Identifying Acute Cardiac Ischemia In Patient Subgroups Gender Minorities

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Knowing whether gender influences the likelihood that a given ED patient is having ACI, and whether any specific presenting clinical features are differentially associated with ACI in women compared with men, can aid clinicians in the accurate diagnosis of ACI. The incidence of AMI in the general population has been shown to be higher in men than women (93-96), but until recently, it has not been clear whether this gender difference holds among symptomatic patients who come to the ED.

Several studies have looked at gender differences in the presentation of patients with AMI (97-101). In a retrospective analysis of patients with confirmed AMI, women had higher rates of atypical presentations such as abdominal pain, paroxysmal dyspnea, or congestive heart failure (CHF) (42,93,102-104). In a group of ED patients with typical presentations, such as chest pain, the prevalence of AMI was lower in women (33,105). However, in another study of ED patients with chest pain, when adjustments were made for other presenting clinical features (specifically ECG), the gender difference was no longer significant (100). From these results, it is difficult to assess whether the gender-specific differences in AMI prevalence among symptomatic ED patients were the result of gender-specific biology or limitations in a particular study's patient selection.

Zucker et al. (106), in a study of 10,525 patients >30 yr old who presented to the ED with chest pain or other symptoms suggestive of ACI, found that AMI was almost twice as common in men as women (10 vs 6%). Among women with ST-segment elevation or signs of CHF, however, AMI likelihood was similar to that in men with these characteristics. This finding suggests that the presence of CHF should be given substantial weight in assessing the likelihood of AMI in women presenting to the ED with symptoms suggestive of ACI. Pope et al. (3) found that among the patients with AMI who present to the ED, women were more likely than men to have been discharged. In addition, among all patients with ACI, women under the age of 55 yr were at highest risk for not being hospitalized.

Blacks have high levels of risk factors for coronary artery disease but how this finding influences diagnosis in patients presenting to the ED with symptoms suggesting ACI is not well understood (107,108). Studies that have included only patients with chest pain and not other symptoms suggestive of ACI, have found no significant differences in presentation, natural history, or final diagnosis of AMI between black and white patients (109). Evaluating chest pain and establishing the diagnosis of coronary heart disease in blacks is often difficult given the presence of excess hypertension and left ventricular hypertrophy and the increased occurrence of out-of-hospital cardiac arrest in blacks (110-113). Furthermore, the paradoxical finding of severe chest pain without significant angiographic coronary artery disease complicates diagnosis and treatment of blacks with symptoms suggestive of ACI (107,110). In another analysis of the ACI-TIPI Trial data, Maynard et al. (114) found that black patients were 8-10 yr younger and that a higher percentage were women than was the case among white patients, which may partially explain why physicians might be less inclined to suspect the presence of ACI in black patients. Finally, Pope et al. (3) found that among patients with ACI, the adjusted risk of being sent home was more than 2X as high among nonwhites as among whites; among those with AMI, the risk was more than 4X as high among nonwhites as among whites. In this study, 5.8% of the black patients with AMI were not hospitalized, as compared with 1.2% of the white patients with infarction.

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