In patients with suspected acute coronary syndromes (ACS), females are significantly less likely to undergo investigations, receive evidence-based treatments, and consistently have worse outcomes than males.
Sex differences in symptom presentation and in the diagnostic threshold for cardiac biomarkers have been suggested as reasons for the under-diagnosis and under-treatment of women. Cardiac troponin (cTn) T and I are proteins specific to the myocardium, which with elevated and changing concentrations detected in the blood, along with signs or symptoms consistent with myocardial ischemia, are indicative of a diagnosis of myocardial infarction (MI). With the introduction of high-sensitivity (hs) cTn tests, which allow the detection of very low concentrations of troponin, it has become evident that the level of cTn in a healthy population is approximately two-fold higher in males than in females. Consequently, the 99th percentile cut-point for cTn, the reference value used in diagnosis of MI, is lower in females compared to males. Despite this evidence and recent guidelines recommending the use of sex specific cut-points, a single, overall cTn cut-point is still being used for diagnosis of MI, in both men and women, in most clinical settings.
A better approach to the diagnostic assessment of females presenting to the emergency department (ED) with chest pain is therefore urgently needed. Several Canadian hospitals have already made the transition from sensitive to high sensitivity cTn assays, allowing for the examination of subtle but important sex-specific differences in cTn concentrations. With this background, we are conducting a nationwide, randomized clinical trial (RCT) to determine whether establishing female cut-points results in improved diagnosis and treatment of MI and therefore improved prognosis in women.
Watch this powerful video, highlighting the importance of sex-differences in symptom presentation, and treatment of women with heart disease: