| BackgroundsAcute chest pain is one of the most common symptoms in the emergency department(ED).According to studies,patients with chest pains account for 4%to 6%of ED visits.The etiology of acute chest pain is complex and the risk varies greatly.The prognosis of high-risk chest pain caused by cardiac or macrovascular disease is poor,such as acute coronary syndrome(ACS),aortic dissection(AD),and acute pulmonary embolism(APE).In recent years,with the increasing prevalence of coronary artery disease(CAD)in China,cardiovascular disease has taken the first place in the proportion of disease death among Chinese residents.ACS is the severe form of coronary heart disease,including ST-segment elevation myocardial infarction(STEMI),non-ST-segment elevation myocardial infarction(NSTEMI),and unstable angina(UA).ACS has become one of the most common causes of high-risk chest pain in the world due to its high morbidity,high risk of death and disability.Sex differences in ACS have been extensively discussed over the past 30 years.Female patients with ACS are more likely to have inadequate treatment and poor prognosis.ED is the first-line for diagnosis and treatment of ACS.Emergency medicine is still developing in China,and the medical conditions of the ED vary from different levels of hospitals and region.Whether the diagnosis and treatment of patients with ACS of different sex in ED is standardized needs to be further evaluated.Although ACS accounts for a high proportion of patients with acute chest pain patients,but the population and etiology of acute chest pain are more complex.Some scholars believe that the conclusion of poor prognosis of women with ACS is mostly based on the studies of obstructive coronary artery disease.While in women,chest pain was more likely to be caused by non-obstructive coronary artery disease.Therefore,the etiological composition of chest pain in patients with different sex may be quite different.The effect of sex on the prognosis of patients with acute chest pain needs to be further explored.So,are there sex differences in the emergency management of patients with chest pain in China?What is the influence of sex on the prognosis of patients with acute chest pain?We still don't have a clear answer.Observing and studying the sex differences in patients with acute chest pain will help to clarify the clinical characteristics and the status quo of emergency management.It is of great clinical significance to improve the quality of emergency medical management for patients with acute chest pain in the ED.Therefore,this study intends to analyze the entire emergency procedures and the short-term clinical outcomes in chest pain patients of different sex,and to seek targeted improvement measures to respond to the emergency treatment needs of patients with chest pain of different sex.Methods1.Research designThis study was a retrospective analysis based on data from a multicenter cohort study.Stratified random sampling design was adopted to select representative sample of public hospitals in Shandong province with independent 24-hour emergency departments.We stratified the eligible hospitals into three strata:grade ?-rural/grade?-rural,grade ?-urban and grade ?-urban.As a coordinating center,Qilu Hospital of Shandong University did not participate in sampling but directly include in the study.One-fifteenth of the hospitals were randomly selected from each stratum.A total of 22 hospitals were randomly selected,including 4 grade ? urban hospitals,6 grade ? urban hospitals and 12 rural hospitals.At the beginning of the study,one grade ? urban hospital refused to participate.A rural hospital withdrew during the operation of the study.Hence,a total of 21 hospitals eventually joined the project.Patients with acute non-traumatic chest pain admitted to the emergency department from August 2015 to September 2017 were continuously enrolled.Ethical approval was obtained from each ethics committees before initiation of the study and all patients provided informed consent.2.Study populationPatients were included if they were(1)18 years and older,(2)presenting to the ED,(3)the symptoms were chest pain or suspected ACS,(4)symptoms begin or worsen within 24 hours and(5)signed an informed consent by themselves or next of kin.Patients were excluded if they were(1)symptoms caused by trauma,(2)systemic pain caused by chronic diseases such as rheumatic and cancer,(3)patients transferred from other hospitals and(4)presented to the ED again within 30 days after initial enrolment.According to emergency diagnosis,ACS subgroup and STEMI subgroup were established.In the analysis of influencing factors for percutaneous coronary intervention(PCI)treatment decision of STEMI patients,patients from hospitals with 24-hour PCI conditions were selected from the cohort to exclude the confounding influence of hospital conditions on patient decision making.3.Data collectionThe data were composed of prehospital and emergency information,follow-up information(information within 30 days from the date of entry).The research team developed a standardized case report form and clinical data management system for this study to record and manage the above information.In order to ensure the reliability and continuity of research data,research assistants are assigned to collect data.The emergency and hospitalization records of patients were scanned and archived without privacy.Follow-up was conducted by telephone interview.Patients were interviewed at 30 days after enrollment by research assistants in participating hospitals.4.Research contents1)Emergency evaluation in patients with acute chest pain of different sexes,prehospital delayed and in-hospital assessment.2)The management of patients with acute chest pain of different sexes,including disease screening,drug intervention in the ACS subgroup and reperfusion therapy in the STEMI subgroup,as well as analysis of factors influencing PCI decision in STEMI patients.3)Analysis of the etiological composition and 30-day follow-up of patients with acute chest pain of different sexes.5.OutcomeOutcomes were the incidence of major adverse cardiovascular events(MACE)and mortality during the 30-day follow-up period from the emergency department visit.MACE events included all-cause death,non-fatal myocardial infarction,cardiogenic shock and cardiac arrest/ventricular fibrillation.The clinical event was independently determined by two cardiologists based on all medical records,and a third expert ruled when there was a disagreement.6.Statistical analysisThe descriptive results are presented as the median(25th,75th percentile),mean±SD for continuous variables and frequency and percentage for categorical variables.Comparison between groups was made by t-test and Wilcoxon rank-sum test for continuous variables appropriately.With regard to categorical variables,?2 test or Fisher's exact test was used.Univariate Logistic regression was used to investigate the risk factors for prehospital delay in patients with acute chest pain,the risk factors for reperfusion treatment in the STEMI subgroup,and the predictors of patients rejecting medical advice for PCI.Multivariate logistic regression analysis was used to examine the sex difference of chest pain patients,variables included in the model were statistically significant variables(P<0.05)in the single factor analysis or clinically meaningful variables.The risk of MACE within 30 days in patients of different sex and age groups was investigated using unadjusted and adjusted Logistic regression analyses.Prognosis and influencing factors of different genders in patients with acute chest pain were analyzed by using stepwise corrected Logistic model.The results are expressed as the OR and 95%CI.Analyses were performed with SAS V.9.4 statistical package(SAS Institute).P<0.05 was considered statistically significant.Results1.Basic information of patients with acute chest pain of different sex1.1 Baseline featuresFrom August 2015 to September 2017,a total of 8,350 patients with acute non-traumatic chest pain who were admitted to the emergency department were included in this study.There were 4776 male patients(57.2%)and 3574 female patients(42.8%).Compared with male patients,female patients are older(67.4±12.4 years vs 61.22±13.8 years,P<0.01).Body mass index(BMI)in female patients is lower than male(24.6±3.6 vs 25.1±3.3,P<0.01).Single(including unmarried,widowed and divorced)patients(19.9%vs 7.9%,P<0.01)and unemployed(54.7%vs 50.5%,P<0.01)were more common in female patients.The education level of female patients was lower than that of male patients(26.2%vs 40.9%,P<0.01).Compared to women,men were more likely to have smoked(39.5%vs 4.6%,P<0.01),had previous coronary angiography stenosis?50%(22.6%vs 17.6%,P<0.01),had previous myocardial infarction(17.2%vs 13.0%,P<0.01),and had been treated with PCI(15.7%vs 11.1%,P<0.01).The prevalence of diabetes mellitus(25.0%vs 17.9%,P<0.01),hypertension(58.9%vs 49.5%,P<0.01)and heart failure(3.6%vs 2.5%,P<0.01)were higher in women than in men.The proportion of female patients visiting the emergency department of tertiary hospitals was higher than that of male patients(74.1%vs 70.6%,P<0.01).1.2 Symptom featuresAtypical chest pain was more common in women(P<0.01).The severity of pain was self-rated on a scale of 0-10,and the male patients with severe pain(?6 points)were more than the female patients(47.1%vs 41.7%,P<0.01).More men showed persistent symptoms(55.1%vs 46.8%,P<0.01).Among the accompanying symptoms,more females had palpitation(15.3%vs 12.7%,P<0.01)and nausea/vomiting(23.7%vs 16.3%,P<0.01)than males.The proportion of men with sweating symptoms is higher than that of women(38.1%vs 28.9%,P<0.01).Chest pain symptoms in women were more likely to be induced by fatigue/exercise(19.1%vs 16.0%,P<0.01)or mood/stress(8%vs 4.9%,P<0.01)than in men,and were more likely to be relieved by rest(13.6%vs 11.9%,P=0.02)or by taking nitroglycerin/SuxiaoJiuxin pills(31.1%vs 23.3%,P<0.01).2.Prehospital evaluation of gender-specific patients with acute chest pain2.1 Pre-hospital informationMost cases of chest pain occurred at home,with a higher proportion in women(92.8%vs 88.3%,P<0.01).The proportion of self-medication in female patients was higher than that in male patients(41.4%vs 33.2%,P<0.01).The percentage of people using 120 emergency services was very low in both male and female patients.Delays in emergency department visits are worse in women than in men(P<0.01).More women than men had a prehospital delay of more than 12 hours(28.0%vs 19.7%).2.2 Prehospital delay in men and women with chest painRegardless of male or female,those with older ages suffer longer prehospital delays.At all ages,women had longer prehospital delays than men(P<0.01).Marital status had no significant effect on prehospital delay in female patients,but single men had longer prehospital delay than married men(P<0.01).Employment or not had no significant effect on the delay time of male patients,while the delay time of unemployed women was longer than that of professional women(P<0.01).Regardless of gender,those with higher education level had shorter pre-hospital delay time(P<0.01).Female patients with a history of myocardial infarction had a shorter prehospital delay(P<0.01).In contrast,men with a history of heart attack had a longer prehospital delay(P<0.01).Both men and women with a history of PCI or with?50%stenosis on previous coronary angiography had longer prehospital delays(P<0.01).The prehospital delay time was significantly longer in both men and women with a history of heart failure(P<0.01).Both male and female patients with home onset showed a longer prehospital delay than those with onset in public places(P<0.01).The prehospital delay time of daytime onset was shorter than that of nocturnal onset in female patients(P<0.01),but there was no significant difference in male patients.Both the female and male groups showed a shorter prehospital delay in patients who visited the ED at night(P<0.01).In both men and women,patients with more severe chest pain(self-score?6),persistent onset of symptoms,and with concomitant symptoms of nausea or sweating had shorter prehospital delays(P<0.01).ED visits are timelier in both male and female patients who self-medicate after the onset of the disease(P<0.01).2.3 Factors influencing prehospital delay in patients with acute chest painWomen are an independent risk factor for delayed prehospital care in patients with acute chest pain(OR 1.17,95%CI 1.03-1.31).Age was a risk factor for delayed prehospital exacerbation for both women(OR 1.01,95%CI 1.00-1.02)and men(OR 1.01,95%Cl 1.01-1.02).Symptoms associated with nausea/vomiting reduced prehospital delay in women with chest pain(P=0.01).Smoking was associated with a shorter prehospital delay in male patients(P=0.02).Married,employed,sweating,and persistent episodes of symptoms were associated with shorter prehospital delays in both men and women(P<0.05).A history of heart failure and symptoms were relieved by rest was associated with an increased prehospital delay in women(P<0.05).Men with home onset have a longer prehospital delay(P<0.05).3.Emergency assessment and triage of patients with acute chest pain3.1 Emergency assessmentAlthough both groups had a higher rate of nocturnal onset,fewer women visited the ED at night than men(59.9%vs 62.5%,P=0.02).The systolic blood pressure(148±29mmHg vs 141±28mmHg,P<0.01)and heart rate(81±19 beats/min vs 79±20 beats/min,P<0.01)of female patients with chest pain were higher than those of male patients.The incidence of lung rales(5.8%vs 4.5%,P<0.01)and lower limb edema(6.5%vs 3.4%,P<0.01)was higher in women than in men.Among all patients,73.2%of them completed electrocardiograph(ECG)examinations within 10 minutes,with a lower proportion of women than men(74.8%vs 79.8%,P<0.01).Only 58.1%of patients with chest pain were examined for myocardial markers,and 0.29%of patients were examined with coronary computed tomography angiography(CTA)at the ED.There were no significant differences between men and women.3.2 Triage after emergency assessmentPatients with chest pain stayed in the ED longer in women than in men[1.6(0.5,9.9)h vs 1.2(0.5,6.2)h,P<0.01].The rate of discharge within 12 hours was lower in both groups.The rate of discharge within 12 hours was lower in both groups.4.Emergency treatment of the etiological subgroup of patients with acute chest pain4.1 Emergency treatment of ACS subgroup patients In patients who diagnosed with ACS by an emergency physician,the proportion of drug use recommended by guidelines was low in both groups.Compared with men,women were less likely to take antiplatelet drugs(35.3%vs 43.8%,P<0.01),statins(17.3%vs 21.9%,P<0.01)and low molecular heparin(12.4%vs 14.8%,P<0.01).Nitrate drug use rate was higher in women(44.8%vs 42.0%,P=0.02).In patients diagnosed with STEMI by an emergency physician,there were very few cases of thrombolysis and emergency coronary artery bypass grafting(CABG),and the rate of emergency PCI was less than 60%.Women were less likely than men to receive emergency treatment for PCI(42.8%vs 56.4%,P<0.01).4.2 Influencing factors of reperfusion therapy in patients with STEMI of the ED For STEMI patients,sex had no significant effect on reperfusion therapy.A faster heart rate,and longer pre-hospital delay were factors that prevented reperfusion therapy in female patients(P<0.05).Women admitted to tertiary hospitals were more likely to receive reperfusion therapy(P<0.05).Age older than 65 years,history of myocardial infarction,heart rate and prehospital delay were risk factors for reperfusion therapy in male patients(P<0.05).While,a higher BMI,history of PCI,persistent symptoms,and visits to tertiary hospitals were the influencing factors for promoting reperfusion therapy in male patients(P<0.05).4.3 Factors influencing PCI treatment decision in STEMI patientsIn order to avoid the influence of hospital conditions on PCI treatment decision of STEMI patients,we selected patients from 6 sub-centers with 24 hours PCI condition to further analyze the influencing factors of STEMI patients' rejection of doctor's recommendation for PCI treatment.The analysis showed that sex was not an influencing factor in STEMI patients rejecting PCI recommendations.Age was not a factor in refusal of PCI in women with STEMI,but age older than 65 years was a risk factor for refusal of PCI in men(P<0.01).For both men and women,married status was a protective factor for receiving the recommendations for PCI,while prehospital delay was a risk factor for refusal of PCI(P<0.05).In addition,BMI and visit to tertiary hospitals were protective factors for receiving PCI in female patients,while history of MI and heart rate were risk factors for refusing PCI(P<0.05).5.Sex difference of disease composition in patients with acute chest painA higher proportion of men than women had a final diagnosis of ACS(66.2%vs 54.7%).The proportion of STEMI(26.9%vs 13.7%)and NSTEMI(13.5%vs 11.1%)was higher in men than that of women,while the proportion of UA was lower than that of women.The difference was statistically significant(P<0.05).We find the adjusted risk of MACE was significantly higher in men younger than 75 years of age than in women.To further analyze the disease composition of patients with chest pain by age,the proportion of acute myocardial infarction(AMI)in men younger than 75 years was significantly higher than that in women(P<0.01),and the difference between the proportion of STEMI(27.8%vs 12.0%)and NSTEMI(13.0%vs 9.5%)in male and female patients was further increased.The proportion of AMI was similar in men and women over 75 years of age with chest pain.6.Influence of sex on short-term outcomes in patients with acute chest painDuring the 30-day follow-up,the incidence of MACE was higher in men than in women(6.9%vs 5.3%,P<0.01),and mortality rates were similar between the two groups.After adjusting for differences in history,cardiovascular risk factors,heart rate,and blood pressure,there was a significant sex-age interaction for 30-day MACE risk in patients with acute chest pain(P<0.05).The 30-day MACE risk was higher in men?54 years of age(P=0.02)and 55 to 74 years of age(P=0.02)than in women,while there was no significant difference in patients?75 years of age(P=0.09).Logistic regression model was used to further analyze the influence of sex on the short-term prognosis of patients with chest pain.After adjustment for age,men had a higher risk of MACE(OR 0.60,95%CI 0.50-0.73,P<0.01)and death(OR 0.71,95%CI 0.56-0.90,P<0.01).After further adjustment for history,cardiovascular risk factors,and prehospital delay,sex differences in MACE and mortality risk remained(P<0.05).After continued adjustment for heart rate and blood pressure,the risk of MACE remained higher in men than in women(P<0.05),and there was no sex difference in the risk of death.After further adjusted of the ruling diagnosis,the sex difference in MACE risk was no longer observed among patients with chest pain.ConclusionsSex-age have an interactive effect on the short-term prognosis of patients with acute chest pain.The prognosis of men with chest pain who under 75 years old is worse than women.The poor prognosis in men is associated with a higher proportion of AMI.The risk of a poor prognosis in women is mainly due to their older age.Emergency physicians should be alert to the higher risk of AMI about male patients and give them more attention and more aggressive treatment.Chest pain assessment and ACS management were severely inadequate in the ED for patients of different sex,with women worse off than men.In the future,emphasis should be placed on strengthening the assessment of chest pain and the implementation of recommended treatment for emergency physicians,while avoiding sex bias.Pre-hospital delay in ED is more serious in female patients.The delay is a negative factor affecting decision making and treatment for both male and female.The publicity and education on acute chest pain should be further strengthened,and the health awareness and enthusiasm of patients should be improved. |
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