Younger Age Impacts Perceptions of Care Received in the Emergency Department Among Women with Spontaneous Coronary Artery Dissection

Abstract

Background:

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic etiology of acute coronary syndrome (ACS) that primarily affects younger women with few traditional cardiovascular disease risk factors. The primary objective of this study was to evaluate how younger age impacts the perception of care women receive in the emergency department (ED) at the time of their first or only SCAD.

Methods:

SCAD survivors were recruited using SCAD Alliance social media platforms to complete a one-time online survey regarding their experiences of seeking treatment for SCAD in the ED and their post-SCAD recovery. A total of 409 participants consented to participate in the parent study and data collected from the 367 participants who reported female gender were further analyzed.

Results:

Fewer participants <50 years old than would be expected under the null hypothesis (i.e., 65.5% observed vs. 71.2% expected, p = 0.009) reported perceived serious treatment by ED staff, more participants <50 years than would be expected under the null hypothesis (i.e., 12.0% observed vs. 9.3% expected, p = 0.049) reported perceived dismissive treatment by ED staff, and more participants <50 years than would be expected under the null hypothesis (i.e., 13.3% observed vs. 10.8% expected, p = 0.02) reported discharge from the ED without a diagnosis.

Conclusions:

Results of this study highlight the different experiences of younger SCAD survivors' engaging with providers in the ED. Further research regarding strategies for increasing ED providers' clinical interrogation of SCAD when treating and evaluating younger female patients presenting with ACS symptoms is indicated.

Introduction

Serious cardiac events experienced by women, compared with men, are often underdiagnosed, misdiagnosed or undertreated with guideline informed care.^1–4 These realities place women presenting with acute coronary syndrome (ACS) at increased risk for mortality and other negative health outcomes, such as hospital readmission, reinfarction, disability, and post-traumatic stress.^3,5–8 Discrepancies in the care women receive are due in part to significant differences in the etiology, pathophysiology, and clinical presentation of ACS among women as compared with men, as well as the historical under-enrollment of female participants in research.^1,3,9,10

Spontaneous coronary artery dissection (SCAD) is a less common nonatherosclerotic cause of ACS that manifests as myocardial infarction 90% of the time.¹¹ SCAD is caused by the formation of an intramural hematoma in the coronary artery wall after a tear or spontaneous hemorrhage in the vessel wall, which obstructs myocardial blood flow.^6,12–15 The incidence of SCAD was previously underestimated in the published literature^12,13; however, recently improved intracoronary imaging techniques suggest SCAD is not rare, and may account for more than a quarter of acute myocardial infarction (AMI) cases among women under age 50 years^10,11,16 and 15%–20% of peripartum AMI.¹¹

SCAD affects predominantly younger women with few, if any, traditional atherosclerotic risk factors.^11–14,17 These women have been described as representing a “unique, high risk phenotype”² because they present with similar symptoms as patients with atherosclerotic disease, but with different risk profiles.^16,17 Thus, providers' responsiveness to AMI may be underestimated when examining SCAD patients using common ACS risk-stratification tools, as many of these patients do not fit the heuristic of a “typical” AMI patient.^12,16 Furthermore, recent investigations highlight that SCAD is often underdiagnosed and mistreated in emergency and cardiac settings^11,18 and application of traditional heuristics may result in erroneous labeling of female ACS patients as experiencing anxiety or other noncardiac symptoms.¹⁹

Findings from several recent SCAD patient research cohorts suggest that even though SCAD has been observed in women ≥80 years of age,¹³ as many as 92%–95% of SCAD patients are women between the ages 44 and 55 years^11,12 and the average age at the time of diagnosis is between 42 and 53 years.^13,20 Notably, this is several decades younger than the average age of AMI in women, which is 72 years.³ Although discrepancies in emergency medical care are known to be related to gender and age across all patients presenting with ACS symptoms, it is not yet known how the experience of SCAD survivors presenting to the emergency department (ED) might differ based on age status.

This study is a preplanned secondary analysis of data collected from a survey conducted regarding SCAD survivors' experiences seeking treatment for SCAD and post-SCAD recovery.²¹ At the time the survey was conducted, it represented the largest sampling of SCAD survivors' experiences interacting with the health care system. The primary objective of this study is to compare the experiences and perceptions of interactions with ED staff across SCAD survivors of younger and older age cohorts. Specifically, this study sought to compare younger (<50 years old) and older (≥50 years old) SCAD survivor cohorts based on ED wait time, perceived quality of treatment by ED staff, and likelihood of being discharged without a diagnosis at the time of one's first or only SCAD.

Given that atherosclerotic ACS is more common among older women,³ we hypothesized that more younger (<50 years old) SCAD survivors than would be expected by chance would experience long ED wait times, perceive dismissive treatment by ED staff, and report discharge from the ED without a diagnosis. We further hypothesized that fewer younger SCAD survivors than would be expected by chance would perceive serious treatment by ED staff. Among SCAD survivors ≥50 years old, we expected that the observed results would be consistent with the expected results under the null hypothesis.

Materials and Methods

Participants

Respondents to the parent study were eligible to participate if they were at least 18 years old at the time of survey administration and if they had experienced at least one SCAD (by self-report). Medical verification of SCAD diagnosis was not required for entry into this study. Data were collected online using Qualtrics.com from June 2015 through September 2015. The data set is available from the corresponding author upon request.

Procedures

This study was approved by the University of Colorado Insitutional Review Board. All procedures were conducted in accordance with ethical principles.

Participants were primarily recruited through social media (i.e., Facebook and Twitter). Recruitment materials were also distributed to practicing cardiologists and cardiovascular patient support organizations, such as the Mended Hearts, American Heart Association, and Women's Heart Alliance. Social media messages were posted by the SCAD Alliance, a nonprofit patient advocacy and physician education group, and invited SCAD survivors to complete a one-time online survey. A link to complete the survey was included in all places where the study was advertised. Following this link brought potential participants to a page where they were asked to confirm their eligibility based on age and personal history of SCAD and then review the informed consent page. Participants gained access to the survey after providing informed consent.

Data collection

Demographics and participant characteristics

As part of the full survey battery for the parent study,²¹ participants completed questions about their identified gender, age at the time of first (or only SCAD), and number of lifetime SCAD events. Participants also provided information about their efforts to seek medical care. Specifically, participants were asked if they sought help immediately when they first developed symptoms: “yes” or “no.” If they did not seek help immediately, they were asked how long they waited before seeking help (“never sought help,” “more than one day,” “within 24 hours,” “within 12 hours,” or “within one hour”).

Patient experience and perception of interactions with ED staff

Regardless of whether participants reported seeking help immediately at the time of symptom onset, all participants were asked if they sought care at the ED at the time of their first (or only) SCAD: “yes” or “no.” Participants who said they sought care at the ED at the time of their first (or only) SCAD were asked to indicate: (1) how long they waited to first be seen in the ED, “immediately,” “<1-hour,” or “>1-hour”; (2) how they perceived they were treated by ED staff, “seriously,” “dismissively,” “neutrally,” or “other”; and (3) if they were discharged from the ED without a diagnosis at the time of their first or only SCAD, “yes” or “no.”

Analysis plan

Data were analyzed using SPSS version 27. Analyses examined the association of age with ED wait time, perceived quality of treatment by ED staff, and discharge from the ED without a diagnosis. For the purposes of this study, younger SCAD survivor participants were those who were <50 years of age at the time of their first or only SCAD and older SCAD survivor participants were those who were ≥50 years of age at the time of their first or only SCAD. This decision was made a priori based on the frequent and consistent use of age 50 as the demarcation line to differentiate younger and older SCAD survivors elsewhere in the literature.^{6,10,11,14,20}

The primary outcome variables of interest (i.e., ED wait time, perceived treatment by ED staff, and discharge without a diagnosis) were each measured using categorical scales as part of the parent study survey. Participant age was treated as a categorical variable (<50 years old vs. ≥50 years old) and chi square tests of independence were used to analyze the data given the categorical nature of the outcome variables. When significant differences were noted between age cohorts on the primary outcomes of interest, data were further analyzed for differences by participant country (dichotomized as United States vs. Not United States due to sample size distribution across countries).

Post hoc analyses of significant chi square tests were conducted using adjusted standardized residuals. These residuals are z-scores; values greater or lesser than 1.96 indicate significant differences between the percentage observed in a given cell and the percentage expected under the null hypothesis. To obtain p-values corresponding to each residual, we converted z-scores to chi square values and then calculated p-values for each chi square using Excel.

Post hoc analyses make comparisons between the observed results and percentage of participants who would be expected to receive the same result if the null hypothesis were true. The null hypothesis is that there are no differences between the observed results, for example, the frequency of participants <50 years who report perceived “serious” treatment in the ED, and the expected results, for example, the frequency of participants <50 years who would be expected to report perceived serious treatment if there were no association between age cohort and perceived treatment by ED staff.

Results

Detailed demographics regarding the study sample are provided in a prior publication.²¹ In brief, N = 409 individuals provided informed consent to participate; of those, n = 9 participants identified their gender as “male,” n = 367 participants identified their gender as “female,” and n = 33 participants did not provide a response regarding gender. As this study is primarily concerned with evaluating discrepancies in care between younger and older female SCAD cohorts, and because there were too few men represented in the sample to make meaningful comparisons across male and female experiences, only data from the 367 participants who reported female gender were further analyzed.

Among the reduced sample of N = 367, age at the time of first SCAD ranged from 26 to 71 years (mean = 44.5, standard deviation [SD] = 8.7, median = 44, mode = 37). Participants reported experiencing between 1 and 4 SCAD events in their lifetimes and participants were an average of 2.7 years (SD = 3.9) out from the time of their first or only SCAD at the time of survey administration. The majority of participants were residing in the United States, n = 222, but responses were also collected from survivors residing in several European countries, n = 74 (with the greatest representation from England, n = 31 and The Netherlands, n = 14), Canada, n = 37, Australia, n = 27, New Zealand, n = 11, and Africa (South Africa, n = 1).

A majority of participants (254/367, 69.2%) reported seeking help immediately when they first experienced symptoms; n = 1 participant did not respond to this question and n = 112 reported not seeking help right away. Of those who did not seek help right away: n = 5 reported “I never sought help for my first or only SCAD, it was diagnosed retrospectively,” n = 29 reported taking more than 1 day to seek help, n = 15 reported taking fewer than 24 hours, but more than 12 hours to seek help, n = 44 reported taking fewer than 12 hours, but more than 1 hour to seek help, and n = 17 reported seeking help within 1 hour of developing symptoms. There were n = 2 participants who reported not seeking help immediately, but did not endorse any of these responses.

Missing data

Data were missing from analyses pertaining to patient experiences and perceptions of interactions with ED staff for several reasons. First, n = 20 participants did not report seeking care in the ED at the time of their first or only SCAD and n = 6 participants did not respond to the survey question “did you seek help at the ED in response to your symptoms?” Therefore, 26 participants were not presented with questions to answer regarding their experiences and perceptions of interactions with ED staff due to survey branching logic. This reduced the sample from 367 to 341. Second, participants were not required to provide a response to every item on the survey to advance and complete the survey.

Data were missing for the following survey items, and thus, not included in subsequent analyses: “what is your country of residence?” (n = 7 missing), “what was your age at the time of your first or only SCAD?” (n = 6 missing), “once you arrived at the ED, what was the wait time to be seen?” (n = 2 missing); “how were you treated by ED staff?” (n = 2 missing); and “were you discharged from the ED without a diagnosis” (n = 3 missing). Third, because SPSS uses casewise deletion, if participants were missing data on at least one variable included in analysis, they would not be included in the analyzed sample. Sample size denominators are specified for each statistic reported hereunder.

Patient experience and perception of interactions with ED staff

Of the 339 participants who reported seeking care at the ED at the time of their first or only SCAD and who responded to the question about ED wait time, n = 269 (79.4%) reported they were seen immediately, n = 53 (15.6%) reported they waited under an hour to be seen, and n = 13 (3.8%) reported waiting more than an hour before being seen. There were 4 (1.2%) participants who selected “other” in response to this question, and thus, it is not known how long they waited to be seen. There were no age cohort differences observed for ED wait time: χ²(4, N = 333) = 4.8, p = 0.305.

A majority of participants who reported seeking care at the ED at the time of their first or only SCAD and who responded to the question about perceived treatment in the ED (242/339, 71.4%) reported perceived “serious” treatment by ED staff at the time of their first or only SCAD; n = 57 (16.18%) reported perceived “neutral” treatment, and n = 32 (9.4%) reported perceived “dismissive” treatment. Another n = 8 (2.4%) selected “other” in response to this survey item. A chi square test of independence found a significant difference in the expected frequencies of perceived treatment by ED staff and age cohort: χ²(3, N = 333) = 13.2, p = 0.004.

Under the null hypothesis, 71.2% of those <50 years would be expected to report perceived serious treatment if there were no association between age cohort and treatment by ED staff, whereas 66.0% of those <50 years in the current sample actually reported perceived serious treatment (p = 0.009). In addition, if there was no association between age cohort and reports of perceived dismissive treatment, 9.3% of those <50 years old would be expected to report perceived dismissive treatment; however, 12.0% of those <50 years old in the current sample reported perceived dismissive treatment (p = 0.049).

Table 1 further displays the breakdown of frequencies regarding perceived treatment by ED staff by age cohort (<50 years old and ≥50 years old) and age by decade to show the range of perceived treatment across age. Younger participants, especially those in their 30s and 40s, reported perceived serious treatment less frequently than would be expected by chance and reported perceived dismissive treatment more frequently than would be expected by chance. The opposite pattern of results was observed for participants in their 50s, 60s, and 70s. Significant differences in the expected frequencies for perceived treatment by ED staff by participant country were not observed: χ²(3, N = 332) = 6.8, p = 0.88 (Table 1).

Table 1.

Patients' Perception of Treatment by Emergency Department Staff by Age Cohort, Age Cohort Decade, and Participant Country

Age cohort	Perceived treatment by ED staff
	Serious	Dismissive	Neutral	Other
	n (%)	n (%)	n (%)	n (%)
<50 years (n = 241)	159 (66.0)	29 (12.0)	46 (19.1)	7 (2.9)
	171.5 (71.2)	22.4 (9.3)	41.3 (17.1)	5.8 (2.4)
≥50 years (n = 92)	78 (84.8)	2 (2.2)	11 (12.0)	1 (1.0)
	65.5 (71.2)	8.6 (9.3)	15.7 (17.1)	2.2 (2.4)
Total N = 333	n = 237	n = 31	n = 57	n = 8
Age cohort decade
26a–29 (n = 10)	8 (80.0)	1 (10.0)	1 (10.0)	0 (0.0)
	7.1 (71)	0.9 (9.0)	1.7 (17.0)	0.3 (3.0)
30–39 (n = 102)	64 (62.8)	13 (12.7)	22 (21.6)	3 (2.9)
	72.6 (71)	9.5 (9.3)	17.5 (17.2)	2.5 (2.5)
40–49 (n = 130)	87 (66.9)	15 (11.5)	24 (18.5)	4 (3.1)
	92.5 (71.1)	12.1 (9.3)	22.3 (17.2)	3.1 (2.4)
50–59 (n = 73)	62 (84.9)	1 (1.4)	10 (13.7)	0 (0.0)
	52.0 (71.2)	6.8 (9.3)	12.5 (17.1)	1.8 (2.4)
60–69 (n = 16)	14 (87.4)	1 (6.3)	0 (0.0)	1 (6.3)
	11.4 (71.2)	1.5 (9.4)	2.7 (16.9)	0.4 (2.5)
70–71b (n = 2)	2 (100)	0 (0.0)	0 (0.0)	0 (0.0)
	1.4 (70.0)	0.2 (10.0)	0.3 (15.0)	0.1 (5.0)
Total N = 333	n = 237	n = 31	n = 57	n = 8
Participant country
United States (n = 213)	155 (72.8)	19 (8.9)	34 (16.0)	5 (2.3)
	152.1 (71.4)	19.2 (9.0)	36.6 (17.2)	5.1 (2.4)
Not United States (n = 119)	82 (68.9)	11 (9.3)	23 (19.3)	3 (2.5)
	84.9 (71.3)	10.8 (9.1)	20.4 (17.2)	2.9 (2.4)
Total N = 332	n = 237	n = 30	n = 57	n = 8

Values shown in bold are the observed frequencies for each cell; values shown without bold are the expected frequencies for each cell under the null hypothesis.

N = 333 for the frequencies provided under “perceived treatment by ED staff” by “age cohort” and “perceived treatment by ED staff” by “age cohort by decade” because n = 6 participants did not report their age and n = 2 participants did not respond to the question about perceived treatment by ED staff. Thus, n = 8 participants are not represented out of the full analytic sample of N = 341.

N = 332 for the frequencies provided under “perceived treatment by ED staff” by “participant country” because n = 7 participants did not report their country of residence and n = 2 participants did not respond to the question about perceived treatment by ED staff. Thus, n = 9 participants are not represented out of the full analytic sample of N = 341.

^a Range for the third decade (participants in their 20s) starts with age 26 because there were no participants reporting female gender who were <26 years old in the sample.

^b Range for the eighth decade (participants in their 70s) ends with age 71 because there were no participants reporting female gender who were >71 years old in the sample.

ED, emergency department.

In this sample, a minority of participants who reported seeking care at the ED at the time of their first or only SCAD and who responded to the question about ED discharge (37/338, 10.9%) reported being discharged from the ED without receiving a diagnosis. A significant difference in the expected frequencies of discharge from the ED without receiving a diagnosis and age cohort was observed: χ²(1, N = 332) = 5.6, p = 0.02. Under the null hypothesis, 10.8% of those <50 years would be expected to be discharged from the ED without a diagnosis, whereas 13.3% of those <50 years were discharged without a diagnosis (p = 0.02). Of the total number of participants who reported discharge from the ED without a diagnosis, 32/36, 88.9% were <50 years old.

In contrast, only 4/36, 11.0%, of the ≥50 cohort reported discharge from the ED without a diagnosis. Table 2 shows a breakdown of the frequencies of participants reporting discharge from the ED without a diagnosis by age decade. Differences in the expected frequencies of discharge from the ED without receiving a diagnosis by participant country were not found: χ²(1, N = 331) = 0.03, p = 0.86; n = 23/213, 10.8%, (observed) versus 22.5/213, 10.6%, (expected) participants from the United States and n = 12/118, 10.2%, (observed) versus 12.5/118, 10.6%, (expected) participants from countries other than the United States reported discharge from the ED without a diagnosis.

Table 2.

Patients Reporting Discharge from the Emergency Department Without a Diagnosis

Age cohort by decade	Reported discharge from the ED without a diagnosis
	Yes	No
	n (%)	n (%)
26a–29 (n = 10)	2 (20.0)	8 (80.0)
	1.1 (11.0)	8.9 (89.0)
30–39 (n = 101)	13 (12.9)	88 (87.1)
	11.0 (10.9)	90.0 (89.1)
40–49 (n = 130)	17 (13.1)	113 (86.9)
	14.1 (10.8)	115.9 (89.2)
50–59 (n = 73)	4 (5.5)	69 (94.5)
	7.9 (10.8)	65.1 (89.2)
60–69 (n = 16)	0 (0.0)	16 (100)
	1.7 (10.6)	14.3 (89.4)
70–71b (n = 2)	0 (100)	2 (100)
	0.2 (10.0)	1.8 (90.0)
Total N = 332	n = 36	n = 296

Values shown in bold are the observed frequencies for each cell; values shown without bold are the expected frequencies for each cell under the null hypothesis.

Total N = 332 for the frequencies provided because n = 6 participants did not report their age and n = 3 participants did not respond to the question about discharge from the ED without a diagnosis. Thus, n = 9 participants are not represented out of the full analytic sample of N = 341.

^a Range for the third decade (participants in their 20s) starts with age 26 because there were no participants reporting female gender who were <26 years old in the sample.

^b Range for the eighth decade (participants in their 70s) ends with age 71 because there were no participants reporting female gender who were >71 years old in the sample.

Finally, an additional chi square test of independence was conducted to determine whether there was any evidence of an association between perceived treatment by ED staff and reported discharge from the ED without a diagnosis, and, if so, whether the pattern of association differed by age cohort. Perceptions of treatment by medical personnel and discharge from the ED without a SCAD diagnosis were significantly associated, χ²(3, N = 338) = 35.2, p = 0.001.

This association held both for women <50 years of age χ²(3, N = 240) = 25.2, p < 0.001 and for those ≥50 years of age χ²(3, N = 92) = 11.3, p = 0.010. For both age cohorts, fewer participants than expected reported discharge from the ED without a diagnosis and perceived serious treatment. Likewise, for both age cohorts, more participants than expected reported discharge from the ED without a diagnosis and perceived dismissive treatment (Table 3). There were no differences in the frequencies of expected versus observed results for perceived neutral or “other” treatment across age cohorts.

Table 3.

Patients Reporting Discharge from the Emergency Department Without a Diagnosis by Perceived Treatment and Age Cohort

Reported discharge from the ED without a diagnosis AND perceived serious treatment by ED staff
Age cohort	n (%)
<50 years (n = 159)	10 (6.3)
	21.2 (13.3)
≥50 years (n = 78)	2 (2.6)
	3.4 (3.8)
n = 237
Reported discharge from the ED without a diagnosis AND perceived dismissive treatment by ED staff
Age cohort	n (%)
<50 years (n = 29)	11 (37.9)
	3.9 (13.4)
≥50 years (n = 2)	1 (50.0)
	0.1 (.05)
n = 31

Values shown in bold are the observed frequencies for each cell; values shown without bold are the expected frequencies for each cell under the null hypothesis.

Discussion

SCAD is a potentially fatal condition that primarily affects younger women who do not present with “typical” ACS risk factors.^11–14,17 This study examined how younger age may impact the perception of care received in the ED among women presenting with their first or only SCAD.

Overall, the majority of participants in both age cohorts perceived serious or neutral treatment by ED staff (Table 1) and the majority of participants in both age cohorts were not discharged without out a diagnosis (Table 2). However, our results did suggest that women <50 years old who would eventually be diagnosed with SCAD were (1) less likely than expected by chance to report perceived serious treatment from providers in the ED, (2) more likely than expected by chance to report perceived dismissive treatment from providers in the ED, and (3) more likely than expected by chance to be discharged from the ED without a diagnosis.

Not surprisingly, discharge from the ED without a diagnosis and perceived treatment by ED staff were significantly associated such that fewer participants than would be expected by chance perceived serious treatment if they were also discharged without a diagnosis and more participants than would be expected by chance perceived dismissive treatment if they were also discharged without a diagnosis. The pattern of results was the same for the <50 and ≥50 age cohorts (Table 3). Although these results might suggest that participants who were discharged without a diagnosis were biased to remember their interactions with ED staff less favorably, this is only an association and we cannot infer that being discharged without a diagnosis (or not) caused participants to recall their experiences with ED staff as more or less dismissive or serious.

In our sample of individuals presenting to the ED with SCAD, 8 out every 9 women who reported discharge without a diagnosis were <50 years old. Across all younger age decades, more participants in their 20s, 30s, and 40s reported discharge from the ED without a diagnosis than would have been expected by chance. The opposite pattern was observed for participants in their 50s, 60s, and 70s. This is a telling illustration of increased risk for morbidity and mortality faced by younger SCAD patients, in particular. Past investigations have demonstrated that patients with serious cardiac symptoms do, on occasion, get inappropriately discharged from EDs.⁴

This is not a novel finding per se; yet, the results of our study suggest younger SCAD patients perceive having different experiences when seeking treatment in the ED in response to their symptoms compared with their older peers. In recent years, advances in the SCAD angiographic classification system and updated imaging techniques^10,16 together with widespread SCAD patient advocacy efforts²¹ have contributed to greater awareness of SCAD and recognition of the unique SCAD presentation profile. It is not yet clear, however, whether these medical advances may translate into differences in patient perceptions of experience seeking emergency care.

Women, and particularly younger women, are vulnerable to depression and anxiety after cardiac events,^22,23 which are associated with increased cardiac morbidity and mortality.^24,25 Recent evidence suggests that SCAD patients frequently experience symptoms of anxiety, depression, and post-traumatic stress disorder in the months to years after their SCAD.^7,8,15

For some SCAD patients, it is possible that the perception of being treated dismissively or discharged from the ED without a diagnosis could leave them feeling invalidated and could subsequently negatively impact their persistence in seeking further appropriate care.²⁶ Such an experience may also contribute to anxiety or traumatic stress reactions by creating a sense of powerlessness or reduced personal control. Furthermore, perceptions of dismissive treatment and discharge from an ED without a diagnosis could lead SCAD patients to doubt the legitimacy of their own symptoms, increasing the risk that they may ignore important symptoms or delay presentation to the ED in the future.²⁶

The results of this study suggest more work may be needed to increase ED providers' clinical interrogation of SCAD when treating and evaluating younger female patients presenting with ACS symptoms. Future study should explore the most effective ways of getting this message out to those providers who may be less familiar with SCAD and whose decision-making may impact the care of these patients. Future study may also explore whether certain provider-level or institution-level characteristics increase the likelihood of negative outcomes for SCAD patients, both those that are objective (e.g., verified ED discharge without a diagnosis) and subjective (e.g., perception of dismissive treatment).

For example, a recent investigation reported evidence that female patients were more likely to survive AMI if they were treated by female physicians or if they were evaluated and treated in an ED with a high number of female physicians.²⁷ A question to be addressed by future study concerns whether provider–patient age concordance or the average age of providers in the ED at a particular institution could similarly influence patient care.

Limitations

There are several limitations that should be considered when interpreting the results. Notably, these cross-sectional data were collected from a convenience sample, by self-report, potentially several years after the initial SCAD event and participants' experiences with ED staff took place. Therefore, issues of recall bias, social desirability bias, or threats to construct validity could influence the findings. Without verification of participants' medical history, it is not possible to know if some respondents did not actually experience a SCAD as reported.

The study characterizes the experiences of women who survived their first or only SCAD; the experiences of women who did not survive are unknown. The results also only offer the perspectives of the participants without additional clarification or clinical rationale from the ED staff with which they interacted. This study did not have a comparison group with which we could compare the experiences of patients reporting to the ED for reasons other than SCAD, thus, we do not know what percentage of patients presenting with other concerns would report perceiving dismissive versus serious treatment or discharge from the ED without a diagnosis across age cohorts.

The parent survey did not collect data from participants regarding race or ethnicity; thus, we are unable to characterize our findings with regard to the broader female SCAD survivorship population. We are also unable to discuss generalizability of our findings to EDs or ED staff as the parent study did not collect information regarding hospital size, location, or the ED providers' professional training. Furthermore, prior studies regarding inequities in emergency medical care have found that younger women of color fare worse than white women of similar age.^4,28 Therefore, it will be critical for future studies examining potential age- and gender-related discrepancies in care received among SCAD patients to do so with the intersectionality of these patient-level characteristics in mind.

Moreover, there are very little data available in the published literature concerning transgender or gender-nonconforming cardiovascular disease²⁹ and essentially no data available regarding rates of SCAD among transgender or gender-nonconforming individuals. Although this study allowed participants to select their identified gender, participants were not given the option to provide responses to this question outside of the gender binary (i.e., male or female). It is, therefore, unknown whether participants who did not provide information about their gender did so because the response options were not appropriate for them, or for some other reason. This is clearly an area that needs additional attention in the SCAD literature.

Conclusions

Women suffering from ACS have worse outcomes than their male counterparts and SCAD patients represent a “high-risk” ACS phenotype² because their typical presenting characteristics (i.e., female, young age, medical history, and fewer typical risk factors) are disparate from those of patients presenting with atherosclerotic disease. Results of this study highlight younger SCAD survivors' potentially negative experiences engaging with providers in ED services. Future research is needed to replicate these findings among individuals with medically verified SCAD diagnoses and ED discharge reports. It will also be important to account for person-level characteristics of SCAD survivors and identify strategies for increasing ED providers' clinical interrogation of SCAD when treating and evaluating younger female patients presenting with ACS symptoms.

Disclaimer

The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Authors' Contributions

C.J.S., K.K.L., and T.P.W. conceived of the study and contributed to the study design and data collection. C.J.S. and J.A.S. conducted the data analysis. C.J.S., J.A.S., K.S.E., and T.P.W. drafted the article. All authors provided substantive comments and feedback for interpreting the data and revising the article critically for important intellectual content. All authors approve the final version of the article and all authors are responsible for their contributions.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Preparation of this article was supported in part by the National Cancer Institute (F31CA180483) and the National Institute of Mental Health (T32 MH073553).