Sex Differences in Diagnoses, Treatment and Outcomes for Emergency Department Patients with Chest Pain and Elevated Cardiac Troponin

Abstract

Objective

While sex differences in the treatment and outcomes of subjects with acute coronary syndromes are well documented, little is known about the impact of cardiac troponin (cTn) levels obtained in the emergency department (ED) on the observed sex differences. We sought to determine whether cTn levels by chest pain features modify sex differences in diagnosis, treatment and outcomes in patients presenting with chest pain suggestive of ischemia.

Methods

All adults presenting to two hospitals in Vancouver, Canada between May 2008 and Mar 2013 with ischemic chest pain and with cTn testing were included in the study. Outcomes were obtained through data linkage with population-based administrative datasets, including Vital Statistics (death), discharge abstract database (hospitalizations) and PharmaNet (medications). Cumulative event rates for the composite MACE endpoint (death, MI, incident admission for heart failure or for angina requiring diagnostic catheterization or revascularization), were estimated for each sex and cTn level using the Kaplan-Meier method; Cox models were used to estimate hazard ratios (HR) and 95% CIs for one-year MACE and seven-day catheterization. Logistic models were used to estimate odds ratios (OR) and 95% CI for 90-day medication use.

Results

Over the five-year study period, 25,539 patients presented to the ED with chest pain of which 7,272 (2,933 females and 4,339 males) met the inclusion criteria. Among patients with chest pain with cardiac features/history and cTn > 99^th percentile, females were less likely to be diagnosed with MI (46.4% vs. 57.5%). Females in the cTnI > 99^th percentile group had the worst outcomes with a one-year MACE rate of 22.7% (95% CI 18.5, 27.7) versus 18.8% (95% CI 16.2, 21.6), though this difference was attenuated and not statistically significant after adjustment for baseline differences. Overall, females underwent fewer diagnostic catheterizations than males within seven days of admission to the ED. Even when cTn was above the 99^th percentile and the chest pain was cardiac in nature, 48.4% of females underwent a diagnostic catheterization compared to 64.3% of males, p<0.001. Within 90 days of discharge, females were less likely to use the evidence-based cardiac medications. The most striking sex differences were noted when cTnI levels were > 99^th percentile and when the chest pain was cardiac in nature; males filled 25% more prescriptions for statins than their female counterparts. Adjustment for baseline differences did not attenuate this difference.

Conclusions

Sex differences in diagnosis and treatment after presentation to the ED with chest pain are not explained by differences in chest pain features or levels of cTn. Even when females have cardiac chest pain and cTn levels > 99^th percentile, they are less likely to be diagnosed with MI, less likely to undergo diagnostic cardiac catheterization within seven days, and less likely to use evidence-based cardiac medications, but they have the highest one-year MACE rate. The higher MACE rate appears to be driven by the higher burden of comorbid conditions.

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