Gender differences in pre-hospital time delay and symptom presentation in patients suspected of acute coronary syndrome in primary care

Are disparities in emergency department imaging exacerbated during high-volume periods?

PURPOSE

Evaluate if disparities in the emergency department (ED) imaging timeline exist, and if disparities are altered during high volume periods which may stress resource availability.

METHODS

This retrospective study was conducted at a four-hospital healthcare system. All patients with at least one ED visit containing imaging from 1/1/2016 to 9/30/2020 were included. Peak hours were defined as ED encounters occurring between 5 pm and midnight, while all other ED encounters were non-peak hours. Patient-flow data points included ED length of stay (LOS), image acquisition time, and diagnostic image assessment time.

RESULTS

321,786 total ED visits consisted of 102,560 during peak hours and 219,226 during non-peak hours. Black patients experienced longer image acquisition and image assessment times across both time periods (TR = 1.030; p < 0.001 and TR = 1.112; p < 0.001, respectively); Black patients also had increased length of stay compared to White patients, which was amplified during peak hours. Likewise, patients with primary payer insurance experienced significantly longer image acquisition and image assessment times in both periods (TR > 1.00; p < 0.05 for all). Females had longer image acquisition and image assessment time and the difference was more pronounced in image acquisition time during both peak and non-peak hours (TR = 1.146 and TR = 1.139 respectively with p < 0.001 for both).

CONCLUSION

When measuring radiology time periods, patient flow throughout the ED was not uniform. There was unequal acceleration and deceleration of patient flow based on racial, gender, age, and insurance status. Segmentation of patient flow time periods may allow identification of causes of inequity such that disparities can be addressed with targeted actions.

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Time to Seek Care and Hospital Length of Stay Among Older Adults With Acute Coronary Syndrome During the COVID-19 Pandemic

The prevalence of prehospital delay is high among older adults with acute coronary syndrome (ACS). The current study aimed to examine the associated factors of prehospital delay among patients with ACS during the COVID-19 pandemic. This cross-sectional study was conducted on a convenience sample of 300 older adults with ACS admitted to the emergency department in Jordan. Data were collected from June 1 to September 1, 2020. Bivariate and multivariate analyses were used to explore the predictors of prehospital delay. Being widowed, educational level, pain intensity, the gradual onset of ACS symptoms, symptoms lasting for more than 30 minutes, patients' feeling anxious about their ACS symptoms, patients' perceiving their symptoms to be particularly dangerous, history of myocardial infarction (MI), and mode of transportation were associated with the time taken before seeking emergency care. Significant predictors of time to seek help were chief complaint of chest pain or palpitations, abrupt onset of symptoms, the associated symptom of vertigo, and a higher number of chronic illnesses; they explained about 17.9% of the variance in the time to seek care. The average time to seek care among patients with ACS during the COVID-19 pandemic was found to be longer than the average time reported by studies conducted prior the pandemic. Improved understanding of the associations between prehospital delay is crucial for optimal ACS patient outcomes under the impacts of the COVID-19 pandemic.

Operative Treatment of Bipartite Patella in Pediatric and Adolescent Athletes: A Retrospective Comparison With a Nonoperatively Treated Cohort

Background:

Bipartite patella (BPP) is a developmental anomaly that forms when incomplete patellar ossification leaves a residual fibrocartilaginous synchondrosis between ossification centers. Repetitive traction forces across the synchondrosis can cause knee pain, most commonly presenting in adolescence. Symptoms frequently resolve with nonoperative management. Few surgical case series exist to guide treatment approaches for refractory pain.

Purpose:

To investigate the clinical features, surgical techniques, and outcomes associated with operative treatment of symptomatic BPP in pediatric and adolescent athletes and to compare features of the series with a large control group managed nonoperatively.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective medical record review was conducted of all patients aged ≤20 years who were diagnosed with symptomatic, radiologically confirmed BPP between 2003 and 2018 at a single tertiary-care pediatric hospital (N = 266). Demographic and clinical variables were analyzed, and additional radiologic and perioperative variables were collected for the surgical subcohort.

Results:

Of the 266 patients included, 27 were treated operatively (10.2%). When compared with those treated nonoperatively (with rest, physical therapy, cryotherapy, and anti-inflammatory medications), the operatively managed group experienced a longer duration of symptoms before first presentation (21.5 vs 7.6 months; P < .001) and were more likely to be older (mean age, 15.4 vs 12.4 years; P < .001), female (59.3% vs 35.6%; P = .03), and competitive athletes (100% vs 84.5%; P = .02). In the 27 patients treated operatively, procedures were categorized as isolated fragment excision (n = 9), fragment excision with lateral release (n = 8), isolated lateral release (n = 5), fragment screw fixation (n = 4), and synchondrosis drilling (n = 1). The mean time between surgery and return to sports was 2.2 months. Four patients (14.8%) reported residual symptoms requiring secondary surgery, including lateral release (n = 1), excision of residual fragment (n = 1), and fixation screw removal (n = 2).

Conclusion:

BPP can cause knee pain in adolescent athletes and is generally responsive to nonoperative treatment. Patients undergoing surgical treatment—most commonly female competitive athletes with prolonged symptoms—represented 10% of cases. A variety of surgical techniques may be effective, with a 15% risk of persistent or recurrent symptoms warranting reoperation. Prospective multicenter investigations are needed to identify optimal candidates for earlier interventions and the optimal operative treatment technique.

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations

BACKGROUND

During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful.

OBJECTIVE

To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk.

METHODS

Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient's general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age.

RESULTS

The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39-2.34, P < 0.001): 2.33 (1.68-3.22, P < 0.001) for men and 1.29 (0.83-1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07-3.10, P = 0.039).

CONCLUSIONS

Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more 'straightaway' could be considered for these patients with chest discomfort.

TRIAL NUMBER

NTR7331.

Implanted Monitor Alerting to Reduce Treatment Delay in Patients With Acute Coronary Syndrome Events

BACKGROUND

Increased pre-hospital delay during acute coronary syndrome (ACS) events contributes to worse outcome.

OBJECTIVES

The purpose of this study was to assess the effectiveness of an implanted cardiac monitor with real-time alarms for abnormal ST-segment shifts to reduce pre-hospital delay during ACS events.

METHODS

In the ALERTS (AngeLmed Early Recognition and Treatment of STEMI) pivotal study, subjects at high risk for recurrent ACS events (n = 907) were randomized to control (Alarms OFF) or treatment groups for 6 months, after which alarms were activated in all subjects (Alarms ON). Emergency department (ED) visits with standard-of-care cardiac test results were independently adjudicated as true- or false-positive ACS events. Alarm-to-door (A2D) and symptom-to-door (S2D) times were calculated for true-positive ACS ED visits triggered by 3 possible prompts: alarm only, alarms + symptoms, or symptoms only.

RESULTS

The Alarms ON group showed reduced delays, with 55% (95% confidence interval [CI]: 46% to 63%) of ED visits for ACS events <2 h compared with 10% (95% CI: 2% to 27%) in the Alarms OFF group (p < 0.0001). Results were similar when restricted to myocardial infarction (MI) events. Median pre-hospital delay for MI was 12.7 h for Alarms OFF and 1.6 h in Alarms ON subjects (p < 0.0089). Median A2D delay was 1.4 h for asymptomatic MI. Median S2D delay for symptoms-only MI (no alarm) in Alarms ON was 4.3 h.

CONCLUSIONS

Intracardiac monitoring with real-time alarms for ST-segment shift that exceeds a subject's self-normative ischemia threshold level significantly reduced the proportion of pre-hospital delays >2 h for ACS events, including asymptomatic MI, compared with symptoms-only ED visits in Alarms OFF. (AngeLmed for Early Recognition and Treatment of STEMI [ALERTS]; NCT00781118).

Are there gender disparities in symptom presentation or triage of patients with chest discomfort at primary care out-of-hours services? An observational study

OBJECTIVES

Previous hospital-based studies have suggested delayed recognition of acute coronary syndrome (ACS) in women. We wanted to assess differences in symptom presentation or triage among women and men who contacted primary care out-of-hours services (OHS) for chest discomfort.

DESIGN

Retrospective observational study.

SETTING

Primary care OHS.

PARTICIPANTS

276 women and 242 men with chest discomfort who contacted a primary care OHS in the Netherlands in 2013 and 2014.

MAIN OUTCOME MEASURES

Differences between women and men regarding symptom presentation and urgency allocation.

RESULTS

8.4% women and 14.0% men had ACS. Differences in symptoms between patients with and without ACS were in general small, for both women and men. In women with ACS compared with women without ACS, mean duration of telephone calls was discriminative; 5.22 (SD 2.53) vs 7.26 (SD 3.11) min, p value=0.003. In men, radiation of pain (89.3% vs 54.9%, p value=0.011) was discriminative for ACS, and stabbing chest pain (3.7% vs 24.0%, p value=0.014) for absence of ACS . Women and men with chest discomfort received similar high urgency allocation (crude and adjusted OR after correction for ACS and age; 1.03 (95% CI 0.72 to 1.48) and 1.04 (95% CI 0.72 to 1.52), respectively). Women with ACS received a high urgency allocation in 22/23 (95.7%) and men with ACS in 30/34 (88.2%), p value=0.331.

CONCLUSIONS

Discriminating ACS in patients with chest discomfort who contacted primary care OHS is difficult in both women and men. Women and men with chest discomfort received similar high urgency allocation.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry

This study was conducted to compare the survival rate and the influencing factors between women and men following ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).A national-wide Acute Coronary Syndrome Full Spectrum Registry conducted by the Taiwan Society of Cardiology was used for data collection between October 2008 and January 2010. Details of 1621 patients with STEMI treated with primary PCI, including 1350 (83%) men and 271 (17%) women, were collected. Composite outcomes included all-cause death, myocardial reinfarction, and an ischemic stroke. Demographic data, comorbidities, clinical presentations, details of treatment received, and outcomes were recorded at 3-month intervals for 1 year.No significant difference was observed between men and women in the composite endpoints after STEMI during their hospital stay (5.5% vs 2.5%, P = .07). However, women showed significantly higher in-hospital and 1-year mortality rates than those of men (4.1% vs 1.8%, P = .008; 11.0% vs 4.1%, P = .000, respectively). Compared with men, women presented with higher age (mean age 68.9 vs 58.9 years, P = .001), less body weight (58.7 vs 70.9 kg, P < .001), more number of risk factors, delayed diagnosis, and more number of inadequate medical treatments. After adjusting for age and cardiovascular risk factors, the difference in mortality ceased to exist between men and women.Although female patients with STEMI-treated primary PCI had higher in-hospital and 1-year mortality rates than those of males in Taiwan, there was no gender difference after adjusting for age and cardiovascular risk factors.

Patient delay in TIA: a systematic review

Background

Patients who suffer a transient ischemic attack (TIA) have a high short-term risk of developing ischemic stroke, notably within the first 48 h. Timely diagnosis and urgent preventive treatment substantially reduce this risk. We conducted a systemic review to quantify patient delay in patients with (suspected) TIA, and assess determinants related to such delay.

Methods

A systematic review using MEDLINE and EMBASE databases up to March 2017 to identify studies reporting the time from onset of TIA symptoms to seeking medical help.

Results

We identified nine studies providing data on patient delay, published between 2006 and 2016, with 7/9 studies originating from the United Kingdom (UK). In total 1103 time-defined TIA patients (no remaining symptoms > 24 h), and 896 patients with a minor stroke (i.e., mild remaining symptoms > 24 h) were included (49.1% men, mean age 72.2 years). Patient’s delay of more than 24 h was reported in 33.1–44.4% of TIA patients, with comparable proportions for minor stroke patients. Delays were on average shorter in patients interviewed at the emergency department than among patients seen at TIA outpatient clinics. Univariably associated with a shorter delay were (1) a longer duration of symptoms, (2) motor symptoms, (3) a higher ABCD2 score, and (4) correct patient’s recognition as possible ischemic cerebrovascular event.

Conclusions

More than a third of patients experiencing a TIA delays medical attention for more than a day, thus critically extending the initiation of stroke preventive treatment. There still seems to be insufficient awareness among lay people that symptoms suggestive of TIA should be considered as an emergency. Additional data and multivariable analyses are needed to define main determinants of patient delay.

A review of sex-specific benefits and risks of antithrombotic therapy in acute coronary syndrome

Over the past decade, more men than women have shown improved outcomes from antithrombotic therapies after acute coronary syndrome (ACS), which raises the question of whether there are sex-specific differences in treatment patterns and response to therapy. Differences in presenting clinical characteristics, pathophysiologic profile, and disparities in treatment may contribute to this outcomes discrepancy. Analyses of large trials and registry data suggest that male and female ACS patients experience similar benefits from antithrombotic therapy without significant difference in treatment utilization rates, yet women are consistently at higher risk of bleeding than men. Bleeding may result in antithrombotic treatment disruption, which increases the risk of long-term thrombotic events. Additionally, female ACS patients are more likely to receive suboptimal medication dosing and have lower rates of long-term medication adherence. These differences have significant clinical implications for women, indicating the need for strategies that will optimize initial treatment and long-term management attuned to these recognized sex-specific gaps.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

BACKGROUND

Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences.

OBJECTIVE

The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS.

METHODS

A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured.

RESULTS

The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00-2.42), shoulder pain (OR, 1.76; CI, 1.13-2.73), and upper back pain (OR, 2.92; CI, 1.81-4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women.

CONCLUSIONS

Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

The cost-utility of point-of-care troponin testing to diagnose acute coronary syndrome in primary care

Background

The added value of using a point-of-care (POC) troponin test in primary care to rule out acute coronary syndrome (ACS) is debated because test sensitivity is inadequate early after symptom onset. This study investigates the potential cost-utility of diagnosing ACS by a general practitioner (GP) when a POC troponin test is available versus GP assessment only.

Methods

A patient-level simulation model was developed, representing a hypothetical cohort of the Dutch population (>35 years) consulting the GP with chest complaints. All health related consequences as well as cost consequences were included. Both symptom duration, selection of patients in whom the POC troponin test is performed, and test performance at different time points were incorporated. Health outcomes were expressed as Quality-Adjusted Life Years (QALYs). The main outcome parameters involve the effect of POC troponin testing on (in)correct hospital referrals, QALYs, and costs.

Results

The POC troponin strategy decreases the referral rate in non-ACS patients from 38.46% to 31.85%. Despite a small increase in non-referral among ACS patients from 0.22% to 0.27%, the overall health effect is negligible. Costs will decrease with €77.25/patient (95% CI €-126.81 to €-33.37).

Conclusions

The POC troponin strategy is likely cost-saving, by reducing hospital referrals. The small increase in missed ACS patients can be partly explained by conservative assumptions used in the analysis. Besides, current developments in POC troponin tests will likely further improve their diagnostic performance. Therefore, future prospective studies are warranted to investigate whether those developments make the POC troponin test to a safe and cost-effective diagnostic tool for diagnosing ACS in general practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0647-6) contains supplementary material, which is available to authorized users.

Gender Differences among Patients with Acute Coronary Syndrome in the Middle East

Background:

There is controversy regarding the relationship between gender and acute coronary syndrome (ACS).

Objective:

To study the impact of gender on presentation, management, and mortality among patients with ACS in the Middle East.

Methodology:

From January 2012 to January 2013, 4057 patients with ACS were enrolled from four Arabian Gulf countries (Kuwait, Oman, United Arab Emirates, and Qatar), representing more than 85% of the general hospitals in each of the participating countries.

Results:

Compared to men, women were older and had more comorbidities. They also had atypical presentation of ACS such as atypical chest pain and heart failure. The prevalence of non-ST-segment elevation myocardial infarction (49 vs. 46%; P < 0.001) and unstable angina (34 vs. 24%; P < 0.001) was higher among women as compared to men. In addition, women were less likely to receive evidence-based medications such as aspirin, clopidogrel, beta-blocker, and angiotensin-converting enzyme inhibitors on admission and on discharge. During hospital stay, women suffered more heart failure (15 vs. 12%; P = 0.008) and were more likely to receive blood transfusion (6 vs. 3%; P < 0.001). Women had higher 1-year mortality (14 vs. 11%; P < 0.001), the apparent difference that disappeared after adjusting for age and other comorbidities.

Conclusion:

Although there were differences between men and women in presentation, management, and in-hospital outcomes, gender was shown to be a nonsignificant contributor to mortality after adjusting for confounders.

Gender differences in health-related quality of life in patients undergoing coronary angiography

Background

Health-related quality of life (HRQOL) reflects the general well-being of individuals. In patients with coronary artery disease (CAD), HRQOL is compromised. Female patients with CAD have been reported to have lower HRQOL. In this study, we investigate gender differences in HRQOL and in associations of patient characteristics with HRQOL in patients with coronary angiography (CAG).

Methods

We cross-sectionally analysed patients from the Utrecht Coronary Biobank undergoing CAG. All patients filled in an HRQOL questionnaire (RAND-36 and EuroQoL) on inclusion. RAND-36 and EuroQoL HRQOL measures were compared between the genders across indications for CAG, CAD severity and treatment of CAD. RAND-36 HRQOL measures were compared with the general Dutch population. Additionally, we assessed interactions of gender with patient characteristics in their association with HRQOL (EuroQoL).

Results

We included 1421 patients (1020 men and 401 women) with a mean age of 65 in our analysis. Women reported lower HRQOL measures than men (mean EuroQoL self-rated health grade 6.84±1.49 in men, 6.46±1.40 in women, p<0.001). The reduction in RAND-36 HRQOL as compared with the general Dutch population was larger in women than in men. From regression analysis, we found that diabetes, a history of cardiovascular disease and symptoms of shortness of breath determined HRQOL (EuroQoL) more strongly in men than in women.

Conclusions

Women reported lower HRQOL than men throughout all indications for CAG and regardless of CAD severity or treatment. As compared with the general population, the reduction in HRQOL was more extreme in women than in men. Evident gender differences were found in determinants of HRQOL in patients undergoing CAG, which deserve attention in future research.

Trial registration

NCT02304744 (clinicaltrials.gov).

The diagnostic value of clinical symptoms in women and men presenting with chest pain at the emergency department, a prospective cohort study

Background

Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking.

Methodology

Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes.

Results

A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).

Conclusion

The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

Gender comparisons in non-acute cardiac symptom recognition and subsequent help-seeking decisions: a mixed methods study protocol

INTRODUCTION

Coronary heart disease (CHD) is one of the leading causes of death in both men and women worldwide. Despite the common misconception that CHD is a 'man's disease', it is now well accepted that women endure worse clinical outcomes than men following CHD-related events. A number of studies have explored whether or not gender differences exist in patients presenting with CHD, and specifically whether women delay seeking help for cardiac conditions. UK and overseas studies on help-seeking for emergency cardiac events are contradictory, yet suggest that women often delay help-seeking. In addition, no studies have looked at presumed cardiac symptoms outside an emergency situation. Given the lack of understanding in this area, an explorative qualitative study on the gender differences in help-seeking for a non-emergency cardiac events is needed.

METHODS AND ANALYSIS

A purposive sample of 20-30 participants of different ethnic backgrounds and ages attending a rapid access chest pain clinic will be recruited to achieve saturation. Semistructured interviews focusing on help-seeking decision-making for apparent cardiac symptoms will be undertaken. Interview data will be analysed thematically using qualitative software (NVivo) to understand any similarities and differences between the way men and women construct help-seeking. Findings will also be used to inform the preliminary development of a cardiac help-seeking intentions questionnaire.

ETHICS AND DISSEMINATION

Ethical approvals were sought and granted. Namely, the University of Westminster (sponsor) and St Georges NHS Trust REC, and the Trust Research and Development Office granted approval to host the study on the Queen Mary's Roehampton site. The study is low risk, with interviews being conducted on hospital premises during working hours. Investigators will disseminate findings via presentations and publications. Participants will receive a written summary of the key findings.

The impact of female sex on long-term survival of patients with severe atherosclerosis undergoing endarterectomy

OBJECTIVES

Long-term age- and sex-specific mortality data in patients undergoing carotid endarterectomy (CEA) and iliac/femoral endarterectomy (FEA) are scarce. We examined long-term mortality in these patient groups, stratified by age and sex.

METHODS

Between 2002 and 2012, 1771 patients (1200 men, 571 women) treated by CEA, and 685 patients (495 men, 190 women) who underwent FEA, were included and linked to the national mortality registry of the Netherlands. Absolute mortality risks during follow-up were analyzed by life-table and Kaplan Meier survival analyses in two age groups and stratified by sex, and compared to a matched sample from the general population. In addition, multivariable Cox regression analyses were performed.

RESULTS

After CEA, with a median follow-up duration of 4.3 years (interquartile range 2.0-7.1), 298 all-cause deaths had occurred in men (25%) and 105 (18%) in women. As in the general population, cumulative survival after CEA was significantly better in women compared to men (P = 0.002) and absolute CEA-associated mortality risk in women was similar to that of the general population. For FEA patients, mortality risk was worse than for CEA patients and the general population in both sexes and surprisingly, female sex did not have a favorable effect on survival. Following FEA, 130 men (26%) and 51 women (27%) died after a median follow-up time of 3.0 years (interquartile range 1.5-5.9). Stratifying by age, and adjusting for cardiovascular risk factors did not change these trends.

CONCLUSIONS

Long-term mortality after CEA is higher in men than in women, and in women mortality risk is similar to the general population. After FEA, the benefit of women as seen after CEA is lost.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature

BACKGROUND

Patients' treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research.

METHODS AND RESULTS

We reviewed the English-language literature from 1998-2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing.

CONCLUSION

We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.