Sex-based and gender-based details in accelerated diagnostic protocol implementation among emergency department patients presenting with chest pain: a systematic review

BACKGROUND: Sex and gender influence how chest pain presents, how it is assessed and its outcomes, yet accelerated diagnostic protocols (ADPs) used in emergency departments (EDs) largely ignore these differences. This systematic review assesses the extent to which sex-based and gender-based factors are addressed in studies implementing ADPs in EDs for adult patients presenting with chest pain. METHODS: Six electronic databases were searched from inception through 31 May 2024, for ED-based studies on ADP implementation in adults with suspected cardiac chest pain. Eligible study designs included randomised controlled trials, controlled clinical trials, cohort studies, before/after studies and observational studies. Two reviewers independently screened articles for relevance and inclusion, with disagreements resolved by third-party adjudication. The primary outcome was the proportion of studies providing sex-disaggregated or gender-disaggregated analyses for key ED outcomes; secondary outcomes included the accuracy of sex and gender reporting per Canadian Institutes of Health Research definitions. RESULTS: From 19 455 records, 211 studies were included, predominantly prospective cohort designs (39%), with most data collected in ED settings (87%). While 95% reported participant sex, 76% did so appropriately; fewer than 20% considered sex or gender explicitly in their analyses or ADP applications. Gender was reported less frequently (37%) and reporting was largely inaccurate (92%). No studies presented sex-disaggregated or gender-disaggregated analyses for key ED outcomes (eg, length of stay, consultations, admissions, major adverse cardiac events). Regression analyses failed to identify significant increases in sex/gender reporting following major international sex-based and gender-based policy initiatives. CONCLUSION: Our findings highlight a critical need for improved and consistent integration of sex and gender in ED cardiac research. While most studies recognise the importance of sex differences, few explicitly addressed them, and even fewer considered the complexity of gender identities meaningfully. Future research should examine sex-specific and gender-specific troponin cut points, investigate at-risk groups and report disaggregated analyses of ED-relevant outcomes. PROSPERO REGISTRATION NUMBER: CRD42022380813.