Sex differences in disease presentation in the emergency department☆
Article Outline
Abstract
[Ann Emerg Med. 2002;40:461-463.]
See related article, p. 453 .
Clinicians constantly strive to identify opportunities for improved diagnosis and treatment for all persons with medical needs. This is particularly important in the emergency department. Unfortunately, the published scientific and medical literature too often fails to aid clinicians who seek to understand potential sex differences in disease presentation. In the absence of research that includes sufficient numbers of women to support a separate analysis and publishes whether the results indicate sex differences, clinicians are often left to apply findings from studies on men to the care of women. Increasingly, we are shown that this is not the ideal way to deliver quality care. Indeed, new sex-specific clinical evidence often invalidates previously accepted conventional wisdom regarding the best choices for patient care and replaces it with more accurate, effective, or safer alternatives.1 Recognizing sex differences in disease presentation is particularly important in EDs, where rapid diagnosis allows for prompt initiation of therapies that reduce mortality and improve functional outcomes.
Sex differences in disease presentation and management have been well documented for coronary heart disease.2, 3, 4 In the case of acute myocardial infarction, women present more frequently than men with atypical chest pain, nausea, and gastrointestinal symptoms. In addition, women presenting to the ED with signs and symptoms suggestive of acute coronary disease are less likely than men with similar symptoms to be admitted for evaluation5 or to receive thrombolytic therapy.6 Fortunately, as a result of the increased recognition of the magnitude and presentation of acute coronary disease in women, the sex gap in receipt of thrombolytic therapy and other interventions is closing.6 This improvement in care further underscores the potential effect of well-conducted research studies on the emergency care that women receive.7
Unfortunately, the pattern of delayed care and poorer outcomes for women appears to persist in stroke, the leading cause of adult disability and the third leading cause of death in the United States. Women with acute stroke wait longer in the ED for physician evaluation8 and have worse functional outcome and mortality.9 In addition, medications such as hormonal therapy can adversely affect women's stroke risk and outcomes. These differential risks and outcomes highlight the need for sex-specific research on disease syndromes other than acute myocardial infarction.
In this issue of Annals, Labiche et al10 advance our understanding of these delays and differential outcomes in stroke. Using data from 10 community hospitals in nonurban East Texas, they provide an assessment of sex differences in presentation for acute stroke. Although prior studies have identified sex differences in treatment for patients presenting with acute stroke, this is the first article to examine the hypothesis that men and women have different presenting symptoms in the ED. Trained chart abstractors identified all patients presenting to participating hospitals with an acute stroke during the 2-year study period. After validation of the diagnosis, a structured interview was conducted with the patient or a proxy to ascertain the symptoms present at onset. The authors defined nontraditional stroke symptoms as pain, change in level of consciousness-disorientation, unclassifiable neurologic symptoms, and nonspecific symptoms. The authors found that women presented with nontraditional stroke symptoms more often than men.
The study by Labiche et al10 underscores the importance of efforts to examine sex differences in disease presentation for a variety of acute syndromes seen in the ED. They have provided a starting point for examining a variety of conditions in which timely diagnosis is essential to modifying the disease course and in which sex differences in therapy and disease outcome have been documented. Indeed, one could argue that the need to assess sex differences in presentation and treatment is greatest in the case of potentially disabling or fatal syndromes for which rapid treatment is critical.
Research such as that conducted by Labiche et al10 is relevant for all front-line providers, including emergency medicine technicians, triage nurses, and emergency medicine clinicians. Whether a patient with a stroke is saved or lost can depend on whether the patient gets to an emergency physician and how quickly the correct diagnosis is made. At issue is not simply whether and how men and women differ in presentation but also to what extent these differences affect triage and diagnosis. One approach to assessing the difficulty of triage is to compare the proportions of men and women who present with only typical symptoms, those who present with only atypical symptoms, and those who present with a combination of the two. Such an approach could be used to develop new protocols for triage. Rather than focusing on the most typical or classic symptoms, research should also highlight the most common types of atypical presentations. Studying these atypical presentations does not preclude the importance of identifying classic disease signs and symptoms. Instead, it facilitates the development of systematic approaches to triage and diagnosis.
Difficulty of triage and diagnosis also depends on whether symptoms are specific to a particular diagnosis. Therefore, it would be important to know whether women present more often than men with only nonspecific atypical symptoms, such as shortness of breath and palpitations, which are also atypical symptoms of acute myocardial infarction. Evaluating the types of symptom combinations (eg, typical, mixed, specific atypical, nonspecific atypical) could provide a basis for evaluating protocols for first-line responders and triage nurses and ultimately for improving patient education. Protocols that overlook sex differences in presentation risk misdiagnosis and delays in treatment.
Sex differences in the ED extend beyond disease presentation to include differences in differential diagnoses for common complaints. For example, obvious differences in anatomy dictate the need for additional considerations in the approach to women with abdominal pain. Prior research suggests that another important area in which to consider sex differences in underlying mechanisms is traumatic injury. Traumatic injury might be more likely to represent domestic violence in women than in men. Moreover, domestic violence in women might present nonspecifically, including as abdominal pain11 or ill-defined signs and symptoms.12 Clinical experience and intuition suggest that there might be additional areas in which ED symptom presentation or differential diagnosis differs by sex. For example, because endocrine disorders and rheumatologic disorders occur more commonly in women than in men, emergency manifestations of these disorders (eg, thyroid disease presenting with cardiac abnormalities, lupus cerebritis presenting with seizures, rheumatoid heart presenting with congestive heart failure) should be greater considerations in the differential diagnosis of women presenting to the ED. Research on areas such as these, in which there are known sex differences in chronic disease prevalence, could improve recognition of sex differences in disease presentation in the ED.
Further work is needed to explain whether sex differences in outcomes can be avoided through improved recognition of men's and women's symptom presentation and differential risk for underlying disorders. Research in such syndromes might yield new insights into sex differences in outcomes of care by simultaneously examining presentation, diagnosis, treatment, and outcomes of care. In addition to providing a more complete understanding of sex differences in disease outcomes, such research would allow us to improve patient education regarding symptom recognition and to improve quality of care from emergency physicians and other first-line responders. Future work in this area promises to lead to improved care for both men and women.
Acknowledgements
We thank Debra Saliba, MD, MPH, Mary Vaiana, PhD, and Susan Lambe, MD, for their helpful comments and suggestions.
References
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- Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J. 1998;136:189–195
- Gender differences in symptom presentation associated with coronary heart disease. Am J Cardiol. 1999;84:396–399
- Gender differences in the presentation, treatment, and short-term mortality of acute chest pain. Clin Invest Med. 1994;17:551–562
- . Effect of sex on the emergency department evaluation of patients with chest pain. Acad Emerg Med. 1995;2:115–119
- Gender differences and factors associated with the receipt of thrombolytic therapy in patients with acute myocardial infarction: a community-wide perspective. Am Heart J. 1996;131:43–50
- The impact of clinical trials on the use of medications for acute myocardial infarction: results of a community-based study. Arch Intern Med. 1996;156:54–60
- . Critical factors determining access to acute stroke care. Neurology. 1998;51:427–432
- Sex differences and similarities in the management and outcome of stroke patients. Stroke. 2000;31:1833–1837
- Sex and acute stroke presentation. Ann Emerg Med. 2002;40:453–460
- Increasing emergency physician recognition of domestic violence. Ann Emerg Med. 1996;27:741–746
- . Indicators of assault-related injuries among women presenting in the emergency department. Ann Emerg Med. 1998;32:363–366
☆ Reprints not available from the authors.
PII: S0196-0644(02)00077-X
doi:10.1067/mem.2002.128859
© 2002 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Sex and acute stroke presentation
