Chest pain main symptom in both men and women with suspected heart disease
A contribution by Monique ten Haaf and Yolande Appelman (both VUmc, Amsterdam, The Netherlands)
During the ACC conference in Chicago (Sunday, April 3) gender-specific research of the PROMISE trial will be presented. In this large randomized multicenter study the effectiveness of two diagnostic strategies in over 10,000 patients (> 5,200 women) with no previous cardiac history and symptoms suspicious for coronary artery disease (CAD) were evaluated. Patients were randomized to either anatomical testing with ≥64-slice multidetector coronary computed tomographic angiography or functional assessment (exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram). Patient characteristics, symptoms, evaluation and test results were compared between men and women.
One of the most important findings was that chest pain and shortness of breath are the most common symptoms for both men and women in suspected stable CAD. The description of chest pain was evident different; men described the pain as “aching”, “dull”, “burning” or “pins and needles”, whereas women were more likely to describe it as “crushing”, “pressure”, “squeezing” or “tightness”. A small proportion of women reported atypical symptoms as the main symptom. This is in contrast with previous (usually old or ACS) studies, which show that women are less likely to present with typical symptoms like chest pain and more often present with atypical symptoms that are not immediately recognizable as heart problems, such as back pain, abdominal pain and fatigue.
Women were on average three years older, were less often white, were less likely to smoke or be overweight and had more conventional risk factors such as hypertension and hypercholesterolemia. The prevalence of diabetes mellitus was similar between men and women. Non-traditional risk factors such as inactivity and depression were significantly more commonly found in women. Despite the typical symptoms and risk profile, women had lower scores than men on heart disease risk-assessment scores (e.a. Framingham risk score), and before any diagnostic tests were conducted, health care providers were more likely to consider that women probably did not have heart disease. Women were more often referred for stress echocardiography or nuclear stress test. They were less frequently found to have a positive test than men (9.7 vs. 15.1%).
This study covers one of the largest cohorts of women with stable angina and shows as in previous studies a higher risk profile in women. Despite this increased risk, and moreover similar symptoms, women have a lower pre-test probability and less often a positive test result. This is in line with angiographic findings from various studies that showed that women have less extensive and less severe obstructive CAD. The fact remains that a large group of women present with symptoms and risk factors at the doctor. New studies on the role of non-traditional risk factors, but also microvascular disease, are necessary for a better diagnostic assessment and treatment in these patients. Unfortunately, hard endpoints such as ACS or death have not been analysed in this study, this will be examined in a subsequent study.