Are women’s chest pains really different?

Make sure your emergency department (ED ) staff are aware that a woman typically presents with cardiovascular problems in a way that differs from a man’s presentation. Women often show up in the ED sicker than men, yet they don’t get EKGs and other diagnostic tests as quickly because of the way they describe their symptoms.

Until recently, women have not been included in clinical trials exploring cardiovascular physiology and treatment. Data coming from trials on men have been routinely extrapolated to women. As a result, little is known about coronary disease as it specifically affects women.

An emerging body of knowledge about gender-specificity is just now attracting attention — that heart disease manifests itself differently, that presenting symptoms and the age at which they appear may be different, and that the "norm" should not be based on what we know are male symptoms.

It may appear women have less coronary disease than men and less or different chest pain. The fact is that cardiovascular disease (CVD) is dangerously underdiagnosed in women. A woman’s response to diagnostic testing and her need for interventions differ from those in men. Women’s disease tends to strike later, and pain may come from comorbidities that confuse the diagnosis, such as arthritis, diabetes, or hypertension.

Judith Monteferrante, MD, a cardiologist at the George E. Reed Heart Canter in Hawthorne, NY, says, "Women typically develop coronary disease at a later age than men because of estrogen’s protective effect. For that reason they can typically have less progressed, less severe, one-vessel disease upon presentation."

"When the Framingham investigators looked at chest pain in women," says Monteferrante, "they contrasted it with chest pain in men. Women’s pain didn’t look ‘typical’ because it was a meld of several types. In fact, the chest pain associated with CVD in women is the same as that associated with the same disease state in men, but other causes for the pain confuse the diagnosis."

Average age of onset and character of symptoms are not the only factors that distinguish heart disease in women.

• Women with angina commonly suffer chest pain longer before presenting for diagnosis than do men. As a result, they tend to be sicker at presentation and have more comorbid conditions.

• Men are less likely than women to experience heart attack warning signs and are likely to have a full-blown MI upon presentation.

How manifestation of a cardiovascular problem is presented can affect its perception by the health care professional. Statistics show that if a cardiac problem is suspected in a woman, she is referred for invasive testing less often than men. In addition, she will receive medical management before being referred for surgery. A recent study demonstrated that EKGs are not done nearly as readily or quickly on women as on men in emergency departments. When a man comes to the ED with chest pain, an EKG is automatic.

To their detriment, women typically delay going for help, and early thrombolytic therapy is vital. To delay seriously reduces a woman’s chances for successful treatment.

A man goes to the doctor with the assumption that his pain is something to be taken care of. A woman typically understates or downplays her problem. Women tend to describe symptoms in ways that elicit diagnoses related to psychology rather than cardiology.

"Women often describe their pain or other symptoms more subjectively than men," says Monteferrante. If appropriate, women should be taught to communicate effectively so their physicians will take seriously their chest pain or other CVD symptomatology.

"If a woman comes in with the understanding that there is not much coronary disease in women," says Monteferrante, "and that it’s a man’s disease, she doesn’t take herself — or her symptoms — seriously."

Several research questions on CVD and women remain unanswered, such as gender differences in recovery patterns, the role of personality in disease progression, and how alcohol dependence affects outcome following heart surgery. A way to enlarge the database on CVD and women is to take a proactive stance on clinical trials. Encourage female patients to take part in studies. The more women that take part in studies, the more data can be gathered.