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Am Fam Physician. 2008;78(7):872-874

Background: Despite current guidelines, significant evidence verifies that women presenting to emergency departments with acute coronary syndromes receive treatment that differs from that given to men in several important respects. In particular, women are less likely to undergo cardiac catheterization and revascularization procedures. Because previous studies tended to focus on single institutions or a defined patient population, Kaul and colleagues studied all patients presenting to emergency departments in a Canadian province to determine the influence of sex on treatment of acute coronary syndromes.

The Study: The researchers studied data on 54,134 patients who presented to 101 emergency departments between July 1998 and March 2001 because of a new episode of acute myocardial infarction (MI), unstable angina, or chest pain. For each sex, the researchers determined and compared the proportion of patients admitted to an acute care facility within 48 hours, the proportion undergoing any revascularization procedure, and the mortality rate at one year.

Results: The most common presentation was chest pain (34,145 patients), and 47.8 percent of these patients were women. Unstable angina was diagnosed in 7,410 patients (39.3 percent women); 6,290 patients (44.8 percent women) had stable angina; and 6,289 (29.7 percent women) had acute MI.

For each presentation, women were significantly less likely than men to be admitted to the hospital. Female patients were significantly older and had more comorbid conditions than male patients, yet female patients were significantly more likely to be discharged from the emergency department after adjustment for age and risk factors. For all four diagnoses, women were less likely to undergo coronary revascularization within one year of emergency department presentation, even after adjustment for baseline age and risk factors.

Despite the differences in initial management, men were significantly more likely than women to present again to the emergency department within one year with a repeat MI, and were more likely to undergo revascularization for unstable or stable angina or chest pain. The unadjusted one-year mortality was significantly increased in women compared with men for patients with MI, but this was not the case for any of the other diagnoses studied. After adjustment, women had decreased mortality for stable or unstable angina or chest pain and similar mortality rates for MI compared with men.

Conclusion: Women who present to the emergency department with acute coronary syndromes are significantly less likely than men to be admitted to a hospital or to receive coronary revascularization. Nevertheless, mortality rates at one year are not significantly worse for female patients.

editor's note: The authors conclude that, even after accounting for differences in presentation of acute coronary syndromes and other factors, women appeared to receive different and less aggressive management than men in emergency departments. A similar conclusion was reached by researchers studying admission to critical care units.1 In this study, the authors reported that older women were less likely to be admitted to critical care units and to receive selected life-supporting treatments than men. In contrast to those in the cardiac study, women in the critical illness study were more likely to die than men. The authors attribute the disparity in outcomes to differences in presentation, clinical decision-making, or unknown confounding factors.—a.d.w.

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