Why the study?
Females historically have lower rates of cardiovascular testing than males, and it was unknown whether clinical decision pathways utilizing standardized risk stratification could minimize sex-based differences in chest pain workup.
Does a standardized clinical decision pathway minimize sex-based differences in the non-invasive workup and risk-stratification of chest pain in the emergency department?
Cohort (n=1,078)
No
Does a standardized clinical decision pathway minimize sex-based differences in the non-invasive workup and risk-stratification of chest pain in the emergency department?
Absolute Event Rate: 33% vs 16%
p-value: p=0.01
While a clinical decision pathway for ED chest pain resulted in similar risk stratification and non-invasive testing rates between sexes, high-risk males still underwent more invasive procedures and experienced more 30-day MACE than high-risk females.
CDPs may reduce sex disparities in non-invasive ED chest pain testing; leaves open effects on invasive care and outcomes in high-risk patients.
Background Females have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification. Methods We conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex. Results A total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs 16%, p = 0.01) and PCI (18% vs 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (9% vs 4%, p = 0.001). Conclusions We identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient’s presentation.
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Titus et al. (2023) conducted a cohort in Chest pain (n=1,078). Male sex vs. Female sex was evaluated on Coronary angiogram in high-risk patients (p=0.01). High-risk males evaluated for chest pain underwent significantly more coronary angiograms than high-risk females (33% vs 16%), and males overall experienced more 30-day MACE (9% vs 4%).
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