Authors: Audrey Enerson, MPH, Meghan Etsey on behalf of Brodsky’s Interns of the AMWA Gender Equity Task Force (GETF)
Heart disease is the leading cause of death for women (CDC 2024 see Figure 1), yet recognition and treatment in emergency departments (EDs) continue to lag behind that of men. A 2025 study found that of participants with missed angina, 63% were women and 37.0% were men (Mostafa et al., 2025). Women presenting with myocardial infarction (MI) are more likely to experience delayed diagnosis, less aggressive treatment, and poorer outcomes (Dawson et al., 2023). These disparities are not simply statistical; they reflect entrenched gaps in clinical recognition, diagnostic pathways, and systemic bias that undermine timely, life-saving care.
A major driver of these gaps lies in how symptoms are perceived and interpreted. One of the most cited reasons for misdiagnosis is that women’s heart attack symptoms often differ from the “classic” male presentation. While chest pain remains the most common symptom across sexes, women are more likely to report additional or alternative features such as shortness of breath, nausea, back pain, or fatigue (Cardeillac et al., 2022; McSweeney et al., 2016). Unfortunately, because medical education and public messaging have historically centered on male patterns of presentation, these symptoms may be mislabeled as anxiety, indigestion, or musculoskeletal pain (Mostafa et al., 2025). This mismatch between presentation and expectation delays recognition and treatment.
Yet symptom differences are only part of the problem. Delays in seeking care among women also contribute to worse outcomes and higher mortality from MI compared to men, further compounding disparities in diagnosis and treatment (Elgendy et al., 2022). To help address this, the American Heart Association started the Go Red for Women campaign in 2004 to help women recognize their specific heart attack symptoms (Williamson, 2024). Yet even when women present to the ED with chest pain, systemic differences influence how they are evaluated. Dawson et al. (2023) found that women with acute chest pain were less likely to undergo immediate diagnostic testing (e.g., EKG, troponins) and were less likely to be admitted for observation or further cardiac evaluation. Furthermore, risk assessment tools widely used in the ED, such as the HEART and TIMI scores, require an EKG and troponin levels – which women were less likely to receive (Dawson et al., 2023). This contributes to under-triage and fewer referrals for advanced care.
Underlying these patterns is the influence of bias. Implicit clinician assumptions also play a role in the inequity of women being diagnosed. Women, especially younger patients, are often perceived as being at lower cardiovascular risk, despite evidence showing that ischemic heart disease affects people of all ages (McSweeney et al., 2016). The limitations of current diagnostic pathways reinforce this perception. For example, atypical EKG changes or smaller rises in troponin levels – which may reflect sex-based biological differences – are sometimes overlooked (Mostafa et al., 2025). Mostafa et al. (2025) highlight how such disparities extend beyond acute MI diagnosis, with women experiencing delayed diagnosis of angina over decades, underscoring how bias and system limitations interact across the spectrum of ischemic disease.
The consequences of these diagnostic gaps are profound. Women with delayed or missed MI diagnoses face higher morbidity, including increased rates of heart failure, recurrent ischemia, and reduced long-term quality of life (Mostafa et al., 2025). Mortality is also higher among women who do not receive timely, guideline-based interventions (Dawson et al., 2023). On a patient experience level, women frequently describe feelings of dismissal or invalidation when their symptoms are minimized, which erodes trust in healthcare systems and may discourage future care-seeking (McSweeney et al., 2016).
Addressing these inequities requires coordinated, multi-level solutions. The 2021 AHA/ACC chest pain guidelines emphasize the need for clinicians to recognize a broad spectrum of ischemic symptoms in women and apply sex-specific considerations to testing and triage (Writing Committee Members, 2021). Education is essential; medical curricula and continuing professional development should incorporate evidence on women’s cardiovascular health to challenge outdated stereotypes. System-level changes are equally important. Integrating sex-specific thresholds for biomarkers like troponin, recalibrating risk scores, and updating triage protocols can help ensure women are not overlooked. Finally, tracking outcomes by sex at the institutional and national levels would provide accountability and drive ongoing improvement.
Ultimately, addressing this issue requires more than clinical awareness – it calls for systemic improvements. Women remain at disproportionate risk of having heart attacks missed or misdiagnosed in emergency departments. Differences in symptom presentation, systemic biases in diagnostic pathways, and clinician assumptions contribute to delays in recognition and treatment. The consequences – higher morbidity, mortality, and diminished trust – are unacceptable in an era of advanced cardiac care. By embracing guideline-driven sex-sensitive approaches and committing to education and systemic reform, emergency medicine can help close this gap. Ensuring that women’s heart attacks are recognized and treated with the urgency they deserve is not just a clinical priority; it is a matter of equity and justice in healthcare.
References
Cardeillac, M., Lefebvre, F., Baicry, F., Le Borgne, P., Gil-Jardiné, C., Cipolat, L., Peschanski, N., & Abensur Vuillaume, L. (2022). Symptoms of Infarction in Women: Is There a Real Difference Compared to Men? A Systematic Review of the Literature with Meta-Analysis. Journal of Clinical Medicine, 11(5), 1319. https://doi.org/10.3390/jcm11051319
Centers for Disease Control and Prevention. (2024). Leading causes of death in females. https://www.cdc.gov/womens-health/lcod/females.html
Dawson, L. P., Nehme, E., Nehme, Z., Davis, E., Bloom, J., Cox, S., Nelson, A. J., Okyere, D., Anderson, D., Stephenson, M., Lefkovits, J., Taylor, A. J., Nicholls, S. J., Cullen, L., Kaye, D., Smith, K., & Stub, D. (2023). Sex Differences in Epidemiology, Care, and Outcomes in Patients With Acute Chest Pain. Journal of the American College of Cardiology, 81(10), 933–945. https://doi.org/10.1016/j.jacc.2022.12.025
Elgendy, I, Wegermann, Z, Li, S. et al. Sex Differences in Management and Outcomes of Acute Myocardial Infarction Patients Presenting With Cardiogenic Shock. J Am Coll Cardiol Intv. 2022 Mar, 15 (6) 642–652. https://doi.org/10.1016/j.jcin.2021.12.033
McSweeney, J. C., Rosenfeld, A. G., Abel, W. M., Braun, L. T., Burke, L. E., Daugherty, S. L., Fletcher, G. F., Gulati, M., Mehta, L. S., Pettey, C., Reckelhoff, J. F., & American Heart Association Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Hypertension, Council on Lifestyle and Cardiometabolic Health, and Council on Quality of Care and Outcomes Research (2016). Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science: A Scientific Statement From the American Heart Association. Circulation, 133(13), 1302–1331. https://doi.org/10.1161/CIR.0000000000000381
Mostafa, N., Sayed, A., Hamed, M., Dervis, M., Almaadawy, O., & Baqal, O. (2025). Gender disparities in delayed angina diagnosis: insights from 2001-2020 NHANES data. BMC Public Health, 25(1), 1197. https://doi.org/10.1186/s12889-025-22214-4
Williamson, L. (2024). The slowly evolving truth about heart disease and women. American Heart Association. https://www.heart.org/en/news/2024/02/09/the-slowly-evolving-truth-about-heart-disease-and-women
Writing Committee Members. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 78(22), e187–e285. https://doi.org/10.1016/j.jacc.2021.07.053
About the Author
Audrey Enerson, MPH, MS4
Audrey Enerson is a fourth year medical student at St. George’s University. She holds a Masters of Public Health in Epidemiology with a concentration in Global Public Health from the University of Minnesota and a Bachelor of Arts in Mathematics from Grinnell College. Prior to medical school she worked at the Minnesota Department of Health tracking antibiotic resistance for the CDC’s MuGSI study. Audrey was a board member of the Infectious Disease Society at SGU where she coordinated funding for STI testing and outreach at community health fairs. Outside of medicine, she enjoys going to spin classes and trying new foods.
Meghan Etsey, MS4
Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.