The Weekly Cheese, a short informative literature review for the EM Doc
Title: Mehilli J, Presbitero P. Coronary artery disease and acute coronary syndrome in women. Heart 2020;106:487-492.
http://dx.doi.org/10.1136/heartjnl-2019-315555
What: Short well-written 5 page review on ACS in women. Traditionally, we’re taught about “classic” cardiac presentations and pathologies that are more specific to male patients. This article succinctly covers some big differences in both pathophysiology and outcomes.
Why: it’s 2020 and we shouldn’t discount the thought of ACS in both young and older women. Women are significantly more likely to present with “atypical” symptoms of ACS, including weakness, breathlessness, and malaise, as opposed to “typical” anginal chest pain. The article highlights evidence demonstrating a sex-related gap in terms of door-to-balloon time and rate of PCI, particularly among younger women with ACS. The reasons for this difference in outcomes and therapy may be partly related to provider and traditional expectations of ACS presentations in conjunction with other systemic factors.
Furthermore, women are significantly more likely to experience myocardial infarction in the absence of obstructive coronary arteries (MINOCA), making the diagnosis more challenging to diagnose and treat under the existing paradigms of ACS. Spontaneous coronary artery dissections (SCAD), a rare cause of ACS in which women may comprise 90% of cases, is another important variant of acute MI that may not demonstrate overt pathology on angiography. ACS in pregnancy, while rare, is also a very real possibility that includes both SCAD and obstructive coronary lesions. It is critical to consider this consider this diagnosis for the pregnant patient presenting with chest pain, even if they are young and otherwise healthy.
To quote the article, “compared with men, women with ACS have additional female sex-specific risk factors, present much more frequently with non-atherosclerotic involvement of coronary arteries, and undergo less frequently use of evidence-based and guideline-recommended diagnostic and revascularization pathways”. Therefore in emergency medicine, we should be mindful of these differences and aim to expand our understanding of ACS beyond the “typical” presentations.
Further reading: Dr. Stephen Smith’s ECG Blog has an excellent array of ECG cases of young women presenting with ACS: https://hqmeded-ecg.blogspot.com/search/label/Young%20Women
Written by Dr. Jorge Aceves, Chief Resident, MD