Cardiovascular Disease in Women in the Emergency Department

A point of care emergency clinical summary has been created for Acute Coronary Syndromes (ACS) in women. This core document will be accompanied by additional documents/tools focusing on specific conditions that can cause MINOCA. The BC Emergency Medicine Network was our first dissemination point, with further dissemination on our horizons. The development of these women’s heart health-specific tools, including checklists and flowcharts, will support front-line decision-making.

Chest Pain in Women in the Emergency Department:
A Focus on Acute Coronary Syndrome

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1. SCOPE OF THE PROBLEM:

Cardiovascular disease (CVD) is the leading cause of premature death in women in Canada¹. Mortality rates in men have stabilized in the last decade but have continued to increase in women in Canada² and can occur for women of all ages. Sex and gender-specific differences exist in awareness, symptom presentation, diagnosis, prognosis, and treatment³. The diagnosis of acute coronary syndrome (ACS) in women presenting to the ER can be complex and challenging. Rapid diagnosis and treatment are vital.

2. SYMPTOMS:

More than 50% of women who experience heart attacks have their symptoms unrecognized by healthcare providers⁴. In addition, women are 7x more likely to be sent home⁵. Chest discomfort is the most common presenting complaint in 90% of ACS, in BOTH men and women⁴. Women may, however, describe their symptoms differently than men, as discomfort or pressure rather than “pain.” Anginal equivalents, such as dyspnea, epigastric pain, and upper back discomfort, are more often reported in women, and may lead to misdiagnosis and delays in treatment. Heart attacks are on the rise and can occur in women of all ages. Assessing for cardiac disease should be prioritized in women who experience chest pain/pressure.

3. RISK FACTORS:

Cardiovascular risk assessment in women requires evaluation of traditional, sex-gender specific, and under-recognized risk factors⁶:

4. PATHOPHYSIOLOGY:

Coronary Artery Disease (CAD), is a type of CVD that can be obstructive or non-obstructive. Obstructive coronary artery disease (ST and non-ST elevation myocardial infarction) is common in both men and women. However, in 5-15% of ACS cases, Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) can occur, particularly in women¹⁵. The coronary angiogram in MINOCA reveals < 50% stenosis in any major epicardial artery. Serial troponins, preferably high-sensitivity assays, using sex-specific thresholds, are critical, as initial results may be normal. Initial troponin should be followed by repeat sample collection 1-3 hours later for high-sensitiviy troponin and 3-6 hours later for conventional troponin assays¹⁶. Long term prognosis for MINOCA patients may include worse quality of life indicators, compared to obstructive MI patients.

5. POTENTIAL CAUSES OF MINOCA:

Possible causes of MINOCA include, but are not limited to, plaque rupture/erosion, coronary artery vasospasm (including ACS syndrome accompanying mast cell activation from allergic, hypersensitivity, or anaphylactic reactions: Kounis syndrome)¹⁷, microvascular dysfunction, coronary artery embolism, and spontaneous coronary artery dissection (SCAD)¹⁵.

6. INVESTIGATIONS AND MEDICAL THERAPY:

7. DIFFERENTIAL DIAGNOSIS:

Beyond MINOCA, elevated troponin levels may also be found in other non-obstructive coronary artery conditions such as myocarditis, stress (Tako-tsubo) cardiomyopathy and non-ischemic critical conditions such as sepsis, pulmonary embolism, chronic kidney disease and aortic dissection.

8. ACS IN WOMEN CHECKLIST:

9. ADDITIONAL RESOURCES:

10. ACKNOWLEDGEMENTS:

This educational material is brought to you by the Knowledge Translation and Mobilization Working Group (KTMWG) of the Canadian Women’s Heart Health Alliance (CWHHA). The composition team includes Dr. Shahin Jaffer, Dr. Christine Pacheco, Dr. Najah Adreak, Dr. Jill Bruneau, Helen Robert, Karen E. Jacques, and Meagan Noble. The CWHHA is powered by the Canadian Women’s Heart Health Centre at the University of Ottawa Heart Institute.

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