Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.
Highlights
Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men [1, 2]
Excess mortality in women appear to be driven by age, as women are older with more co-morbidities which may contribute to delays in aggressive treatment, and lower preventive therapy compared to men [4, 5]
Sex and gender differences are well-described in questionnaire tools, including the Rose Questionnaire [60], the Diamond and Forrester tool [61], the updated Diamond-Forrester score (UDF), CAD Consortium clinical score (CAD2), and CONFIRM risk score (CRS), [62] the Duke Clinical Score [61, 63]
Summary
Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men [1, 2]. Women are underdiagnosed for myocardial infarction, less likely to undergo coronary angiography, and less likely to receive therapies such as revascularization and mechanical circulatory support [8, 10,11,12,13]. Excess mortality in women appear to be driven by age, as women are older with more co-morbidities which may contribute to delays in aggressive treatment, and lower preventive therapy compared to men [4, 5]. Even though standardized STEMI protocols appear to eliminate sex-differences in age-adjusted mortality, contemporary data demonstrate persistent delayed contact-to-reperfusion time, and less guideline-recommended medical therapy in women compared to men [15,16,17]
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