Women and Heart Disease:Triage Criteria

Symptoms versus Reality

Mars vs. Venus

When it comes to cardiovascular disease,Women and Men ARE Different !

Heart Disease is the #1 Killer of Women

• Heart disease is the leading cause of death of American women

• 8,000,000 American women are currently living with heart disease

• 435,000 American women have heart attacks each year with an average age of 70.4 years

• Women are more likely than men to have a heart attack without chest pain

The Need for Prevention in Women

• 9,000 US women younger than 45 sustain a heart attack each year.

• “Thus the priority for coronary prevention is substantial for women of all ages.”

• Mortality associated with acute MI among women younger than 65 years is almost twice as high among men.

• Women tend to get heart disease about 10 years later than men and are more likely to have coexisting chronic illnesses

• Research also shows that women may not be diagnosed or treated as aggressively as men, and their symptoms may be very different from those of men having a heart attack

Coronary Heart Disease in Women

Coronary Heart Disease in Women

Presentation and differences from men:

• 2/3 of women who die suddenly have NO previously recognized symptoms.

• Women are more prone to non-cardiac chest pain…..

• In fact they may experience little or no squeezing chest pain in the center of the chest with an MI (as seen on “ER”).

Case Study: 86 Y/O woman

• Presented to ED at 4pm with back and shoulder pain, nausea, anxiety and feeling like she “can’t relax”

• Stated woke at 3am “sweating, nauseated and anxious”

• DENIED ANY CHEST PAIN

• Did not present in acute distress

Case Study: continued

• Triaged within 10 minutes

• EKG not done for another 40 minutes

• EKG showed STEMI in the inferior leads

• At that point, Code STEMI was called and patient taken emergently to the Cath lab.

• A 50 minute delay in diagnosis due to atypical symptoms.

Nationally: The Problem is AWARENESS

Perception:• 67% of women are

knowledgeable that chest pain can be heart disease

• But, less than 10% are knowledgeable that shortness of breath, nausea, indigestion can be heart disease

Reality:• Chest pain is the

presenting symptom in less than 50% of women

• Almost half of MIs in women present with shortness of breath, nausea, sleep disturbance, fatigue and shoulder pain

Symptoms in Men vs. Women

Men WomenChest pain Neck/shoulder pain

Shortness of breath Nausea/vomiting

Sweating Fatigue

Pain in one or both arms Indigestion

Jaw Pain Dizziness

Lightheadedness

Shortness of breath

Women’s Common Pre-heart attack symptoms :

Women are more likely to have:

• Unusual Fatigue– 70%

• Sleep disturbances—48%

• Shortness of breath– 42%

• Indigestion—39%

• Anxiety-35%

• Cold sweat rather than a hot sweat—39%

Women’s Major Symptoms during a Heart Attack

• Shortness of breath– 58%

• Weakness--55%

• Unusual Fatigue– 43%

• Cold Sweat– 39%

• Dizziness– 39%

Not so straightforward

• Because of these atypical symptoms, women seek medical care later than men and are more likely to be misdiagnosed.

• Women presenting with MI and Coronary artery disease are more likely to be older, have a history of diabetes, high blood pressure, high cholesterol, CHF, and unstable angina than male counterparts. (JAm Coll Cardiol 1997;29).

Misperceptions and Missed Opportunities Leading to Unequal Diagnosis and Treatment

• Women are less likely to have an EKG or be admitted to the telemetry floors.

• Women are under-diagnosed and can therefore get a false sense of security.

• Less aspirin, beta-blockers, cholesterol meds, antiarrhythmic treatment, cardiac cath, balloon angioplasty, and cardiac bypass surgery are prescribed for women

• Women are less likely to enroll in cardiac rehabilitation after an MI or bypass surgery.

Conclusion

Women presenting with atypical symptoms of chest pain should be triaged just like a man presenting with classic symptoms of chest pain

• Delay of triage due to atypical symptoms may lead to a delay in treatment resulting in significant injury to the patient