Under-Investigation and Delays Experienced by Females Presenting with Chest Pain to Emergency Departments: A Study of Five Linked Canadian Hospitals

BACKGROUND: Previous research has shown that among patients presenting with classic cardiac pain, women receive fewer investigations than men do. OBJECTIVE: To assess whether a protocolized assessment strategy for chest pain presentations would mitigate sex-based differences in clinical testing or investigations. METHODS: We conducted a retrospective cohort study of all adult patients presenting with chest pain, including what was felt to be ischemic/cardiac (Canadian Triage Acuity Score (CTAS) II) and non-cardiac (CTAS III) chest pain from November 9, 2020, to June 20, 2022. An advanced diagnostic pathway including high-sensitivity troponin (hs-TnI) was in use. The primary outcome was a composite of repeat hs-TnI testing, imaging, and consultations. Secondary outcomes included 30-day major adverse cardiac events (MACE). RESULTS: Overall, 19,324 patients (49.7% females) were included. Women had a higher proportion of single hs-TnI testing (75.1% vs 64.7%; p < 0.0001) than men; this finding persisted when adjusting for age, comorbidities, acuity, and troponin results. Women waited 19% longer to be assessed by a physician (median difference 16 (95% CI: 12.4-19.6) minutes). Finally, men experienced a higher risk of MACE (aHR: 1.45, 95% CI: 1.29-1.63). CONCLUSION: Women were significantly less likely to receive serial troponin testing, while experiencing delays in care and longer length of stay; however, MACE outcomes were worse in men. Evidence-based protocols with specific risk stratification based on initial hs-TnI results do not prevent sex-based differences from occurring.