If you had told me 5 years ago that this would be the front page of JACC CI, I'm not sure I would have believed you. My thanks to these colleagues for their work.

I appreciate this unsolicited swipe at Canadian ERs. But guess what happens when you call a cardiologist about a low positive troponin at 0400AM? Sure, go ahead and blame ER - everyone does. But first understand what ER faces to get cardiology interest in a case. 👇👇👇 It could be true that the threshold of a high sensitivity troponin for diagnosing myocardial ischemia in women is different. If that's new - which it would be - that's important. Professional guidelines and continuing education has not reflected this possibility. In the last 2 weeks, I attended 2 lectures by physicians passionate about diagnosing myocardial infarction and there was zero mention of the concerns raised in this article. It could be charged that is the problem - doctors are dumb and sexist - but again, these are physicians with an incredible research, publishing and teaching record in diagnosing MI in all types of patients. They are dedicated to finding the elusive heart attacks. New guidelines could be forthcoming but that doesn't excuse taking a swipe at ERs that are doing their best under difficult circumstances. Avis should take a breath and talk to an ER doctor next time before unloading a headline on ER. When you call cardiology about a female with a low troponin - they'll account for it over the phone, calling it "strain" or not worrisome and direct you to outpatient follow-up or calling internal medicine. You can call a cardiologist about a patient with EKG changes, worrisome troponin, and active chest pain, and they are not going to rush in every time. That's reality. Would ER like more cardiology interest? Sure. Just remember, it's cardiology and not ER that control who gets interventional angiography. ER behaves the way it does because it knows the interest of cardiology. They know the institutional guidelines when to call them. ER isn't making the rules, they are following them. This article does cite important anginal equivalents like nausea, shortness of breath and indigestion - and in defense of ER - this is well known. If you ask a real ER doctor - we are smashed by EKGs for far far less during a regular shift. These types of patients are already being evaluated for myocardial ischemia. But too bad Avis didn't think of asking an ER doctor what happens in the ER rather than just taking a kick at them and the brutal work they do when everyone else is having Thanksgiving turkey. Favaro cites Alberta data saying "300 women a year were sent home from emergency departments in the province, then returned with a heart attack within 30 days". No where in the article (which I read) does it actually describe what really happened. Was it because the ER doctor made a mistake? Was it because cardiology refused to see the patient despite the advocacy of the ER doctor? Was it because the hospital guidelines meant the patient was ineligible for real-time cardiology consultation? We don't know. The articles doesn't say. But yah, it's all ER's fault as the click-bait headline reads. ER is an easy target for criticism. But very few can do the job for a career. And if you do, you should be ready for criticism by people on the sidelines who aren't going to put on a stethoscope and see patients. This type of journalism - isn't helping the situation. It's click-bait and riles up people to read the article and learn how they've been shafted by dumb and uncaring doctors and to be upset at ER when ER is powerless over who gets invasive testing. So - to conclude - would ER like more cardiology interest in women - yes, for sure. But maybe blame the cardiologists alongside the ERs because at 0400AM we know who is working hard in terrible conditions getting the middle finger from patients, getting kicked punched and swore at - and who isn't. @Avis_Favaro @ECGcases @smithECGBlog @amalmattu