Gender-specific uncertainties in the diagnosis of acute coronary syndrome
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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.
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.
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).
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.
KeywordsGender Diagnostic uncertainty Acute coronary syndrome Delayed diagnosis
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.
Compliance with ethical standards
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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