I have nothing to disclose. I presented a case of a 39-year-old premenopausal patient that has dysepidemia. She was treated with statins, family history of CAD. Her mother had an MI at the age of 48. She has a high BMI of 37. She has iron deficiency anemia. She's lifetime non-smoker and regularly not active. She was referred for the investigation of effort dyspnea. She had a positive exercise stress and she was referred for a SPECT-NPI. So again, her stress part was positive. She had a single day, single isotope protocol with technician MIBI and she was scanned with a SPECT-CT scanner, the 570 of GE. These are her non-attenuation correction images. And as you can see, there's moderate to severe reduction in tracer uptake in the apex and also in the apical anterior anterolateral wall that goes down almost to the mid-ventricle. There's some improvement and significant but not complete improvement during rest, as you can see here. These are attenuation correction images and CT performed for attenuation correction showed a coronary artery calcium scoring of zero. These are her gated images. And as you can see, the gated images of the rest are fairly normal. But here, there's a development of hypokinesis, probably akinesis of the apex and also of the apical anterior wall. Her ejection fraction went from 51% at rest to 44% after stress. This is her invasive coronary angiography. And as you can see, the right system is normal. And here is the left system. This is one view showing the circumflex and marginals completely normal. And there's a late filling of the LAD. This is another view that shows the complete occlusion of the mid-LAD with a retrograde filling of the LAD. Therefore, the patient was referred for LEMAT LAD bypass. Thank you very much. Thank you for that kind introduction. I'm going to be talking today about assessment of chest pain in women. And I have no disclosures. What we do know is that chest pain is incredibly common and it accounts for 6.5 million visits to the emergency department and over 4 million visits to the office in the United States. Of course, most of chest pain is nonspecific chest pain. Even after it gets evaluated, that ends up being the diagnosis for every age group. But after the age of 45, the next most likely cause is related to coronary atherosclerosis as demonstrated by these orange bars. For the emergency department, what they're trying to determine is something life-threatening and particularly if it's cardiac in nature. But they need to determine obviously in acute chest pain settings what might kill men and women. And of course, stable chest pain can also present to the emergency department but hopefully presents more to the office setting. When we're assessing acute symptoms, the priority is of course the life-threatening causes. Acute coronary syndrome, but also aortic dissection, pulmonary embolism, and other non-vascular syndromes. Things like esophageal rupture, attention pneumothorax, and other causes. So when we take a history, and the history does still matter, when we take the history, we need to know about the nature of the chest pain, the onset, the duration, the location, radiation, precipitating factors, relieving factors, and associated symptoms. Now of course, in the cardiac community, we are also specifically looking for cardiac causes. And looking again, certain characteristics make it more likely cardiac, like retrosternal chest discomfort, gradual in intensity, precipitated by stress, radiation down the arm or the jaw, and associated with other symptoms like dyspnea, nausea, and lightheadedness. Now, we have talked about the differences between men and women in terms of how they present in a lot of different cardiac diseases. And I think going back a little bit historically, I would talk, I'd like to talk about Yentl syndrome, which was coined by Bernadine Healy, the first woman director of the National Institute of Health. Dr. Bernadine Healy noted the discrepancy of inclusion of women in trials and compared this to the story of Yentl. Yentl is a very Yentl was a woman who wanted to study the Talmud. And because she was a woman, she couldn't. So in order to be taken seriously, she had to disguise herself as a man. And Dr. Healy's point of saying, you know, do women have to present like men? Do they have to present like Yentl? It was the fact that maybe there's differences between men and women. And in terms of our trials and the inclusion might be all based on what we think is normal, but is really based on what we think is normal in men. So the idea that women might present differently is certainly true in many connotations in cardiovascular disease and particularly acute chest pain. There may be some differences when we're talking about acute coronary syndrome. So what do we know? Well, from the Virgo study, which is a study of young men and young women under the age of 55, we really didn't know much about their presentation when they present with an acute coronary syndrome and everybody in Virgo went on to have a myocardial infarction. But what the study showed is that 90% of men and 90% of women reported the classical symptoms of chest pain, chest pressure, chest tightness, or chest discomfort. The difference between men and women was that women were more likely to present with additional or accompanying symptoms. Compared with men. Of course, in the study, they also showed that when women sought care for their symptoms, they were less likely to be told that they were heart related. And again, everybody in the study went on to have a myocardial infarction. So you can just see here quickly, looking at the Virgo results, women themselves are more likely to think it was anxiety or stress. Men were more likely to think it was muscle pain. And the reason that they sought medical care is men were more worried about heart issues. Women were also worried about heart issues, but also worried about other health problems. Women did have a longer delay to getting care. More than six hours was more likely in women compared with men. But many women sought out care in advance of their actual myocardial infarction for their symptoms. And as you can see, providers were less likely to think in women that they were heart related. So really one in two told them that they weren't heart related in contrast with men. So there is some bias in how we perceive symptoms. Now the AIRME studies tried to eliminate bias by recording or using cardiolinguistic technology or artificial intelligence to record what was heard in the conversation between the physician and the patient. And again, showed 90% of women and 90% of men actually reported chest pain. But the difference again, there was more atypical symptoms, if you will, that were recorded in women, but also seen in men, but not in those people who went on to have obstructive coronary disease. And so the authors of AIRME's really said that, you know, we needed to get rid of this word atypical because it just really wasn't helpful and really interfered with making an accurate diagnosis in women. And other people have also shown this, the high stakes group showed this, and this was not a particular age group, but again, showed 90% of women had the symptoms that you would classically think that they are cardiac in nature when they had a myocardial infarction. In fact, more women than men in this group, in this study actually had what the symptoms that we think about being related to heart disease, but again, more associated with accompanying symptoms. Now, why is this all a problem? We know that if we don't recognize somebody having heart disease, there may be delays in care. And we know that for quite some time, there's been delays in care. Again, back to the Virgo study in those patients under the age of 55, when we looked at the STEMI group of them, the door-to-balloon time was eight minutes longer in women compared with men if they had angioplasty on site, but if they required a transfer to a hospital that performed angioplasty, actually, it was 30 minutes longer to treat a woman exceeding the 120-minute threshold we set for places where there's transfer required for door-to-balloon time. We also know after a myocardial infarction, though, that women are less likely to get guideline-directed medical care, which also worsens outcomes. Additionally, with young women, where we know that we haven't made much headway in narrowing that gap, this seems to be the group that has the highest risk of cardiovascular events, we continue to ignore symptoms in young women. This is recently published. I actually should have updated their reference. This was published just a week or so ago in JAHA, and was shown that young women were less likely to be triaged as an emergent case, less likely to get an EKG or receive cardiac monitoring, waited longer to about 10 minutes longer to be evaluated and less likely to be seen by a cardiologist and less likely to be admitted to the hospital or to an observation unit. Again, if these are the kind of differences we're seeing, it shouldn't be surprising that young women who have a myocardial infarction do less well. In our chest pain guidelines, we wanted to really put this at the forefront. The first thing is we understand that chest pain is not always pain in the chest. That's one of our opening statements about the guidelines. Additionally, we want to make everyone understand the initial assessment of chest pain is really recommended to triage a patient effectively based on the likelihood that their symptoms may be due to myocardial ischemia. Really, it's a probability of ischemia. There's not one symptom that necessarily makes it not possible to be a myocardial infarction or acute coronary syndrome, but there's a probability of symptoms that we classically think are related with ischemia and some that are less likely. Then our next recommendation is to not use the word atypical anymore. As we put it, non-cardiac is in, atypical is out. We feel that the word atypical has been misused rather than meaning or being used to communicate that somebody's presenting differently, that this is an atypical presentation. Usually, when people use the word atypical, it's our way of communicating that it's non-cardiac. We said chest pain should not be described as atypical because it's not helpful and can be misinterpreted. That's a class one recommendation in our most recent guidelines. We also suggest that people should be using their description based on what they think it is. It should be described as cardiac if you think it's cardiac, non-cardiac if you think it's not cardiac, and possibly cardiac for those patients that you're not sure. Again, reminding you that 90% of women and men actually have what we had previously described as typical symptoms, so let's stop using the word atypical. Within our guidelines also, we highlight the fact that women often present with these accompanying symptoms, and it's one of our top messages. We want to not miss women, and so we said that women who present with chest pain are at risk for underdiagnosis and potential cardiac causes should always be considered. That's a class one recommendation. Additional class one recommendation is to understand that women who present with chest pain, it's important to get a full history that emphasizes their accompanying symptoms that are more common in women with acute coronary syndrome. To understand that those might be the most important symptoms that they think they're experiencing, and chest pain is just one of them. Hopefully, this will narrow the gap in our care for women, which continues to be an issue. We also, for both men and women, want our patients to seek early care, and our recommendations in the chest pain guidelines are to, first of all, not have delays in our care. Whether a patient presents in an office setting, they should be emergently transported by EMS if there's evidence of an acute coronary syndrome, and there shouldn't be delays necessarily to get an EKG. If you can't get an EKG in your office, we should get them to the emergency department as quick as possible, and to avoid delays in any way, including waiting for troponins to come back before sending someone to the emergency department. That is not helpful. We can't always initiate treatment in our clinical settings, except in the emergency department, so early care is key. Again, within our guidelines, we focused on women because they have been historically undertreated and under-recognized, but there is other groups that also needed emphasis. Elderly, ethnically diverse, elderly patients, particularly when you see an elderly patient who's had an unexplained fall, we should think about ischemic causes, potentially, amongst other causes. And then our ethnically diverse population, we need to be sensitive and a cultural competency is a class one recommendation to help us achieve the best care of all our patients, but also for patients whose first language is not English, to use a formal translation service if they are not able to communicate to us about their symptoms, it will never really understand what they're experiencing. So that also is a class one recommendation. Within our guidelines, we talk about using, when we identify a patient as intermediate risk, to use our guidelines to help us decide to identify the patients that need further testing. That intermediate risk group, we've given a class one recommendation to coronary CCTA, but also to all forms of stress testing to really determine what's going on with our patient. And always your choice of testing is going to depend on the expertise you have at your institution, its availability, depending on the location, particularly for the emergency department. All of this is going to matter. And if you don't have the test available, you certainly can't use the test, but we wanted to recognize the newer data that has really shown us that particularly cardiac imaging has really helped us, whether you use anatomic or functional testing, is really a decision between the patient and the physician with some shared decision making. And again, for stable chest pain, the same. So a nice way of summarizing it is in our guidelines, again, high risk, it's pretty easy to decide who needs to go to the cath lab. Low risk, again, they may not need any additional testing. Asymptomatic, we don't necessarily need to be testing, particularly in the emergency department, although delayed testing for patients might be useful in the low risk or asymptomatic group to help further re-stratify patients. But it's the intermediate risk group that again, anatomic or functional testing is what you would use to try to determine if this is myocardial ischemia. Now, specifically for women, especially when they're pregnant or postpartum or childbearing ages, we should always be concerned about radiation exposure. And that actually is true for all patients. But for women, obviously, when they're pregnant, we want to avoid radiation. If we have to use it, then certainly we should try to use something, the lowest effective dose of radiation should be used. But we have so many other choices that we can use that we should be thinking about them when we have women, again, who are pregnant, postpartum or of childbearing ages. Within the chest pain guidelines, we have some concepts that are new. And I think that they're important because they at least this first one affects women more is really defining coronary artery disease. For us, we've included now in these guidelines that coronary artery disease is more than obstructive coronary artery disease. And we included the definition of non-obstructive coronary disease within that definition. We've known that, again, that microvascular disease may be part of this problem. And that is not always seen compared to what we classically think of in terms of obstructive coronary disease. And we have terms now, ANOCA and MINOCA ischemia with no obstructive coronary arteries and MINOCA is a myocardial infarction with no obstructive coronary arteries. Again, these occur in men too, but occur more frequently in women. And these deserve a thorough evaluation. So again, it's not just one disease process, we should understand that. But when we identify patients with a MINOCA or ANOCA, we're trying to determine what the underlying causes and also determining non-ischemic causes of their presentation. And within the guidelines, we have really outlined this. Again, the point is we have a pathway for non-obstructive coronary disease at the same point as we do have for obstructive coronary disease. And we also provide a pathway for patients who you want to work them up further for ANOCA to make a diagnosis beyond just saying you have ischemia with no obstructive coronary arteries, what's the underlying pathophysiology. So we can use invasive coronary function testing to help us determine if it's vasospasm or coronary microvascular dysfunction, or to determine if it's non-cardiac. Again, if it's available at your institution, you may be able to do this. But even when it's not, we can use cardiac imaging, particularly PET and CMR are very useful to help us know what's going on and determine what underlying ischemic process might be causing their symptoms. And I think in Europe, they tend to use also more stress echo. And that's certainly a consideration if you know how to use it specifically for ANOCA patients. But I think PET and CMR are highly used in the United States and can help us. Again, for all of these patients, we still recommend guideline-directed medical therapy, but it's a little hard when we don't have great guideline-directed therapy for patients with ANOCA. And I think this is an area of ongoing research. Certainly, it's important to understand that the mechanism and characteristics of myocardial ischemia based on sex differs. And that's why we need to do more work in this area. And I think that, again, ANOCA is showing us so many different processes that might be different in women or more predominant in women. But just to understand that men and women are not the same. I think as I didn't get to dive in too much today, but you know, there's differences in risk factors based on sex. There's differences in presentation. As I said, ANOCA and MINOCA are more common. SCAT is more common as well in women. Access to care will always affect outcomes. And again, the access for women and diagnosis, there are delays. So, women do tend to do less well compared with men. And ultimately, that determines their outcomes. So, we do have a lot more work to do. Now, we certainly have some evidence gaps in areas that we need future research specifically related to women. The idea that we know everything about MINOCA, NONOCA is not true. And we still have a lot of work to do to understand that really the underlying pathophysiology, how to make the best diagnosis, and how to medically manage these patients to reduce cardiovascular events in the future. And I think that's an area of interesting research. I think, again, the idea of symptom classification, some of the work I showed you, for example, with the AIRMAID study is interesting to note that when we use artificial intelligence, maybe we will remove our bias. And so, more work like that, I think, might help us and how we can incorporate that into our clinical care. So, those are some of the things to highlight that are specifically related to women. I'll refer you to some resources that we have. Of course, our guidelines are published in Circulation and Jack and also translated into Spanish just a few weeks ago. But we have a chest pain hub at the ACC.org site that has a lot of resources for you, as well as the heart.org also has resources. And all these slides are available, as well as apps that we've created that can also be used in real time with your patients. So, thank you for allowing me to present today and I hope to take some questions.

assessment

chest pain

women

life-threatening causes

non-life-threatening causes

atypical symptoms