analysis F is an independent risk factor for an initial impression of non-ACS. Conclusions 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.

Value of Two-Dimensional Speckle Tracking at Rest and During Dobutmaine Stress Echocardiography in Diagnosis of Coronary Artery Disease

IntroductionCAD (coronary artery disease) is a major cause of death and disability in developed countries. Exercise testing is recommended as a first-line diagnostic test in patients with stable angina pectoris. However, the limited sensitivity and specificity have been criticized. Myocardial strain can predict the presence of significant coronary artery disease.Aim of workto assess the utility of myocardial strain obtained by 2D-speckle tracking at rest and under stress for the detection of CAD in patients referred to chest pain unit with stable and low risk unstable angina pectoris.Methods108 individuals matched the inclusion criteria and gave their written consent to be enrolled in this study. Coronary angiography was performed within 48 hours from admission to the chest pain unit. Myocardial strain by 2D-speckle tracking was obtained at rest and under dobutamine stress.ResultsGlobal longitudinal strain at stress revealed a moderate correlation with the presence of significant CAD; r= 0.41, p <0.0001. While a moderate correlation was established between global strain under stress with the severity of coronary occlusion, r= 0.62, p <0.0001. Global longitudinal strain under stress showed a sensitivity of 74.1% and a specificity of 76.7% in detecting significant CAD at a cut-off value of -19.1.ConclusionLongitudinal strain parameters at rest and under stress could predict the presence of coronary artery disease in patients with stable angina pectoris. The obtained strain data could add value in detecting the severity of CAD.