Sex Differences in Acute Chest Pain Care

Quick Takes

  • In general, women presenting with chest pain are less likely to have cardiovascular disease. However, among patients with STEMI, women have worse outcomes.
  • Delays in guideline-directed care were noted for women during the prehospitalization and hospitalization management.
  • Efforts to improve guideline-directed care for women may need to include sex-specific reporting for key performance measures.

Study Questions:

What are the sex-related differences in epidemiology and care pathways for emergency medical services (EMS) related to chest pain?


Data from a population-based observational cohort study of consecutive adult patients attended by EMS for acute chest pain between January 2015 and June 2019 in Victoria, Australia, were used for the present analysis. EMS data were linked by individuals to emergency and hospital administrative datasets and mortality data. Care measures were selected based on Ambulance Victoria clinical guidelines, key performance metrics defined by the Victoria Department of Health, and existing management guidelines for acute coronary syndromes (ACS). These included prehospital rates of ambulance arrival to the patient within 15 minutes of call time, transport to hospital, aspirin administration, 12-lead electrocardiogram (ECG), analgesia, or nitrate administration for patients with a pain score >2 out of 10 and intravenous (IV) cannulation. Hospital care process and quality measures included rates of emergency department (ED) clinician review within the target time, ambulance off-load within 40 minutes, and ED length of stay <4 hours. ACS care measures included rates of angiography for patients transported to a revascularization-capable center (by ACS group), rates of transfer for patients transported to a non–revascularization-capable center, and rates of admission to cardiac or intensive care unit (CCU or ICU). Clinical outcomes included mortality rates and EMS reattendance for chest pain, with each reported at 30 days and long-term (mean follow-up, 2.3 years).


A total of 256,901 EMS attendances for chest pain occurred during the study period, of which 129,096 (50.3%) were for female patients. The mean age was 61.6 years. Age-standardized incidence rates were marginally higher for women compared to men (1,191 vs. 1,135 per 100,000 person-years). In multivariable models, women were less likely to receive guideline-directed care across most care measures, including transport to the hospital, prehospital aspirin or analgesia administration, 12-lead ECG, IV cannula insertion, and off-load from EMS or review by ED clinicians within target times. Women with ACS were less likely to undergo angiography or be admitted to a cardiac or intensive care unit. Thirty-day and long-term mortality were higher for women diagnosed with ST-elevation myocardial infarction (STEMI) but lower overall.


The authors concluded that substantial differences in care are present across the spectrum of acute chest pain management from first contact through to hospital discharge. Women have higher mortality for STEMI but better outcomes for other chest pain etiologies than men.


These data suggest the need for ongoing efforts to reduce gender-related differences in care for chest pain. This large study added detailed data on performance measures from prehospitalization to beyond discharge and allow for the identification of gaps in care for women.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Analgesia, Angiography, Aspirin, Cannula, Catheterization, Chest Pain, Electrocardiography, Emergency Medical Service Communication Systems, Intensive Care Units, Length of Stay, Myocardial Revascularization, Nitrates, Patient Discharge, Primary Prevention, Quality of Health Care, Sex Characteristics, ST Elevation Myocardial Infarction

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