Sex differences in triage priority, predictors, and outcomes in consecutive emergency department patients with chest pain

BACKGROUND: Chest pain (CP) is a common reason for Emergency Department (ED) presentation and may signal life-threatening cardiovascular emergencies (CVE). Sex-related differences in CP management are increasingly recognised, and multimodal sex-neutral assessment and sex-specific troponin thresholds have been proposed to reduce disparities. METHODS: Consecutive adults with haemodynamically stable CP presenting to a tertiary ED (2021-2023) were prospectively enrolled. A sex-neutral triage protocol incorporating symptom severity, physiological parameters, ECG findings, and cardiovascular risk factors was applied, alongside sex-specific troponin thresholds. Clinical characteristics, ED management and 30-day outcomes were recorded. RESULTS: Among 6017 patients, 2703 (44.9%) were women. Median age was 60 years in females vs 59 in males (p < 0.001). Women showed greater clinical heterogeneity, more frequently reporting posterior CP, epigastric pain, dyspnoea, and nausea/vomiting. High-priority triage codes were less often assigned to women (29.2% vs 37.9%, p < 0.001). Female sex independently predicted lower CVE risk (adjusted OR 0.48, 95% CI 0.39-0.59). CVE predictors differed by sex, with dyspnoea, peripheral artery disease, and Q waves associated with CVE in women. Women were hospitalised less frequently but experienced a longer ED stay before admission (19.0 vs 11.9 h, p < 0.001). Females with CVE were more frequently assigned lower-priority triage codes and experienced longer delays to troponin testing and to hospital admission. CONCLUSION: Clinically relevant sex differences persist in CP evaluation, even with sex-neutral, risk-informed triage protocols incorporating ECG findings and cardiovascular risk factors, alongside sex-specific troponin thresholds. Further strategies addressing sex-specific patterns across the entire CP pathway are needed to improve equity in emergency care.