Atypical MI symptoms in women mean delays

EDs must raise staff awareness to reduce disparity

A recent study by a University of Michigan cardiologist on behalf of a Michigan-wide angioplasty research group produced a sobering statistic: Of 1,551 heart attack patients who had emergency angioplasty at hospitals in Michigan, women waited on average more than 118 minutes before treatment began, compared with 105 minutes for men. Even after correcting for the fact that the women in the study had more co-existing health problems, they still found that women were slightly more likely to die before returning home.1

Another University of Michigan study conducted nearly simultaneously revealed some possible causes for these delays that will ring true to many ED managers: Women with acute myocardial infarction (AMI) often present with atypical symptoms; and there is an underlying biased assumption, even among female nurses, that men are more likely to suffer heart attacks than women.2 "[Triage] nurses do understand the different ways in which patients present, but they still tell me the first thing they think with women is gallbladder or anxiety; with men, they think heart attack," says Cynthia Arslanian-Engoren, PhD, RN, CNS, University of Michigan School of Nursing in Ann Arbor, and author of the second study. Often, these nurses have practiced in the ED for 15 to 20 years, she says.

Women are less likely to have an EKG seen and read in less than 10 minutes, Arslanian-Engoren says. Nurses also are less likely to consider the possibility of a cardiac problem in younger women, she adds.

Abdominal pain is a most common presenting symptom in women with AMI, says Jennifer Gegenheimer-Holmes, RN, BSN, MHSA, director of operations for the ED at the University of Michigan Hospitals and Health Centers in Ann Arbor, who aided Arslanian-Engoren with data collection for her study.

"Triage nurses may not recognize this and give the patient a lower acuity level, and they may wait an hour or two to be seen by a physician," Gegenheimer-Holmes explains. "It often turns out in the course of evaluation that, in fact, the abdominal pain was probably chest pain, and the EKG shows a cardiac event or angina."

University of Michigan cardiologist Mauro Moscucci, MD, who directs interventional cardiology at the University of Michigan Cardiovascular Center and who was lead author of the first study, concurs. "I believe [the reason for longer door-to-balloon times for women] predominantly is the atypical symptoms — and we tend to be less suspicious with woman than men; we believe they are at lower risk," he says.

One of the keys to reducing door-to-balloon times is to reinforce staff awareness of the different symptoms with which women may present, says Ron Dobson, MD, director of emergency services at Swedish Medical Center in Seattle.

"The challenge for us in emergency medicine is to make it widely known — not only at the physician level, but in nursing and triage protocols — this widened range of presenting symptoms for women," he says. "We have to lower our threshold for suspecting heart attacks."

That range of symptoms, he continues, is outlined in a study in Circulation in 2003 that looked at women who presented with AMI. (For information on the study, see resources, below.) The symptoms include fatigue, sleep disturbance, indigestion — even just vague anxiety.

"These are not things that make MI pop into mind," Dobson observes. "It’s not even incorporated into triage protocols, so when a female shows up saying, I’ve been really fatigued of late,’ it does not trigger the same awareness as, I have chest pain.’"

Dobson is working to educate his staff to suspect MI under those conditions, "and to get those patients back at least for an immediate electrocardiogram (EKG)." He’s doing this education through inservices, one-on-one meetings and, periodic presentations at his monthly ED meetings.

This is a good avenue for a clinical nurse specialist to update the staff and remind them to adhere to national guidelines put out by the American Heart Association and the American College of Cardiology, adds Arslanian-Engoren. (For information on how to access these guidelines, see the resources, below.)

Be familiar with those atypical symptoms, and set up a process, Moscucci advises. "Sometimes, there are time delays in obtaining EKGs, or sometimes they are obtained on a routine basis, but not immediately assessed or checked," he says.

Moscucci currently is working with the hospitals that participated in his study to improve door-to-balloon times — in men as well as in women. "The current American College of Cardiac Surgeons’ gold standard is 90 minutes, and that was reached in only 35% to 38% of patients for all genders," he says.

For several years, Gegenheimer-Holmes has been covering this topic with triage nurses as part of continuous quality improvement.

"We’ve dealt with it in case review and regularly at staff meeting reviews," she says. Now she is developing a formal educational program for nurses.


1. Moscucci M, Smith DE, Jani S, et al. Gender differences in time to treatment for patients undergoing primary percutaneous coronary intervention for acute ST segment elevation MI: An important target for quality improvement. Presented at the American Heart Association Scientific Sessions. Dallas; November 2004.

2. Arsianian-Engoren C. Do emergency nurses’ triage decisions predict differences in admission or discharge diagnoses for acute coronary syndromes? J Cardiovasc Nurs 2004; 1:280-286.


For more information about women and acute myocardial infarction (AMI), contact:

  • Cynthia Arslanian-Engoren, PhD, RN, CNS, University of Michigan School of Nursing, 400 N. Ingalls Building, Room 2175, Ann Arbor, MI 48109-0477. Phone: (734) 647-0182. E-mail:
  • Ron Dobson, MD, Director, Emergency Services, Swedish Medical Center, Seattle. Phone: (206) 386-6069. E-mail:
  • Jennifer Gegenheimer-Holmes, RN, BSN, MHSA, Director of Operations, ED, University of Michigan Hospitals and Health Centers, UH B1C202 Box 0014, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0014. Phone: (734) 647-7590. E-mail:
  • Mauro Moscucci, MD, Director of Interventional Cardiology, University of Michigan Cardiovascular Center, 8B02 300 North Ingalls Building, Ann Arbor, MI 48109-0477. Phone: (734) 615-3878. E-mail:

For more information on atypical AMI symptoms in women, see:

  • McSweeney JC, Cody M, O’Sullivan P, et al. Women’s early warning symptoms of acute myocardial infarction. Circulation 2003; 108:2,619-2,623.

For more information on national guidelines for triaging possible AMI patients, contact:

  • American Heart Association. Web: On the left-hand side of the page, click "Science & Professional." Next, click "Get with the Guidelines." Scroll down to "Current Program Modules: Coronary Artery Disease," then click on "GWTG-CAD."
  • American College of Cardiology. Web: On the left-hand side of the page, click "Guidelines Applied in Practice." Then, click the "ACC/AHA practice guidelines" link. Under "Search the A-Z Guide, by topic or" click on "Search for Clinical Practice Guidelines," then scroll down to "Percutaneous Coronary Intervention."