Heart attack! Don’t delay ED care for women

(Editor’s note: This is the second article in a two-part series on chest pain in the ED. Last month, we gave strategies to speed door-to-needle time. This month, we cover treatment delays due to atypical presentation.)

Would you ever believe that women could be waiting longer than men to receive life-saving treatment in your ED? Researchers looked at records of 1,551 heart attack patients who had emergency angioplasty and found that women on average waited more than 118 minutes for treatment, compared with 105 minutes for men.1

"We need to do a better job in making sure that both men and women recognize and react to heart attack symptoms as quickly as possible, and that our emergency medical professionals work to ensure immediate diagnosis and treatment," says Mauro Moscucci, MD, the study’s lead author and director of interventional cardiology at the University of Michigan Cardiovascular Center in Ann Arbor. "These delays result in worse outcomes, and there should be no gap between the genders."

The study found that only 25% of female patients underwent emergency angioplasty within the recommended 90 minutes, as compared with 34% of male patients.

A delay in diagnosis or treatment leading to worse outcomes poses potential liability risks, Moscucci warns. Take these steps to reduce treatment delays for female heart attack patients:

  • Watch for atypical symptoms.

The gender gap identified by the study could be partly because women tend to have less of the "typical" symptoms of heart attack, such as crushing chest pain and left arm pain, says Moscucci.

"Remember that females do not always present with the classic signs and symptoms of an MI [myocardial infarction]," says Kimberly Henson, RN, a nurse in the emergency center chest pain unit at Spartanburg (SC) Regional Healthcare System. "Women are more difficult to diagnose but are becoming more and more common."

Any patient who complains of pain in the left arm, jaw, chest, or abdomen, if diabetic, could be having an MI, underscores Lori Pelham, RN, clinical nursing supervisor at University of Michigan’s ED in Ann Arbor.

"At triage, the patient’s chief compliant may not necessarily be chest pain, but if their symptoms are significant enough in combination with their chief compliant, they are sent directly to the treatment areas and care is started," says Pelham. If atypical symptoms are overlooked, there will be a delay in door-to-needle or whatever intervention is needed, she adds.

Suspect MI whenever women present with symptoms of fatigue, nausea, heartburn, or shortness of breath, says Moscucci. "The first step toward making a timely diagnosis of acute myocardial infarction is to consider the possibility of such diagnosis," he emphasizes. Among other steps, your initial approach should include a prompt electrocardiogram with appropriate interpretation, he adds.

Educate nursing staff on typical clinical presentation of MI, but also on atypical presentation, says Moscucci. "The educational program should focus on the time is muscle’ concept and the need to avoid any delay," he says.

  • Educate women about atypical symptoms.

"As patient advocates, ED nurses need to teach families and staff the different signs and symptoms of a possible MI," says Henson.

Women with heart attack or cardiac ischemia may delay coming to the ED because their symptoms are not typical, says Pelham. In the study, the women’s symptoms started on average 105 minutes before they got to the ED, compared with only 85 minutes for the men.

The symptoms may be vague to the women, Pelham says. They rationalize it is not chest pain and delay in presenting to the ED, she says. "It’s just like with stroke," Pelham says. "We need to make people understand that we only have a small window of time when we can help them without damage occurring."

Patients need to know the full range of symptoms that could mean a heart attack, emphasized Pelham. "And when they do come to the ED and it’s not a heart attack, we should remind them that it’s better to be safe than sorry," she says.

  • Activate the cardiac catheterization lab faster.

To reduce delays, Moscucci recommends that electrocardiograms be read or transmitted during patient transport, and that ED physicians, not just cardiologists, are allowed to activate the cardiac catheterization lab when patients present with acute ST-segment elevation MI.

"Faster activation of the cath lab would result in shorter door-to-balloon time for both women and men," he says.


1. Moscucci M, Smith DE, Jani S, et al. American Heart Association Scientific Sessions Abstract Oral Presentation Session 98.1, Abstract 3692. New Orleans; Nov. 9, 2004.


For more information about heart attack treatment delays, contact:

  • Kimberly Henson, RN, Emergency Center, Chest Pain Unit, Spartanburg Regional Healthcare System, 101 E. Wood St., Spartanburg, SC 29303. E-mail: khhenson@srhs.com.
  • Mauro Moscucci, MD, Associate Professor of Medicine, Director, Cardiac Catheterization Laboratory, Taubman Center B1 226, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0311. Telephone: (734) 615-3878. Fax: (734) 764-4142. E-mail: moscucci@umich.edu.
  • Lori Pelham, RN, Clinical Nursing Supervisor, Emergency Department, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Telephone: (734) 647-7565. E-mail: lpelham@med.umich.edu.