Women with heart disease may be overlooked in EDs

Study: They're at risk even if no blockage is visible

If women present to ED nurses with chest pain but no evidence of clogged arteries, they may be told it's heartburn and sent home — but many are at high risk for serious cardiac complications or death, according to new research.1

Researchers studied 564 women with chest pain who underwent coronary angiography and were found to have no visible obstructive coronary artery disease. They compared them with 1,000 women free of documented heart disease. The women with chest pain were four times as likely to develop serious cardiac complications or die within a five-year period. "The message here is, you do not want to tell a woman who comes to you and says, 'I have chest pain,' not to worry," says Rhonda Cooper-DeHoff, PharmD, the study's author and research assistant professor at the University of Florida in Gainesville.

Patients with chest pain but no visible blockage may have coronary microvascular syndrome, in which smaller arteries become glazed with plague. Symptoms may be triggered, but the condition is not detectable using standard coronary angiography. "Typically, when men present with chest pain and signs and symptoms of cardiovascular disease and we take them to the cardiac catheterization lab, they end up having some sort of obstruction in a major cardiac vessel," Cooper-DeHoff says. However, in women with similar signs and symptoms of ischemic disease, most do not have obstruction, she explains.

"Women who don't present with typical symptoms may get triaged the wrong way," says Cooper-DeHoff. "You need to be sure these women get a thorough cardiac work-up, which should include being evaluated by a cardiologist."

Even if only minor plaque is detected by cardiac catheterization, women should be referred to a cardiologist for aggressive management of their cardiac risk factors. The disease process they have does not go away even though the symptoms may resolve, Cooper-DeHoff says. "Days, months, or a year down the road, these symptoms will present again," she says.

Refer these patients to a cardiologist, because aggressive management of risk factors can prevent or delay future significant cardiovascular events, says Cooper-DeHoff. "These women should not be sent home and told the pain is in their head," she says. "We should not be discounting symptoms that women present with and tell them, 'Go home take an antacid and you'll be fine.'"

Speed care with protocol

At Shands at the University of Florida in Gainesville, anyone who presents to the ED with chest pain is brought right back to a room from the triage area, placed on a monitor, and started on the chest pain protocol, says Coleen G. Booker, RN, an ED nurse at the hospital. The protocol includes an electrocardiogram (ECG), intravenous placement with blood draw for cardiac enzymes that are sent to the lab and tested at the bedside, medications including nitroglycerin and aspirin if not contraindicated, and a physician called to the bedside to evaluate the patient.

ED nurses ask the following questions: What is the location of the pain? What is the nature of the pain (dull, sharp, heaviness)? How long has it been present? How long does it last? Is it constant or intermittent? What makes it start or stop, if anything? Is it associated with dizziness, shortness of breath, diaphoresis, nausea, vomiting, or any other concerning symptoms?

The patient does not always have to have chest pain in order to be placed on the chest pain protocol, says Booker. "Anyone who is the least bit concerning for a cardiac event may be placed on the protocol once the physician sees the patient," she says. "These patients are also brought right to a room from the triage area." This includes patients with unexplained syncope or shortness of breath or symptoms of congestive heart failure.

The protocol has caught several patients with vague symptoms who might have otherwise been overlooked, says Booker. When a man came to the ED complaining of scapular pain, with no other symptoms and no cardiac history, he was sent home for treatment for muscle strain. He returned a few days later. "The pain was no better and upon further history, the patient admitted that he also had left arm pain," says Booker. "The physician got an ECG, and the diagnosis of myocardial infarction was made."

Similarly, when a registration clerk felt weak and dizzy with slight chest tightness while working in the ED, she was sent for a dobutamine stress test, which came back positive. "She went for a cardiac cath, which found blockages, and she underwent an emergent bypass," says Booker.


  1. Cooper-DeHoff RM, McClure CK, Johnson B, et al. Adverse cardiovascular outcomes in women with no obstructive coronary artery disease: A report from the WTH project. Circulation 2006; 114:1991.


For more information on female ED patients with chest pain, contact:

  • Coleen G. Booker, RN, Emergency Department, Shands at the University of Florida, 1600 S.W. Archer Road, Gainesville, FL 32608. Phone: (352) 265-0990. Fax: (352) 265-0991. E-mail: bookec@shands.ufl.edu.
  • Rhonda Cooper-DeHoff, PharmD, Associate Director, Clinical Research Program, University of Florida, Division of Cardiovascular Medicine, P.O. Box 100277, Gainesville, FL 32610-0277. Phone: (352) 392-6388. Fax: (352) 371-0370. E-mail: dehofrm@medicine.ufl.edu.