Women Have Same Cardiac Symptoms as Men, but Describe Them Differently, Influencing Testing Choices

The two most common presenting symptoms in the setting of suspected coronary artery disease —chest pain and dyspnea—occur to the same degree in both sexes, but men and women tend to describe them differently, potentially leading to different diagnostic tests. 

Take Home. Women Have Same Cardiac Symptoms as Men, but Describe Them Differently, Influencing Testing ChoicesThose are the key results from a new analysis from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE), which examined whether presentation, risk assessment, and testing choices differs between men and women.

“Our findings suggest there might be need for heart-health resources specifically aimed at women, because much of what is provided is for men, and there are significant sex-based differences,” lead author Kshipra Hemal (Duke Clinical Research Institute, Durham, NC), said in a press release.

Hemal will present the study results here later today at the American College of Cardiology (ACC) 2016 Scientific Sessions; they were also published in JACC: Cardiovascular Imaging.

The study included 10,003 stable, symptomatic patients (52.7% women) from 193 centers in the United States and Canada, randomized to either functional testing or anatomical testing with multidetector CT angiography. Primary results from PROMISE were presented at the ACC 2015 meeting.

In the current analysis, more than 70% of men and women in the study reported chest pain as their primary symptom. However, descriptions of the pain varied, with more women than men describing it as “crushing/pressure/squeezing/tightness” (52.5% vs 46.2%; P < 0.001), and more men than women describing it as “aching/dull” (27.2% vs 23.6%; P < 0.001) or “burning/pins and needles” (10.3% vs 8.3%; P = 0.003).

Although more women than men reported back, neck or jaw pain, as well as palpitations, the percentage reporting those as their primary symptoms was very small. Dyspnea was equivalent, at approximately 15% in both sexes.

Prediction and Diagnostic Differences 

On each of the five global risk scores (Framingham, ASCVD, Diamond and Forrester, modified Diamond and Forrester, and combined Diamond-Forrester and CASS), the risk of events and pretest likelihood for CAD was lower for women compared with men. Overall, 40.7% of women were considered by their physicians to have a very low or low pretest likelihood of epicardial stenosis versus 34.1% of men (P < 0.001), and nearly twice as many men as women were considered to have a high or very high risk (6.3% vs 3.5%; P < 0.001).

Strikingly, the manner in which physicians responded to patient symptoms diverged.

Women were more frequently sent for nuclear stress testing compared with men, while men were more likely to undergo exercise ECG than women. Even after controlling for possible confounders, doctors were 21% more likely to refer women for stress echocardiography or a nuclear stress test than they were men, although the likelihood of a positive test was lower in women. Moreover, predictors of a positive test differed, with only BMI and Framingham risk score showing predictive ability in women.

“For healthcare providers, this study shows the importance of taking into account the differences between women and men throughout the entire diagnostic process for suspected heart disease,” Hemal said. 

Underestimation of Risk Possible

In an editorial accompanying the study, Jennifer H. Mieres, MD (Hofstra Northwell School of Medicine, Hempstead, NY), and Robert O. Bonow, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), say the results “add credence to the ongoing concerns that women are preferentially likely to receive less intensive management of CAD than their male counterparts.”

But they note that the emphasis on the use of diagnostic testing in the study likely underestimates the full pathophysiologic spectrum of ischemic heart disease (IHD) that appears to be unique in women.

“This underestimation of future IHD risk could have profound implications, resulting in the potential of a false sense of security (on the part of the physician as well as the patient) in symptomatic women with negative noninvasive tests,” they write.

Mieres and Bonow agree with the study investigators, however, that “focused sex-specific diagnostic strategies are needed to reduce the cardiovascular mortality and morbidity in women.” They add that diagnostic algorithms must include functional and anatomic cardiac tests, as well as physiologic assessments of endothelial and microvascular function, in order to accurately diagnose and predict the course of the disease in women.

  • Hemal K, Pagidipati NJ, Coles A, et al. Sex differences in demographics, risk factors, presentation, and noninvasive testing in stable outpatients with suspected coronary artery disease: insights from the PROMISE trial. J Am Coll Cardiol Img. 2016;9:337-346.
  • Mieres JH, Bonow RO. Ischemic heart disease in women: a need for sex-specific diagnostic algorithms. J Am Coll Cardiol Img. 2016;9:347-349.


  • The study was funded by the National Heart, Lung, and Blood Institute.
  • Hemal, Mieres, and Bonow report no relevant conflicts of interest.

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