Chest Pain In Women Research Articles

The time has come to change how emergency physicians evaluate chest pain in women

The time has come to change how emergency physicians evaluate chest pain in women

Chest Pain in Women: Gender- and Sex-based Differences in the Presentation and Diagnosis of Heart Disease

Ischemic heart disease is a major cause of morbidity and mortality in the US, affecting both men and women significantly. The presentation of chest pain is largely similar in female and male patients, but additional non-chest pain symptoms can confound timely diagnosis in women. Management, diagnostic evaluation, and clinical outcomes for patients admitted with chest pain differ significantly between men and women, and understanding of these discrepancies is limited. The objective of this review is to familiarize readers with gender- and sex-specific differences in the presentation, diagnosis, and management of chest pain.

Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender.

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

Reappraising Ischemic Heart Disease in Women.

Despite advances in the management of ischemic heart disease worldwide, mortality in women remains disproportionally high in comparison to men, particularly in women under the age of 55. The greater prevalence of ischemia with non-obstructive coronary arteries (INOCA) in women has been highlighted as a potential cause of this disparity. Moreover, current guideline recommendations for computed tomography coronary angiography (CTCA) as the first line of investigation for stable chest pain may further amplify this inequality. Traditional cardiovascular risk factors carry greater influence in women than men in the development of ischemic heart disease. Despite this, women have been consistently under-represented in large-scale clinical trials. Chest pain in women is more likely to be overlooked due to the higher likelihood of atypical presentation and normal anatomical imaging, despite persistent symptoms and decreased quality of life indicators. Accordingly, we call into question a CTCA-first approach in clinical guidelines; instead, we favor a personalized, patient first approach. Due to the misdiagnosis of ischemic heart disease in women, a large proportion are denied access to preventative therapy. This is especially true of women with INOCA, for which there is a critical lack of specific guidelines and rigorous evidence-based therapies. Ongoing clinical trials aim to identify potential management options that may benefit those with INOCA, bringing the field closer to eliminating sex-related disparities in the diagnosis, management and prognosis of ischemic heart disease.

Beyond the AJR: Comparison of Coronary CTA and Invasive Coronary Angiography for Evaluation of Stable Chest Pain in Women and in Men.

Beyond the AJR: Comparison of Coronary CTA and Invasive Coronary Angiography for Evaluation of Stable Chest Pain in Women and in Men.

CHEST PAIN IN WOMEN. IS IT ALWAYS ATHEROSCLEROTIC?

Patients both male and female with diagnosis of Acute Coronary Syndrome (ACS) present with chest pain as presenting complaint. Lichtman JH et al. in his study with ACS showed that 93% of women presented with chest pain or discomfort.1 As compared to men women experience more associated symptoms as primary complaint. The associated symptoms are fatigue, dyspnea, backache, flue like symptoms, indigestion, palpitations and most common is anxiety & feeling scarry.2 Keeping these scenarios in mind one should inquire this associated presentation along with chest pain or discomfort in evaluating ACS in women. In continuation with symptoms there is quite a debate on pathophysiology of Acute Myocardial infraction in men and women regarding coronary pathologic features.3 Type 1 plaque rupture most common in both genders with plaque erosion most common in women in non-obstructive coronary artery disease.4 Spontaneous coronary artery dissection (SCAD) having high mortality exists in the absence of risk factor of ACS.5 It was found in women up to 35% of patients with mean age of 42 to 53 years with a MACE (Major acute coronary event) of 47.4% and 10 years mortality rate of 7.7%2 SCAD seen in peripartum cases, oral contraception use, lack of exercise, connective tissue disorders and vasculidites. It is important for the physician to have in mind these disorders to avoid complications of coronary interventions. In a scientific statement from AHA, Mehte LS et al. showed a lower prevalence of atheroscrotic CAD in women.3 These are certain scoring system,6 that under present women because of vague symptoms and presentation. These scoring systems lead to decrease hospital admission and less noninvasive cardiac testing. For risk satisfaction of chest pain female gender should not be taken as sole criteria for presence or absence of coronary events in presence of other multiple factors. The last but not the least is the psychosocial stress more in women than in men. It has been found that young women who present with early onset myocardial infarction have more psychosocial risk factors in comparison to men of similar age,3 probably having high rates of poverty and trauma exposure during childhood because of various reasons.7 Different studies are endorsing relationship between depression and ischemic heart disease as prognostic factor after ACS.7 In our population where there is lack of education, poverty, awareness of disease especially in women the physician should ponder on different factors mentioned above i.e. presentation perceptions, prevalence, pathophysiology and psychosocial stress for evaluation and management of chest pain.

Unmasking Syndrome X

Background. The differential diagnosis of chest pain in women is complex, ranging from atypical angina to chest pain in the absence of coronary artery disease (i.e., Syndrome X). The mechanism of these conditions remains unexplained. The purpose of this study was to examine coronary blood flow based on a new angiographic technique. Methods. Patients with chest pain were enrolled. In the new technique, as the contrast injection stopped, the blood in white color moved in and displaced the black contrast. Characteristics of blood flow could be observed and classified by type and time. The duration of the arterial phase was calculated and compared with the control. Results. Sixty patients were enrolled. Ten patients with normal coronary arteries and ventricular function; without chest pain served as controls. In the control group, the duration of the arterial phase in the RCA was 1.76 sec, while it was 3.76 sec for the syndrome X group (p<0.05). From the mMID segment to the distal segment, syndrome X patients had a much longer delay compared to control subjects (0.81 vs. 0.26 sec) (p<0.05). From the distal segment (bDIS) to the origin of the PDA, syndrome X patients had an average duration of 0.81 sec compared to 0.40 sec in controls (p<0.05). The largest difference was the period of time when the contrast left the PDA until flushed from the distal vasculature, which was 1.66 sec and 0.40 sec in syndrome X vs. control. Syndrome X patients with prolonged myocardial phase (1.89 sec) had dense and prolonged contrast retention at the myocardium. Conclusions. In patients with syndrome X, the prolonged arterial phase deprived the myocardium of highly oxygenated blood and triggered ischemia. This new imaging method allows for a better understanding of the mechanism of ischemia in Syndrome X patients.

Abstract 13064: Sex-Related Differences in Chest Pain and Asymptomatic Myocardial Ischemia Experienced During Exercise Stress Echocardiogram

Background: Coronary artery disease (CAD) continues to account for significant morbidity and mortality for both men and women. Women present with greater variability in symptoms from coronary artery disease than men. This study seeks to describe the potential differences between men and women in the association between stress test-related chest pain and obstructive CAD. Methods: Patients with an exercise stress test who underwent a coronary angiogram from September 2013 to January 2019 were included in our analyses. The patients’ clinical characteristics, symptoms, coronary angiography and ECGs were analyzed to determine the relationship between ischemia, chest pain, and obstructive coronary artery disease (CAD; stenosis > 70%). T-tests and chi-square tests described differences in continuous and categorical variables, respectively. Logistic regression was used to adjust for demographic, imaging, and stress testing factors. Results: A total of 368 patients were included in our analyses: 297 patients had a positive stress echocardiogram or ECG; 71 patients had negative stress tests but continued to have persistent symptoms. The study population had a mean age of 63 years and included 29% female, 11% African-American, and 61% obstructive CAD. In those with obstructive CAD, only 39% of women experienced chest pain during stress (p>0.2), but in men, 48% experienced stress test related chest pain (p<0.001). Adjusting for baseline demographics in sex-stratified models, echo-based ischemia and ECG-based ischemia were significantly associated with obstructive CAD in women, but stress-test related chest pain was not (p=0.02; p<0.001; p>0.2, respectively). In men, echo-based ischemia, ECG-based ischemia, and stress-test related chest pain all associated with obstructive CAD (p<0.001; p<0.001; p=0.008, respectively). These changes persisted with adjustment for stress test performance (METS, heart rate achieved) as well as baseline left ventricular ejection fraction. Conclusion: In women, stress test-related chest pain during stress testing was not associated with obstructive CAD. Further studies are needed to understand the role, significance, and management of potential myocardial ischemia without chest pain in women.

Sex differences of the association between marital status and coronary artery disease in patients experiencing chest pain: The Korean Women's Chest Pain Registry.

Marriage is an important social practice that predicts various health outcomes, including those of cardiovascular disease. This study investigated the sex-specific association between marital status and coronary artery disease (CAD) in patients experiencing chest pain. Study data were obtained from a nationwide registry of patients with suspected CAD who underwent coronary angiography. We dichotomized all participants according to marital status as follows: without a spouse (single, divorced, or widowed), and with a spouse. Significant CAD was defined as greater than 50% narrowing of the lumen diameter in any of the coronary arteries. The presence of significant CAD was significantly higher in female participants without a spouse than in female participants with a spouse. However, there was no significant difference in the presence of CAD in men between the two groups. Interestingly, there was also no significant difference in the presence of CAD between women without a spouse and men without a spouse. After adjustment for all possible confounding factors, women without a spouse had a 1.62-fold increased hazard for significant CAD in multivariate regression analysis. In contrast to men, a without spouse status is independently associated with significant CAD in women experiencing chest pain. Women with a spouse had the lowest presence of CAD among all groups. In the management of female patients experiencing chest pain, clinicians should consider their social characteristics, including marital status, to predict subsequent cardiovascular disease and determine the appropriate treatment. : Video Summary:http://links.lww.com/MENO/A567.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women's Chest Pain Registry.

Background/AimsChest pain in patients with obstructive coronary artery disease (OCAD) is affected by several social factors. The gender-based differences in chest pain among Koreans have yet to be investigated.MethodsThe study consecutively enrolled 1,549 patients (male/female, 514/1,035; 61 ± 11 years old) with suspected angina. The predictive factors for OCAD based on gender were evaluated.ResultsMen experienced more squeezing type pain on the left side of chest, while women demonstrated more dull quality pain in the retrosternal and epigastric area. After adjustment for risk factors, pain in the retrosternal area (odds ratio [OR], 1.491; 95% confidence interval [CI], 1.178 to 1.887) and aggravation by exercise (OR, 2.235; 95% CI, 1.745 to 2.861) were positively associated with OCAD. In men, shorter duration (OR, 1.581; 95% CI, 1.086 to 2.303) and dyspnea (OR, 1.610; 95% CI, 1.040 to 2.490) increased the probability for OCAD, while left-sided chest pain suggested a low probability for OCAD (OR, 0.590; 95% CI, 0.388 to 0.897). In women, aggravation by emotional stress (OR, 0.348; 95% CI, 0.162 to 0.746) and dizziness (OR, 0.457; 95% CI, 0.246 to 0.849) decreased the probability for OCAD.ConclusionsThis is the first study to focus on gender differences in chest pain among Koreans with angina. Symptoms with high probability for OCAD were different between sexes. Our findings suggest that patient’s medical history in pretest assessment for OCAD should be individualized considering gender.

Deciphering chest pain in women

The causes of chest pain range from benign sources such as muscle strain to life-threatening diagnoses such as aortic dissection and myocardial infarction. The likelihood and presentations of disorders causing chest pain are different between women and men. This article highlights important features in determining a correct diagnosis.

Sex Differences in the Relationship Between Left Ventricular Diastolic Dysfunction and Coronary Artery Disease: From the Korean Women's Chest Pain Registry.

Although coronary artery disease (CAD) is an important comorbidity, the influence of CAD on left ventricular diastolic dysfunction (LVDD) is not clear. This study aims to assess differences in the relationship between CAD and LVDD according to sex and comorbidities. A total of 1109 consecutive patients who visited an outpatient clinic with chest pain were included. The outcomes in 295 men and 295 women were compared after propensity score 1:1 matching. The evaluation of LVDD was based on guidelines recommended by the American Society of Echocardiography. The presence and severity of obstructive CAD was assessed by coronary angiography. After propensity score matching, both men and women were well balanced, with no significant differences of baseline covariates. Differences in diastolic functional parameters according to CAD severity were observed only in women (three parameters of LVDD except e' velocity, p < 0.05). Multiple logistic regression for matched pair data demonstrated that CAD severity was associated with the presence of LVDD only in women (odds ratio 1.919, 95% confidence interval 1.343-2.741, p < 0.001). Interaction between sex and severity of CAD was significant (p = 0.025). The association of LVDD and CAD severity was observed only in women. Myocardial ischemia may be a potential pathophysiology for higher prevalence of LVDD and heart failure with preserved ejection fraction in women.

Utility of Imaging in Risk Stratification of Chest Pain in Women.

Recent decades have seen a growing recognition that the understanding of sex differences in cardiovascular disease (CVD) is vital to optimal diagnosis and management, particularly of women (Mosca et al. Circulation 124:2145-54, 2011). There is simultaneously an increasing appreciation of the multifactorial nature of ischemic heart disease (IHD) in many patients, in whom disease may extend beyond the epicardial coronaries. While obstructive coronary artery disease (CAD) remains underdiagnosed in women and still represents a major burden of disease, women also present with nonobstructive CAD more commonly than men (Patel et al. N Engl J Med 362:886-95, 2010). Indeed, microvascular dysfunction, coronary artery vasospasm, and coronary dissections contribute to a larger proportion of IHD in women than men (Bairey Merz et al. J Am Coll Cardiol 47:S21-9, 2006). Here, we review the symptom presentation of women with IHD and the noninvasive modalities used to risk stratify women with suspected IHD.

P2436Sex difference in the association of left ventricular diastolic function with coronary artery disease: from the Korean women's chest pain registry (KoROSE)

P2436Sex difference in the association of left ventricular diastolic function with coronary artery disease: from the Korean women's chest pain registry (KoROSE)

Gender Differences in Post-Traumatic Stress

Acute stress can trigger cardiovascular events and disease. The earthquake is an “ideal” natural experiment for acute and chronic stress, with impact mainly on the cardiovascular system. On May 20th and 29th, 2012, two earthquakes of magnitude 5.9° to 6.4° on the Richter scale, hit the province of Modena and Reggio Emilia, an area of the north-center of Italy never considered at seismic risk. The purpose of our study was to assess whether there were gender-specific differences in stress-induced incidence of cardiovascular events and age of patients who arrived at the Emergency Departments (ED) of the three main teaching hospitals of the University of Modena and Reggio Emilia. Global access of patients, divided in relation to age, gender, and diagnosis was compared with that one detected in the same departments and in the same interval of time in 2010. The data collected were relative to consecutive cases derived by retrospective chart and acute cardiovascular events were classified according to ICD-9 (International Classification of Diseases, ninth revision). A total of 1,401 accesses were recorded in the year of earthquake versus 530 in 2010 (p ≤ 0.05), with no statistically significant differences in number of cases and mean age in relation to gender, despite the number of women exceeded that of men in 2012 (730 vs. 671); the opposite occurred, in 2010 (328 vs. 202). The gender analysis of 2012 showed a prevalence of acute coronary syndromes (ACSs 177 vs. 73, p ≤ 0.03) in men, whereas women presented more strokes and transient ischemic attacks (TIAs) (90 vs. 94, p ≤ 0.05), atrial fibrillation (120 vs. 49, p ≤ 0.05), deep venous thrombosis and pulmonary embolism (DVT/PE; 64 vs. 9, p ≤ 0.05), panic attacks (124 vs. 26, p ≤ 0.03), aspecific chest pain (122 vs. 18, p ≤ 0.05), TakoTsubo cardiomyopathy (10 vs. 0, p ≤ 0.05), and DVT/PE (61 vs. 3, p ≤ 0.03). The gender analysis of 2010 showed no difference in number of accesses and age, with higher incidence of ACS in men (130 vs. 34, p ≤ 0.05) and aspecific chest pain in women (42 vs. 5, p ≤ 0.05). The analysis between 2012 and the standard period (2010) showed women recurring to ED in larger number with more panic attacks (124 vs. 3, p ≤ 0.01), more atrial fibrillation (120 vs. 40, p ≤ 0.01) and, as a possible consequence, more TIAs and strokes (190 vs. 25, p ≤ 0.005), more TakoTsubo (10 vs. 0, p ≤ 0.05), DVT/PE (61 vs. 3, p ≤ 0.05), and aspecific chest pain (122 vs. 5, p ≤ 0.01). The difference between men's accesses to ED was less striking, but in 2012 men reported more panic attacks (26 vs. none, p ≤ 0.05), more atrial fibrillations, TIAs, and strokes (49 vs. 13, p ≤ 0.05 and 94 vs. 18, p ≤ 0.03). In conclusion, clinical (stress induced) events recorded during and immediately after the 2012 earthquakes were quite different between women and men, although the pathophysiological mechanism was probably the same, consisting acute sympathetic nervous activation, with elevation of blood pressure and heart rate, endothelial dysfunction, platelet and hemostatic activation, increased blood viscosity, and hypercoagulation. Women, in our observation, appeared to be more sensitive and responsive to acute stress, although men also appeared to suffer from stress effects when compared with a standard period, which, nevertheless, reflects in our population the most common epidemiology of gender difference in ED accesses for cardiovascular events.

OS 23-05 LEFT VENTRICULAR HYPERTROPHY AND SIGNIFICANT CORONARY ARTERIAL STENOSIS INTERACTION IN HYPERTENSIVE WOMEN

Objective: Left ventricular hypertrophy (LVH) and coronary atherosclerosis are common cardiac complications of hypertension. Previous studies have shown that LVH is associated with increased cardiovascular mortality, regardless of coronary artery disease. The purpose of this study was to evaluate the relationship between LVH and significant coronary arterial stenosis in hypertensive women with chest pain. Design and Method: One hundred ninety four hypertensive women with eligible data from the Korean women's chest pain registry (KoROSE) study were included. We analyzed echocardiographic data, demographic information, risk factors for cardiovascular disease, medical history, medication, and biochemical data. Patients with history of arrhythmia or significant valvular heart disease were excluded. LVH was defined if left ventricular mass index (LVMI) normalized by body surface area was more than 95 g/m2. Significant coronary arterial stenosis was defined as ≥50% luminal obstruction at least in one major epicardial coronary artery. Results: LVH group (n = 108) showed higher prevalence of significant coronary arterial stenosis compared with group without LVH (n = 86) (67.1% vs. 50.0%, p = 0.035). Body weight, height, blood pressure (BP), and lipid profile and hematologic findings were not significantly different between two groups. Total duration of exercise and the amount of work were not significantly different between two groups. However, LVH group showed higher diastolic BP at peak exercise in treadmill exercise test (85.4 mmHg vs. 77.1 mmHg, p = 0.003). Left ventricular ejection fraction (LVEF) was lower and parameters of diastolic function such as left atrial size were distorted in LVH group (p < 0.05). LVMI was correlated with LVEF and diastolic parameter. LVH was a predictor of significant coronary arterial stenosis (Odds ratio 2.037, 95% confidence interval = 1.066–3.894). Conclusions: LVH defined by LVMI is associated with higher prevalence of significant coronary arterial stenosis in hypertensive women with chest pain.

Sex Difference in the Association Between Brachial Pulse Pressure and Coronary Artery Disease: The Korean Women's Chest Pain Registry (KoROSE).

This study was performed to investigate the association between brachial pulse pressure (PP) and the presence/extent of obstructive coronary artery disease (CAD) in men and women. Study data were obtained from a nation-wide registry composed of 632 patients (173 men and 459 women, 58.1±10.5 years) with suspected CAD who underwent invasive coronary angiography. PP was higher in patients with obstructive CAD (≥50% stenosis) than those without CAD in both sexes (P=.032 in men; P<.001 in women). However, PP increased proportionally with the increasing number of obstructed coronary arteries in women (P<.001) but not in men (P=.070). Multiple logistic-regression analyses demonstrated that higher PP (≥50.5 mm Hg) was an independent factor for determining obstructive CAD even after controlling for potential confounders in women (odds ratio, 2.83; 95% confidence interval, 1.40-5.73; P=.004). These results were consistent in 173 selected women matched with 173 men based on age and CAD severity. In conclusion, the association between brachial PP and obstructive CAD was more pronounced in women than in men. Brachial PP can be a simple and useful indicator of CAD especially in women.

Is there any gender difference in coronary angiography of chest pain in women? From the Korean women's chest pain registry (KOROSE)

Is there any gender difference in coronary angiography of chest pain in women? From the Korean women's chest pain registry (KOROSE)

Identifying and managing chest pain in women.

Heart disease continues to be the leading cause of death in women in the United States. Sex disparities remain despite research highlighting the unique aspects of managing women with ischemic heart disease. Increased mortality in women may be related to the critical differences in the clinical presentation of ischemic heart disease between the sexes. Sex-related differences in the pathophysiology of ischemic heart disease also influence diagnostic testing and management. This article reviews the differences in diagnosis and management between men and women with ischemic heart disease.

Characteristics of Chest Pain in Women

According to this study: * The characteristics of chest pain in men and women with acute myocardial infarction (AMI) were similar. However, chest pain characteristics alone weren't helpful for early detection of AMI in women.