Transcript Document

Bethlehem University & Care
International
Emergency Care
Conference
Access for All
18+19/1/2005
Chest Pain Among Women
Underestimation??
Presented by:
Etaf Maqboul, RN, MSN
Bethlehem University
Objectives
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Recognize certain facts related to chest pain among
women.
Get some local and international statistics.
Understand the gender gap in relation to chest pain.
Identify the role of estrogen in protection against heart
disease.
Adopt certain strategies that prevent underestimation
of chest pain among women.
Chest Pain:
Is an extremely common symptom in both
men and women.
several previous studies have suggested
that in women this complaint is more
frequently under-diagnosed than in men.
Facts
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Women account for nearly half of all heart attack
deaths.
Heart disease is the number one killer of both women
and men.
Heart disease is the first killer of women (more than all
cancers combined).
Women tend to be about 10 years older than men
when they have heart attack.
Women are more likely to have DM, HTN and CHF.
Facts
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women have been shown to respond better than men
to life style changes, such as smoking cessation,
weight control and exercise.
Over 60% of women believe their biggest health threat
is breast cancer but heart disease kills 6 times as many
women as breast cancer.
Women are almost twice as likely as men to die from
heart attack because they tend to be older and in
poorer health and their symptoms are less obvious.
Facts
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Some risk factors are different for women than
for men. e.g menopause.
Between ages 40 and 49, men are seven times
more likely to develop CAD than women of the
same age. After menopause, by age 65,
women are just as likely as men to have heart
attacks.
Facts
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Women are more likely to die of a first MI.
Women have more co morbidity (because they are
usually older on presentation )
Studies
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Most medical research has been performed on men
(for a variety of reasons), assuming that the results
would apply equally to women. Unfortunately, this has
not always been true. The studies on women and heart
disease have produced disturbing facts .
One in nine women(aged 45-64) have some form of
cardiovascular disease. After age 65 the odds climb to
one in three
Studies
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in USA : yearly:26,000 (ED) patients with acute cardiac ischemia are
mistakenly not hospitalized: 12,000 with heart attacks and 14,000 with
unstable angina.
Failure to hospitalize patients with acute cardiac ischemia was more
likely if:
The patient was non-white (2.2 times more than white).
a woman under age 55 (6.7 times more likely).
Had a primary symptom of shortness of breath rather than chest pain (2.7
times more likely), or had a normal or a non-diagnostic
electrocardiogram (EKG)(3.3 times more).
Studies
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2003 survey indicates only 38% of women have discussed
heart health with their health care provider.
One year death rate for men following heart attack is 25%,
for women 38%.
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In Italy: October/2002
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747 women with chest pain came to ER:
446(60%) were discharged, 2 (0.2%) died, 298 (40%)were
hospitalized:
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Studies
*336(45%): Typical chest pain
*60(6.7):AMI
*42(5.6%): Atrial fibrillation
* 60(10.6%): Typical Angina
* 3 (0.4%)Aortic dissection
During Follow up (6 months) cardiac events occurred in 7.6% of 446
women discharged from the ER.
In this study: DX tests are underutilized in women with chest pain:
16%:Stress test
56% :Echocardiography, 11% Catheterization.
In Palestine
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Very Limited research:
Al- Ahli Hospital/Hebron (2004):
CCU Admission:285:177 (62%) males and 108
(38%)females.
198 Echocardiography: 120 (61%) males and 78 (39%)
females.
48 cases received streptokinase: 46 (96%)males and 2 (4%)
females.
Studies
In Makassed hospital/Jerusalem (2004)
 Cardiac Catheterization :447 cases
* 137 (31%) females
CCU Admission
2003 :860, females 325 (38%)
2004:750, females 262 (35%)
Note: Cath. Lab was closed for 3 months in 2004.
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Why The Gender Gap?
Women present to ER with chest pain 1-2 hours later than
men. This may be due to:
*Women play multiple roles which takes on delay because of
her responsibilities to others (nurturer and caregiver).
*Women might perceive that heart disease is something that
happens to her father, brother, spouse.
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Why The Gender Gap?
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The community has viewed women’s health almost
looking essentially at her reproductive system and
breasts, while ignoring the rest of the women as part of
her health.
Women tend to take their symptoms less seriously.
Women and health professionals often do not
recognize the warning signs until it’s too late.
Estrogen and Heart Disease
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After menopause, the production of estrogen by the ovaries
gradually diminishes over several years. Along with this
reduction, there is an increase in LDL (“bad” cholesterol)
and a small decrease in HDL (“good” cholesterol). These
changes in lipid levels are believed to be one of the reasons
for the increased risks of developing CAD after menopause.
Women who have had their ovaries surgically removed
(oophorectomy) or experience an early menopause also
have an accelerated risk of CAD.
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Estrogen maintains normal blood vessel responses to
stress, even in the face of blood vessel damage &
reduces inflammatory changes in blood vessel lesions.
– Diabetes triples a woman’s risk for heart disease
and puts younger women at special risk because
type II diabetes can negate the positive affect that
estrogen normally has on the heart, Smoking also
can undo the protective benefits of estrogen.
Do Men and women have the same
S&S of a heart attack?
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Most men experience chest pain, discomfort and tightness,
however women experience chest pain and most women say the
experience feels more like a bad case of indigestion and
heartburn, and SOB. N&V and back or jaw and shoulder pain.
Women have a significantly higher number of silent episodes of
angina and even silent heart attacks.
Stress tests are inaccurate and show false positive in about 40%
of premenopausal women and up to 60% of postmenopausal
women tested, that may lead to unnecessary angiograms.
Recommendations
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Health Professionals should Consider risk factors
when evaluating chest pain syndromes in women
and not just the presence of typical chest pain.
Recognition of symptoms by both women and
healthcare providers which may not be dramatic or
sudden.
Healthcare provider education on avoiding
stereotypes.
Recommendations
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To identify earlier recognition of chest pain among
women such as determination of institutional and
individual missed-diagnosis rates
To have Palestinian research about chest pain among
women as well among men.
Summary
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Cardiovascular disease is under recognized, underdiagnosed and under-treated by women patients and
by some physicians.
Women have their unique risk factors.
Women should be more taught about chest pain and
early recognition of heart attack.
Health care providers should maximize the diagnostic
and treatment modalities for women with chest pain as
required.
References
Auerbach, I., Chouraqui, P., Motro, M., Douglas, P. S., Ginsburg, G. S. (1996). Chest Pain in Women. N Engl
J Med 335: 820-821.
Barrett-Connor, E., Giardina, E. -G. V., Gitt, A. K., Gudat, U., Steinberg, H. O., Tschoepe, D. (2004). Women
and Heart Disease: The Role of Diabetes and Hyperglycemia. Arch Intern Med 164: 934-942.
Boccardi L, Verde M. (2003). Gender differences in the clinical presentation to the emergency department
for chest pain. Italian Heart Journal; 4: 371-373.
Diercks, D. B., Hollander, J. E., Sites, F., Kirk, J. D. (2004). Derivation and Validation of a Risk Stratification
Model to Identify Coronary Artery Disease in Women Who Present to the Emergency Department with
Potential Acute Coronary Syndromes. Acad Emerg Med 11: 630-634.
Thank
You
Questions??