Bethlehem University

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Bethlehem University Care International

• Emergency Care Conference
• Access for All
• 1819/1/2005

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Chest Pain Among Women
Underestimation?? Presented by Etaf Maqboul,
RN, MSN Bethlehem University
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Objectives

• Recognize certain facts related to chest pain
  among women.
• Get some local and international statistics.
• Understand the gender gap in relation to chest
  pain.
• Identify the role of estrogen in protection
  against heart disease.
• Adopt certain strategies that prevent
  underestimation of chest pain among women.

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Chest Pain Is an extremely common symptom in
both men and women. several previous studies have
suggested that in women this complaint is more
frequently under-diagnosed than in men.
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Facts

• Women account for nearly half of all heart attack
  deaths.
• Heart disease is the number one killer of both
  women and men.
• Heart disease is the first killer of women (more
  than all cancers combined).
• Women tend to be about 10 years older than men
  when they have heart attack.
• Women are more likely to have DM, HTN and CHF.

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Facts

• women have been shown to respond better than men
  to life style changes, such as smoking cessation,
  weight control and exercise.
• Over 60 of women believe their biggest health
  threat is breast cancer but heart disease kills 6
  times as many women as breast cancer.
• Women are almost twice as likely as men to die
  from heart attack because they tend to be older
  and in poorer health and their symptoms are less
  obvious.

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Facts

• Some risk factors are different for women than
  for men. e.g menopause.
• Between ages 40 and 49, men are seven times more
  likely to develop CAD than women of the same age.
  After menopause, by age 65, women are just as
  likely as men to have heart attacks.

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Facts

• Women are more likely to die of a first MI.
• Women have more co morbidity (because they are
  usually older on presentation )

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Studies

• Most medical research has been performed on men
  (for a variety of reasons), assuming that the
  results would apply equally to women.
  Unfortunately, this has not always been true. The
  studies on women and heart disease have produced
  disturbing facts .
• One in nine women(aged 45-64) have some form of
  cardiovascular disease. After age 65 the odds
  climb to one in three

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Studies

• in USA yearly26,000 (ED) patients with acute
  cardiac ischemia are mistakenly not hospitalized
  12,000 with heart attacks and 14,000 with
  unstable angina.
• Failure to hospitalize patients with acute
  cardiac ischemia was more likely if
• The patient was non-white (2.2 times more than
  white).
• a woman under age 55 (6.7 times more likely).
• Had a primary symptom of shortness of breath
  rather than chest pain (2.7 times more likely),
  or had a normal or a non-diagnostic
  electrocardiogram (EKG)(3.3 times more).

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Studies

• 2003 survey indicates only 38 of women have
  discussed heart health with their health care
  provider.
• One year death rate for men following heart
  attack is 25, for women 38.
• In Italy October/2002
• 747 women with chest pain came to ER
• 446(60) were discharged, 2 (0.2) died, 298
  (40)were hospitalized

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Studies

• 336(45) Typical chest pain
• 60(6.7)AMI
• 42(5.6) Atrial fibrillation
• 60(10.6) Typical Angina
• 3 (0.4)Aortic dissection
• During Follow up (6 months) cardiac events
  occurred in 7.6 of 446 women discharged from the
  ER.
• In this study DX tests are underutilized in
  women with chest pain 16Stress test
• 56 Echocardiography, 11 Catheterization.

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In Palestine

• Very Limited research
• Al- Ahli Hospital/Hebron (2004)
• CCU Admission285177 (62) males and 108
  (38)females.
• 198 Echocardiography 120 (61) males and 78
  (39) females.
• 48 cases received streptokinase 46 (96)males
  and 2 (4) females.

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Studies

• In Makassed hospital/Jerusalem (2004)
• Cardiac Catheterization 447 cases
• 137 (31) females
• CCU Admission
• 2003 860, females 325 (38)
• 2004750, females 262 (35)
• Note Cath. Lab was closed for 3 months in 2004.

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Why The Gender Gap?

• Women present to ER with chest pain 1-2 hours
  later than men. This may be due to
• Women play multiple roles which takes on delay
  because of her responsibilities to others
  (nurturer and caregiver).
• Women might perceive that heart disease is
  something that happens to her father, brother,
  spouse.

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Why The Gender Gap?

• The community has viewed womens health almost
  looking essentially at her reproductive system
  and breasts, while ignoring the rest of the women
  as part of her health.
• Women tend to take their symptoms less seriously.
  
• Women and health professionals often do not
  recognize the warning signs until its too late.

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Estrogen and Heart Disease

• After menopause, the production of estrogen by
  the ovaries gradually diminishes over several
  years. Along with this reduction, there is an
  increase in LDL (bad cholesterol) and a small
  decrease in HDL (good cholesterol). These
  changes in lipid levels are believed to be one of
  the reasons for the increased risks of developing
  CAD after menopause. Women who have had their
  ovaries surgically removed (oophorectomy) or
  experience an early menopause also have an
  accelerated risk of CAD.

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• Estrogen maintains normal blood vessel responses
  to stress, even in the face of blood vessel
  damage reduces inflammatory changes in blood
  vessel lesions.
• Diabetes triples a womans risk for heart disease
  and puts younger women at special risk because
  type II diabetes can negate the positive affect
  that estrogen normally has on the heart, Smoking
  also can undo the protective benefits of
  estrogen.

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Do Men and women have the same SS of a heart
attack?

• Most men experience chest pain, discomfort and
  tightness, however women experience chest pain
  and most women say the experience feels more like
  a bad case of indigestion and heartburn, and SOB.
  NV and back or jaw and shoulder pain.
• Women have a significantly higher number of
  silent episodes of angina and even silent heart
  attacks.
• Stress tests are inaccurate and show false
  positive in about 40 of premenopausal women and
  up to 60 of postmenopausal women tested, that
  may lead to unnecessary angiograms.

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Recommendations

• Health Professionals should Consider risk factors
  when evaluating chest pain syndromes in women and
  not just the presence of typical chest pain.
• Recognition of symptoms by both women and
  healthcare providers which may not be dramatic or
  sudden.
• Healthcare provider education on avoiding
  stereotypes.

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Recommendations

• To identify earlier recognition of chest pain
  among women such as determination of
  institutional and individual missed-diagnosis
  rates
• To have Palestinian research about chest pain
  among women as well among men.

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Summary

• Cardiovascular disease is under recognized,
  under-diagnosed and under-treated by women
  patients and by some physicians.
• Women have their unique risk factors.
• Women should be more taught about chest pain and
  early recognition of heart attack.
• Health care providers should maximize the
  diagnostic and treatment modalities for women
  with chest pain as required.

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References

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• Auerbach, I., Chouraqui, P., Motro, M., Douglas,
  P. S., Ginsburg, G. S. (1996). Chest Pain in
  Women. N Engl J Med 335 820-821.
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• Barrett-Connor, E., Giardina, E. -G. V., Gitt, A.
  K., Gudat, U., Steinberg, H. O., Tschoepe, D.
  (2004). Women and Heart Disease The Role of
  Diabetes and Hyperglycemia. Arch Intern Med 164
  934-942.
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• Boccardi L, Verde M. (2003). Gender differences
  in the clinical presentation to the emergency
  department for chest pain. Italian Heart Journal
  4 371-373.
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• Diercks, D. B., Hollander, J. E., Sites, F.,
  Kirk, J. D. (2004). Derivation and Validation of
  a Risk Stratification Model to Identify Coronary
  Artery Disease in Women Who Present to the
  Emergency Department with Potential Acute
  Coronary Syndromes. Acad Emerg Med 11 630-634.

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• Thank You
• Questions??