Coronary Artery Disease
Angina symptoms in men and women with
stable coronary artery disease and evidence
of exercise-induced myocardial perfusion defects
Bianca D’Antono, PhD,
Gilles Dupuis, PhD,
Christophe Fortin, MA,
Andre´ Arsenault, MD,
and Denis Burelle, MD
Montreal, Quebec, Canada
To examine sex differences in pain and associated symptoms in patients with exercise-related ischemia,
as well as the independence of these findings from other clinical factors.
Prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with
myocardial perfusion imaging (MPI). Analyses were performed on 38 women and 94 men with both angina and MPI
evidence of ischemia during exercise.
Chest pain localization, extension, intensity, quality, and presence of various non–pain-related symptoms.
Women rated their pain as more intense, used different words to describe it, and reported more non–pain-related
symptoms than men ( P b .05). They experienced pain and other sensations in the neck area more frequently ( P b .05).
Most of these differences remained after controlling for clinical or psychological variables, with the exception of pain
Sex differences in the experience of symptoms associated with MPI evidence of myocardial ischemia may
complicate timely and accurate diagnosis of ischemia in women. (Am Heart J 2006;151:813-19.)
Research in coronary artery disease (CAD) has gener-
ally been targeted toward white middle-aged men.
CAD is the leading cause of mortality in women in
Neglect of women in research
may have contributed to sex disparities in the diagnosis
and management of suspected CAD.
The interpretation of early symptoms of CAD in
women may constitute a barrier to proper diagnosis.
The most common symptom is chest pain or angina.
Studies suggest that chest pain presentation in women
differs from that in men (eg, see Refs 9,12 -16). This is
worrisome given that the standard diagnostic criteria of
acute coronary events were developed from research
with men. If women’s reports do differ, albeit in only
some respects from men, this may lead them or their
caretakers to disregard important warning signals, thus
delaying diagnosis and treatment.
We previously investigated sex differences in pain
diagnosis, quality, and locus in patients with nontrau-
matic chest pain presenting to the ambulatory emergency
Consistent with growing evidence,
a variety of sex differences emerged and suggested that
nonpain symptoms may also be important in women.
Limitations in previous studies may have led to under-
estimations of sex differences in CAD symptoms.
Goldberg et al
used a retrospective chart review
approach to data collection, raising questions as to the
reliability of these data. Studies were also limited in the
number of examined symptoms.
Their focus on patients
having had a myocardial infarction (MI)
generalizability to individuals having milder or more
stable forms of CAD.
Finally, control for clinical factors
that may impact on pain and symptom experience, such
anxiety, or depres-
was lacking. This is particularly important
given that women diagnosed with CAD are often older
and have other CAD-related risk conditions.
We conducted a prospective correlational investiga-
tion of the symptoms of men and women experiencing
angina and ischemia during exercise stress testing with
nuclear imaging. A standardized approach to measure-
ment of pain and nonpain symptoms was used. We
Montreal Heart Institute, Montreal, Quebec, Canada,
Psychology, University of Quebec in Montreal, Montreal, Quebec, Canada, and
Department of Psychiatry, University of Montreal, Montreal, Quebec, Canada.
This research was supported in part by the Canadian Institutes for Health Research (CIHR,
MOP 53242), as well as by the Heart and Stroke Foundation of Canada.
Submitted November 11, 2004; accepted June 17, 2005.
Reprint requests: Bianca D’Antono, PhD, Psychosomatic Medicine, Montreal Heart
Institute, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada.
0002-8703/$ - see front matter
n 2006, Mosby, Inc. All rights reserved.