1. Women and Heart Disease: Triage Criteria Symptoms versus Reality

2. Mars vs. Venus When it comes to cardiovascular disease, Women and Men ARE Different !

3. Heart Disease is the #1 Killer of Women Heart disease is the leading cause of death of American women 8,000,000 American women are currently living with heart disease 435,000 American women have heart attacks each year with an average age of 70.4 years Women are more likely than men to have a heart attack without chest pain

4. The Need for Prevention in Women 9,000 US women younger than 45 sustain a heart attack each year. “Thus the priority for coronary prevention is substantial for women of all ages.” Mortality associated with acute MI among women younger than 65 years is almost twice as high among men.

5. Women tend to get heart disease about 10 years later than men and are more likely to have coexisting chronic illnesses Research also shows that women may not be diagnosed or treated as aggressively as men, and their symptoms may be very different from those of men having a heart attack Coronary Heart Disease in Women

6. Presentation and differences from men: 2/3 of women who die suddenly have NO previously recognized symptoms. Women are more prone to non-cardiac chest pain….. In fact they may experience little or no squeezing chest pain in the center of the chest with an MI (as seen on “ER”).

7. Case Study: 86 Y/O woman Presented to ED at 4pm with back and shoulder pain, nausea, anxiety and feeling like she “can’t relax” Stated woke at 3am “sweating, nauseated and anxious” DENIED ANY CHEST PAIN Did not present in acute distress

8. Case Study: continued Triaged within 10 minutes EKG not done for another 40 minutes EKG showed STEMI in the inferior leads At that point, Code STEMI was called and patient taken emergently to the Cath lab. A 50 minute delay in diagnosis due to atypical symptoms.

9. Nationally: The Problem is AWARENESS Perception: 67% of women are knowledgeable that chest pain can be heart disease But, less than 10% are knowledgeable that shortness of breath, nausea, indigestion can be heart disease Reality: Chest pain is the presenting symptom in less than 50% of women Almost half of MIs in women present with shortness of breath, nausea, sleep disturbance, fatigue and shoulder pain

10. Symptoms in Men vs. Women Men Women Chest pain Neck/shoulder pain Shortness of breath Nausea/vomiting Sweating Fatigue Pain in one or both arms Indigestion Jaw Pain Dizziness Lightheadedness Shortness of breath

11. Women’s Common Pre-heart attack symptoms : Women are more likely to have: Unusual Fatigue– 70% Sleep disturbances—48% Shortness of breath– 42% Indigestion—39% Anxiety-35% Cold sweat rather than a hot sweat— 39%

12. Women’s Major Symptoms during a Heart Attack Shortness of breath– 58% Weakness--55% Unusual Fatigue– 43% Cold Sweat– 39% Dizziness– 39%

13. Not so straightforward Because of these atypical symptoms, women seek medical care later than men and are more likely to be misdiagnosed. Women presenting with MI and Coronary artery disease are more likely to be older, have a history of diabetes, high blood pressure, high cholesterol, CHF, and unstable angina than male counterparts. (JAm Coll Cardiol 1997;29).

14. Misperceptions and Missed Opportunities Leading to Unequal Diagnosis and Treatment Women are less likely to have an EKG or be admitted to the telemetry floors. Women are under-diagnosed and can therefore get a false sense of security. Less aspirin, beta-blockers, cholesterol meds, antiarrhythmic treatment, cardiac cath, balloon angioplasty, and cardiac bypass surgery are prescribed for women Women are less likely to enroll in cardiac rehabilitation after an MI or bypass surgery.

15. Conclusion Women presenting with atypical symptoms of chest pain should be triaged just like a man presenting with classic symptoms of chest pain Delay of triage due to atypical symptoms may lead to a delay in treatment resulting in significant injury to the patient