Gender Bias in Cardiovascular Testing Persists after Adjustment for Presenting Characteristics and Cardiac Risk

Abstract

Objectives: Previous studies have found that female patients receive fewer invasive tests for cardiovascular disease than male patients. The authors assessed whether different clinical characteristics at emergency department presentation account for this gender bias.Methods: Patients with potential acute coronary syndrome (ACS) who presented to a university hospital were prospectively identified. A structured data instrument that included demographic information, chest pain description, history, physical examination, chest radiography, and electrocardiogram (ECG) data was completed. Hospital course was tracked daily. Patients received 30-day telephone follow-up. The main outcome was whether the patients received objective evaluation for coronary artery disease after adjustment for cardiac risk, including race, age, total number of risk factors, Thrombolysis in Myocardial Infarction (TIMI) score, ECG, and whether the patient sustained an acute myocardial infarction on index hospitalization.Results: There were 3,514 women (58%) and 2,547 men (42%) studied. They had similar presenting characteristics: chest pain quality (pressure/tightness: female 60% vs. male 59%, p = 0.6), location (substernal: female 82% vs. male 80%; p = 0.2), radiation (female 27% vs. male 26%; p = 0.3), and most associated symptoms. Men had more cardiac risk factors (mean 1.5 vs 1.4; p < 0.001), more abnormal ECGs (59% vs. 48%; p < 0.001), and a higher TIMI risk score (p < 0.001). With respect to the main outcome, men received more cardiac catheterizations (12.6% vs. 6.0%; odds ratio [OR], 2.25; 95% confidence interval [CI] = 1.88 to 2.70) and more stress tests (14.7% vs. 12.3%; OR, 1.22; 95% CI = 1.05 to 1.42). After adjustment for age, race, cardiac risk factors, ECG, and TIMI risk score, men still received more cardiac catheterizations (adjusted OR, 1.72; 95% CI = 1.40 to 2.11) and stress tests (adjusted OR, 1.16; 95% CI = 1.01 to 1.33). Models adjusting for acute myocardial infarction or death, high-risk initial clinical impression, or emergency department disposition found similar results for increased likelihood of cardiac catheterization in men but no difference in stress testing between men and women.

Gender Differences in Scene Time, Transport Time, and Total Scene to Hospital Arrival Time Determined by the Use of a Prehospital Electrocardiogram in Patients with Complaint of Chest Pain

“…It has been well described that female ACS patients present with significantly more complaints of nausea, emesis, indigestion, fatigue, and back pain when compared to male patients (40)(41)(42). Additionally, recent reports have demonstrated that women are less likely to have a history of ACS and that, comparatively, men often present with increased cardiac risk factors, higher Thrombolysis in Myocardial Infarction trial scores, and more often have abnormal ECGs on presentation (14,42,43). Other investigations into the presentation of ACS have demonstrated that women often present at an older age and often have significantly more comorbidities associated with greater cardiac risk, including noninsulin-dependent diabetes and hypertension (42,(44)(45)(46)(47).…”

“…Despite 53% of these deaths occurring in women, recent studies in the setting of acute coronary syndrome (ACS) have described a significant gender bias against women in admission rates and likelihood of revascularization (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13). Possible explanations accounting for this gender bias, including an increased likelihood of significant comorbidities masking ACS and the often atypical presentation of ACS in women, have not been supported (14). Within the emergency medicine and cardiology literature, multiple studies of prehospital 12-lead electrocardiography have demonstrated reductions in door-to-drug and door-to-balloon times in patients with ST-elevation myocardial infarction (STEMI) (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26).…”

Treatment and outcome in acute myocardial infarction in a community in relation to gender

“…Previous studies have also shown that female gender is independently associated with an increased risk of inappropriate discharge from the emergency department among patients with acute coronary syndromes [13]. A recent large survey indicated that females with potential acute coronary syndrome receive fewer catheterizations than male patients [14]. Finally, it has been shown that, among patients with acute coronary syndrome admitted to the CCU, women have to wait longer in the emergency department than men [15].…”

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

“…Gender differences in the use of cardiac tests in patients with suspected or confirmed coronary artery disease (CAD) have been known for decades 1, 2, 3, 4, 5, 6, 7, 8. After an abnormal cardiac stress test, women are less likely to undergo any subsequent diagnostic testing, including secondary stress testing or angiography 6, 7, 8.…”

“…After an abnormal cardiac stress test, women are less likely to undergo any subsequent diagnostic testing, including secondary stress testing or angiography 6, 7, 8. These gender differences persist even after considering patient factors that may explain variation in care such as differences in comorbidities, presentation, appropriateness of treatment, and patient preferences—suggesting that these differences represent disparities , as defined by the Institute of Medicine 7, 8, 9, 10, 11, 12. Despite studies documenting gender disparities in the use of cardiovascular tests, few have examined the underlying reasons for these disparities in management.…”