Chest Pain in Women
Several important differences must be considered during the evaluation of women with chest pain. First, compared with men of the same age, women have an overall lower prevalence of obstructive CAD and a higher likelihood of atypical symptoms, which can lead to delayed diagnosis and increased likelihood of being discharged with missed myocardial infarction.9,101 Second, ECG criteria for detection of myocardial infarction are different in women. Minor J-point elevation in V2-V3 can be a normal variant in men and women, but a study of 1332 healthy volunteers established that the upper limit of normal in women is lower than that of men.102 Third, exercise stress testing is less accurate in women; a meta-analysis including 4113 women found that the sensitivity of exercise electrocardiography and exercise myocardial perfusion imaging for the detection of CAD was 0.61 and 0.78, respectively, compared to 0.68 and 0.85 in similar meta-analyses of studies that included a majority of men.103 Interestingly, of the clinical risk scores discussed previously, only PURSUIT includes gender in the model, but this score should not be used for ED patients with undifferentiated chest pain.
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