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Factors associated with erroneous emergency department noncardiac chest pain classifications in men and women
Òscar Miró1, Gemma Martínez-Nadal1, Ana García1
1Área de Urgencias, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
Insights
Initial noncardiac chest pain (NCP) classifications are erroneous in 0.8-0.9% of cases. Women have more associated clinical factors for erroneous NCP classification, suggesting a need for different acute coronary syndrome assessment in women.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Assessment
Background:
- Noncardiac chest pain (NCP) is a common emergency department presentation.
- Accurate initial classification of chest pain is crucial for timely diagnosis and treatment.
- Misclassification of NCP can delay the diagnosis of acute coronary syndrome (ACS).
Purpose of the Study:
- To determine the frequency of erroneous initial NCP classifications.
- To identify clinical characteristics associated with misclassified NCP in men and women.
- To explore sex-specific risk factors for erroneous NCP classification.
Main Methods:
- Retrospective analysis of 18,072 emergency department case records (2008-2017).
- Initial NCP classification defined as erroneous if final diagnosis was ACS.
- Multivariable analysis used to identify risk factors for erroneous classification, with separate analyses for men and women.
Main Results:
- Erroneous NCP classification occurred in 0.9% of women (72/8093) and 0.8% of men (83/9979).
- In women, obesity, cocaine use, recent exertion, radiation exposure, and vegetative symptoms were associated with erroneous NCP classification.
- In men, age over 40 and hypertension were associated with erroneous NCP classification; no clinical signs were significant.
Conclusions:
- Clinical characteristics associated with erroneous NCP classification differ between men and women.
- The findings highlight the need for distinct assessment strategies for potential ACS in women, given their atypical presentations.
- Improved risk stratification for NCP is essential to reduce misdiagnosis of ACS.
Objectives:
To analyze the frequency and clinical characteristics associated with erroneous initial classifications of noncardiac chest pain (NCP) in men and women.
Material And Methods:
We analyzed all case records in which chest pain was initially classified as noncardiac in origin according to clinical signs and electrocardiograms evaluated in our emergency department between 2008 and 2017. We considered the initial evaluation of NCP to be in error if the final diagnosis was acute coronary syndrome. A risk model for an erroneous initial classification of NCP was developed based on multivariable analysis of our patient data. We also used multivariable analysis to explore associations between 10 clinical signs of chest pain and an erroneous initial NCP classification. The data for men and women were analyzed separately.
Results:
NCP was the initial classification for 8093 women; their median (interquartile range) age was 54 (38-73) years. The classification was in error for 72 women (0.9%). Odds ratios (ORs) showed that patient risk factors associated with an erroneous NCP classification in the women in our series were obesity (OR, 0.40; 95% CI, 0.17- 0.97) and cocaine consumption (OR, 5.18; 95% CI, 1.16-23.2). Clinical risk factors associated with erroneous NCP classification in women were recent physical exertion (OR, 2.01; 95% CI, 1.21-3.33), radiation exposure (OR, 2.05; 95% CI, 1.23-3.41), and vegetative symptoms (OR, 1.86; 95% CI, 1.02-3.41). For 9979 men with a median age of 47 (33-64) years, NCP was the initial classification; in 83 of the men (0.8%) the classification was erroneous. Patient factors associated with erroneous NCP classification in men were age over 40 years (OR, 1.74; 95% CI, 1.04-2.91) and hypertension (OR, 0.45; 95% CI, 0.24-0.84). No clinical signs of chest pain in men were associated with error.
Conclusion:
More clinical characteristics are associated with an erroneous classification of NCP in women. Our findings underline the need to assess the possibility of acute coronary syndrome differently in women, in whom the signs have usually been considered to be atypical.
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