1. Bethlehem University & Care International Emergency Care Conference Access for All 18+19/1/2005

2. Chest Pain Among Women Underestimation?? Presented by: Etaf Maqboul, RN, MSN Bethlehem University

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

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

9. 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

10. Studies in USA : yearly:26,000 (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).

11. 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:

12. 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: 16%:Stress test 56% :Echocardiography, 11% Catheterization.

13. In Palestine Very Limited research: Al- Ahli Hospital/Hebron (2004): CCU Admission:285:177 (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.

14. Studies In Makassed hospital/Jerusalem (2004) Cardiac Catheterization :447 cases * 137 (31%) females CCU Admission 2003 :860, females 325 (38%) 2004:750, females 262 (35%) Note: Cath. Lab was closed for 3 months in 2004.

15. 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.

16. Why The Gender Gap? The community has viewed women ’ s 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 it’s too late.

17. 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.

18. 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 woman’s 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.

19. Do Men and women have the same S&S 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. N&V 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.

20. 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.

21. 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.

22. 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.

23. References Auerbach, I., Chouraqui, P., Motro, M., Douglas, P. S., Ginsburg, G. S. (1996). Chest Pain in Women. N Engl J Med 335: 820-821. 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. Boccardi L, Verde M. (2003). Gender differences in the clinical presentation to the emergency department for chest pain. Italian Heart Journal; 4: 371-373. 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.

24. Thank You Questions??