Atypical chest pain in women revisitedLiterature - Kreatsoulas C, Shannon HS, Giacomini M, et al. - JAMA Intern Med. 2013 Apr 8:1-2. doi: 10.1001/jamainternmed.2013.229. [Epub]
Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men.
Kreatsoulas C, Shannon HS, Giacomini M, et al.
JAMA Intern Med. 2013 Apr 8:1-2. doi: 10.1001/jamainternmed.2013.229. [Epub]
Coronary artery disease (CAD) is the leading cause of mortality in the Western world. The prevalence of angina and proportion of deaths from CAD is higher among women than men [1,2], but it is still perceived that CAD is a man’s disease[3-5], powered by assumptions in the construct of angina, failure to systematically include women in clinical studies, and differences in age-specific incidence rates [5,6]. The term “typical angina” is therefore often used to describe symptoms in men, whereas “atypical angina” is used for women. This lack of clarity has been a source of controversy in understanding CAD in women. The objective of this study was to quantify male-typical vs female-typical angina symptoms
as they range along a continuum among patients with obstructive CAD. From June through November 2010, 128 men and 109 women were enrolled. Traditional risk factors were present in 118 participants (50% of the sample).
- The most common descriptors used by men and women with obstructive CAD included “chest pain” (82% vs 84%; P=.72), “pressure” ([54% vs 58%; P=.65), and “tightness” (43% vs 58%; P=.08), respectively.
- Women used certain descriptions approximately twice as often as men, including “discomfort” (46% vs 28%; P=.03), “crushing” (24% vs 9%; P=.02), “pressing” (28% vs 14%; P=.04), and “bad ache” (30% vs 15%; P=.04).
- Men and women reported pain in the same areas outside the chest region, including the arms (43% vs 50%; P=.40), back (26% vs 30%; P=.65), and shoulders (32% vs 26%; P=.45), respectively.
- Other symptoms reported by men and women included shortness of breath (67% vs 76%; P=.25), fatigue (56% vs 62%; P=.52), sweating (48% vs 46%; P=.80), and weakness (32% vs 46%; P=.11), respectively.
There is a substantial overlap of shared symptoms between men and women with obstructive CAD. This information can help clinicians to better recognize symptoms associated with obstructive CAD rather than adhering to the conventional “typical” and “atypical” angina distinction. Future studies should test and validate the symptom continuum according to gender in diverse patient populations.
“Women and men are more alike than we think in presentation of CAD, and both are most likely to experience chest pain, pressure, and tightness. It is likely that atypical symptoms represent women who do not have ischemic CAD. These findings should be a great relief to the many women who have been concerned that they could be having a myocardial infarction unbeknownst to them because they would not get the typical warning symptoms of chest pain.
Editorial comment 
1. Hemingway H, Langenberg C, Damant J, et al. Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries. Circulation. 2008;117(12):1526-1536.
2. Lloyd-Jones D, Adams RJ, Brown TM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2010 update [published corrections appear in Circulation. 2010;121(12):e260 and Circulation. 2011;124(16):e425]. Circulation. 2010;121(7):e46-e215.
3. Grundy SM, D’Agostino RB Sr, Mosca L, et al. Cardiovascular risk assessment based on US cohort studies: findings from a National Heart, Lung, and Blood Institute workshop. Circulation. 2001;104(4):491-496.
4. Mosca L, Mochari-Greenberger H, et al. Twelveyear follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health. Circ Cardiovasc Qual Outcomes. 2010;3(2):120-127.
5. Shaw LJ, Bairey Merz CN, Pepine CJ, et al; WISE Investigators. Insights from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study: part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol. 2006;47(3)(suppl):S4-S20.
6. Kannel WB,Castelli WP. The Framingham study of coronary disease in women. Med Times. 1972;100(5):173-175.
7. Redberg RF. Debunking Atypical Chest Pain in Women Comment on "Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men" JAMA Intern Med. 2013 Apr 8:1. doi: 10.1001/jamainternmed.2013.1187. [Epub]
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