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Gender-specific uncertainties in the diagnosis of acute coronary syndrome

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Abstract

Background

It is unknown whether higher rates of delayed diagnosis and misdiagnosis of acute coronary syndrome (ACS) in women might have contributed to the poorer outcome of women.

Methods

In a prospective diagnostic multicenter study, we recruited patients presenting to the emergency department (ED) with any kind of chest discomfort/chest pain with onset or peak within the last 12 h. We quantified early diagnostic uncertainty for the presence of ACS among treating physicians at the ED after 90 min, possibly responsible for delayed diagnosis, using a visual analogue scale. Late diagnostic uncertainty, possibly responsible for misdiagnosis, was defined as disagreement among two independent cardiologists’ adjudication of the final diagnosis after complete work-up.

Results

Among 2795 patients (897 women and 1898 men), ACS was the adjudicated final diagnosis in 24 % of women and 35 % of men. Early diagnostic accuracy of clinical judgment of the ED physician for ACS as quantified by the area under the receiver-operating characteristics curve was 0.89 (95 % CI 0.87–0.92) in women and 0.86 (95 % CI 0.85–0.88) in men (p = 0.046). Late diagnostic uncertainty regarding the diagnosis of ACS was 5 % in women and 7 % in men (p = 0.069).

Conclusion

Diagnostic uncertainty for the presence of ACS in women is not more common as compared to men and does, therefore, not explain the poorer outcome observed in women with ACS.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.

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Acknowledgments

We thank the patients who participated in the study, the staff of the participating EDs, the research coordinators, and the laboratory technicians (particularly Michael Freese, Claudia Stelzig, Kathrin Meissner, Esther Garrido, Irina Klimmeck, Janine Voegele, and Fausta Chiaverio) for their most valuable efforts.

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    Authors and Affiliations

    1. Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland

      Petra Hillinger, Raphael Twerenbold, Maria Rubini Gimenez, Cedric Jaeger, Jasper Boeddinghaus, Thomas Nestelberger, Karin Grimm, Tobias Reichlin, Fabio Stallone, Christian Puelacher, Zaid Sabti, Nikola Kozhuharov, Ursina Honegger, Kris Denhaerynck, Temizel Ekrem, Roland Bingisser, Stefan Osswald & Christian Mueller

    2. Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland

      Petra Hillinger, Raphael Twerenbold, Karin Wildi, Cedric Jaeger, Jasper Boeddinghaus, Thomas Nestelberger, Karin Grimm, Tobias Reichlin, Fabio Stallone, Christian Puelacher, Zaid Sabti, Nikola Kozhuharov, Ursina Honegger, Temizel Ekrem, Stefan Osswald & Christian Mueller

    3. Department of Internal Medicine, University Hospital, Basel, Switzerland

      Karin Wildi

    4. Emergency Department, Hospital del Mar, Barcelona, Spain

      Maria Rubini Gimenez

    5. Emergency Department, San Martino Hospital, Genoa, Italy

      Paola Ballarino

    6. Emergency Department, Hospital Clinic, Barcelona, Spain

      Oscar Miro

    7. Medizinische Klinik, Kantonsspital, Olten, Switzerland

      Claudia Kohler

    8. Emergency Department, University Hospital, Basel, Switzerland

      Roland Bingisser

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    1. Petra Hillinger
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    Corresponding author

    Correspondence to Christian Mueller.

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    Funding sources

    This study was supported by research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University Basel, and the University Hospital Basel.

    Conflict of interest

    Professor Mueller has received research grants from the Swiss National Science Foundation and the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, 8sense, Abbott, ALERE, Brahms, Critical Diagnostics, Nanosphere, Roche, Siemens, and the University Hospital Basel, as well as speaker honoraria from Abbott, ALERE, BG medicine, Biomerieux, Brahms, Cardiorentis, Novartis, Radiometer, Roche, and Siemens. We disclose that Dr. Reichlin has received research grants from the Swiss National Science Foundation (PASMP3-136995), the Swiss Heart Foundation, the University of Basel, the Professor Max Cloetta Foundation and the Department of Internal Medicine, University Hospital Basel as well as speakers honoraria from Brahms and Roche. Dr. Rubini has received speakers honoraria from Abbott. All other authors declare that they have no conflict of interest with this study. The sponsors had no role in the design of the study, the analysis of the data, the preparation of the manuscript, or the decision to submit the manuscript for publication.

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    P. Hillinger and R. Twerenbold have contributed equally and should be considered first author.

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    Hillinger, P., Twerenbold, R., Wildi, K. et al. Gender-specific uncertainties in the diagnosis of acute coronary syndrome. Clin Res Cardiol 106, 28–37 (2017). https://doi.org/10.1007/s00392-016-1020-y

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    • DOI: https://doi.org/10.1007/s00392-016-1020-y

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