The presentation and treatment course of classic CAD appear to differ between men and women. Anginal symptoms are less predictive of abnormal coronary anatomy in women than in men. In the Coronary Artery Surgery Study (CASS), CAD was diagnosed by catheterization in 63% of women with definite angina, 40% of women with probable angina, and 4% of women with nonischemic pain. In addition, referral patterns for cardiac catheterization vary by sex, in part due to the lower incidence of CAD in younger women, compared with younger men. The clinical diagnosis of angina occurring in women can be especially difficult because women may perceive chest pain differently than men. In addition, coronary vascular spasm is a more frequent contributor to anginal chest pain in the absence of true atherosclerosis in women compared to men.

There is a substantial sex difference in the presentation and natural history of acute coronary syndromes (unstable angina and acute myocardial infarction). The National Registry of Myocardial Infarction investigators reported a higher mortality rate among women during the index hospitalization. Women arrived later after symptom onset for evaluation, received less fibrinolytic therapy, and underwent fewer coronary interventions or bypass surgeries. Mortality rates are higher in women than in men at similar age deciles, despite a similar prevalence of cardiogenic shock, sudden death, arrhythmias, rupture, and electromechanical dissociation, as well as similar rates of intervention. In the GUSTO IIb Acute Coronary Syndrome Trial, women were more often diagnosed with unstable angina; were more elderly; and had more comorbid conditions than men, including diabetes, hypertension, angina, and congestive heart failure (41). Additionally, women were more likely than men to be smokers or have prior myocardial infarction, angioplasty, and bypass surgery. Women with acute coronary syndromes were more likely than men to demonstrate coronary vessels that were not significantly affected by CAD. After non–ST-elevation myocardial infarction, 9% of women had no diseased vessels on angiography versus 4% of men, and after ST-elevation myocardial infarction, 10% of women had no diseased vessels versus 7% of men. In the GUSTO IIb trial, 30-day mortality was higher for women than men, despite a similar reinfarction rate. However, women with myocardial infarction tend to be older and women have higher prevalence of hypertension and diabetes. With adjustment for age and risk factors, outcomes are similar for men and women undergoing PCI for acute myocardial infarction (42).

Electrocardiogram stress testing is less specific and less sensitive in women compared with men. Some studies suggest that stress echocardiography or nuclear perfusion imaging has a higher accuracy than stress electrocardiogram for detection of coronary disease in women, and some investigators recommend stress imaging as the initial test in women with suspected CAD. This approach is controversial, however, and current guidelines continue to recommend a similar diagnostic approach in women and men with chest pain symptoms.

The initiation and follow-up of secondary prevention measures are critically important for women. Especially efficacious —although less often prescribed—are daily aspirin and cholesterol-lowering therapies. Cardiac rehabilitation is equally effective for men and women; however, men are more likely than women to have participated in postischemic rehabilitation.

41. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. N Engl J Med. 1999;341:226-32. [PMID: 10413734]
42. Mehilli J, Kastrati A, Dirschinger J, Pache J, Seyfarth M, Blasini R, et al. Sex-based analysis of outcome in patients with acute myocardial infarction treated predominantly with percutaneous coronary intervention. JAMA. 2002;287:210-5. [PMID: 11779263]

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