ACS Diagnosis Missed in Women More Frequently than in Men, Study Finds

Suspicion for ACS in women was lower than that for men even in the presence of significant risk factors for heart attack, study authors report.

Chest pain is misdiagnosed in women more frequently than in men, according to research presented recently at ESC Acute CardioVascular Care 2021, an online scientific congress of the European Society of Cardiology (ESC).

Women with chest pain, the study found, also are more likely than men to wait >12 hours before accessing medical care.

“The low suspicion of heart attack occurs in both women themselves and in physicians,” said study author Dr Gemma Martinez-Nadal of the Hospital Clinic of Barcelona, Spain in an ESC press release, “leading to higher risks of late diagnosis and misdiagnosis.”

Gender differences were examined in presentation, diagnosis, and management of patients admitted with chest pain to the chest pain unit of an emergency department between 2008 and 2019. Data were recorded on risk factors for a heart attack including blood pressure, smoking status, and obesity. Each physician’s initial diagnosis was recorded after the first evaluation of a patient and was based on clinical history, physical examination, and an electrocardiogram (ECG); this impression is recorded before other examinations like blood tests.

“We had the first impression of the doctor as to whether the chest pain had a coronary cause or another origin such as anxiety or a musculoskeletal complaint,” explained Martinez-Nadal, in the ESC release.

A total of 41 828 patients with chest pain were included (42% women; median age 65 years in women, 59 years in men). Women were significantly more likely to present late to the hospital (ie, ≥12 hours after symptom onset) (41%) compared to men (37%).

“This is worrying since chest pain is the main symptom of reduced blood flow to the heart (ischaemia) because an artery has narrowed,” said Martinez-Nadal in the news release. “It can lead to a myocardial infarction which needs rapid treatment.”

In the physician’s initial diagnosis, acute coronary syndrome (ACS) was more likely to be considered the cause of chest pain in men compared to women. In addition, in those patients for whom ECG results did not lead to a definitive diagnosis, physicians noted a probable ACS in 39% of women vs 44.5% of men (p<.001).


This lower suspicion of ACS in females was maintained regardless of the number of risk factors or the presence of typical chest pain. _______________

Author Martinez-Nadal noted that the presence of risk factors such as hypertension and smoking taken together with a presentation of chest pain should greatly increase the suspicion of possible ischemia.

In women, 5% of ACS were initially misdiagnosed, whereas in men, 3% of ACS were initially misdiagnosed (p<.001). After multivariate analysis, female gender was an independent risk factor for an initial impression of non-ACS.

“Heart attack has traditionally been considered a male disease, and has been understudied, underdiagnosed, and undertreated in women, who may attribute symptoms to stress or anxiety. Both women and men with chest pain should seek medical help urgently,” concluded Martinez-Nadal.

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