Women's Chest Pain not Taken Seriously as Men's

Women's Chest Pain

Women with stable chest pain are less likely than men to be referred for diagnostic tests, receive revascularization procedures or be prescribed preventive medication, according to a study published in Circulation: Journal of the American Heart Association.

After one year of follow-up, a European study found women with confirmed coronary artery disease (CAD) were twice as likely as men to suffer a heart attack or die.

"Women are under-investigated and under-treated," said Caroline Daly, M.B., lead author of the study and a cardiologist in training at the Royal Brompton and Harefield National Health Service Trust in London. "Women's symptoms are not investigated in the same way, whether it is invasive or non-invasive diagnostic testing.

"Something is happening here either in the way women impart their symptoms to physicians or the way that physicians interpret those symptoms," she said. "Even with a clinical diagnosis of stable angina, women aren't receiving medication to prevent death or heart attack to the same extent as men."

Stable angina (chest pain on exertion) is the most prevalent symptom of CAD, the build up of fatty plaque in the arteries which can result in a heart attack. While the overall incidence of CAD is higher in men, stable angina is more commonly the initial symptom that sends women to the doctor.

Researchers collected diagnostic and treatment information on 3,779 stable angina patients in 197 centers across Europe. The patients, average age 61, mostly had mild to moderate stable angina. Women represented 42 percent of the group and the primary outcome was death or heart attack over 13 months.

Although women in the study were experiencing chest pain of similar severity, fewer women underwent the initial test to confirm the diagnosis or to determine if invasive testing was required. In most cases, the initial test was an exercise electrocardiogram (ECG), but may have been an alternative stress test if exercise was not possible for the patient. Seventy-eight percent of men and 73 percent of women had at least one ECG after the initial clinical diagnosis of stable angina.

Even when CAD was confirmed with exercise ECG, fewer women underwent coronary angiography (56 percent) than men (65 percent). Coronary angiography is an X-ray examination of the blood vessels of the heart to determine if blockages exist within the vessels. A small tube (catheter) is inserted in a blood vessel in the groin or arm, then is positioned in the arteries supplying the heart with blood. A contrast medium or dye is injected and is visible by X-ray.

If the results of the exercise ECG were inconclusive, women also were less likely to receive angiography. Forty-two percent of men and 34 percent of women with inconclusive findings had the procedure to diagnose possible blockages. When CAD was detected on angiography, women were more likely to have single vessel disease and men were more likely to have two or three vessel disease.

Women also were less likely than men to undergo percutaneous coronary intervention procedures such as stenting, or bypass surgery to provide adequate blood flow to the heart. Researchers found that even with proven CAD, women were 30 percent less likely to have revascularization procedures than their male counterparts.

After adjusting for severity of CAD, the difference in rates of revascularization procedures between men and women was not statistically significant but still showed a trend. Daly said men were more likely to have severe CAD requiring bypass surgery and women were more likely to have single vessel disease, which is a possible reason for the difference in rates of revascularization. "Revascularization procedures were not used in women in the same way the procedures were used in men," Daly said. "Women's symptoms aren't being treated as aggressively."

At one year, researchers also discovered that women with confirmed CAD were less likely than men to be prescribed cholesterol-lowering drugs and the combination of cholesterol-lowering and anti-platelet drugs. Women with confirmed CAD also were less likely to have successful treatment for their chest pain, with only 43 percent of women reporting no angina at study end compared to 53 percent of men.

The results don't indicate that every woman with stable angina should have coronary angiography, but the guidelines for appropriate treatment for cardiovascular disease need to be applied equally in men and women, Daly said.

"Angina is not something to be taken lightly," she said. "Women with angina need to be worked up appropriately and secondary prevention implemented as necessary."

In an accompanying editorial, Viola Vaccarino, M.D., Ph.D., associate professor of medicine, Emory University School of Medicine, division of cardiology in Atlanta, Ga., said results of this study indicates the need to continue striving towards improving cardiac care of women. Vaccarino also suggested the use of appropriate noninvasive diagnostic techniques in women with chest pain, and a better education of clinicians towards risk assessment and management of women with suspected or confirmed CAD.