Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients With Suspected Coronary Artery Disease

Abstract

STRUCTURED ABSTRACT Objectives To determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). Background Although established CAD presentations differ by sex, little is known about stable, suspected CAD. Methods Characteristics of 10,003 men and women in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial were compared using chi-square and Wilcoxon rank sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. Results Women were older (62.4 years vs. 59.0) and more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p-values<0.005). Women were less likely to smoke (45.6% vs. 57.0%; p<0.001), while diabetes prevalence was similar (21.8% vs. 21.0%; p=0.30). Chest pain was the primary symptom in 73.2% of women vs. 72.3% of men (p=0.30) and was characterized as “crushing/pressure/squeezing/tightness” in 52.5% of women vs. 46.2% of men (p<0.001). Compared to men, all risk scores characterized women as lower risk, and providers were more likely to characterize women as having low (<30%) pre-test probability for CAD (40.7% vs. 34.1%; p<0.001). Compared with men, women were more often referred to imaging tests (adjusted OR 1.21; 95% CI 1.01–1.44) than non-imaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p<0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, BMI, and Framingham risk score were predictive of a positive test in women, while Framingham and Diamond and Forrester risk scores were predictive in men. Conclusion Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches to CAD evaluation.

Sex differences in cardiovascular disease – Impact on care and outcomes

“…Post-hoc analysis of the PROMISE study, however, identified sex-differences in risk assessment, noninvasive test outcomes and noninvasive test prognostic value, highlighting the importance of sex-specific approaches for the evaluation of CAD 124, 252 . For example, not only were women more likely to be characterized as lower risk by providers and by risk scores despite having a greater number of cardiac risk factors, women were also less likely to have a positive test 252 . The Diamond and Forrester risk score, which classifies chest pain as typical, atypical, and nonanginal, was predictive of a positive test in men but not in women.…”

Sex Differences in Ischemic Heart Disease

“…34 The higher burden of nonobstructive atherosclerosis in women may result in negative stress tests and obscure the diagnosis of IHD, underscoring the need for additional diagnostic imaging that reveals the nonobstructive pathophysiological mechanisms of IHD. 30,35 Consequently, the 2014 AHA consensus statement for noninvasive evaluation of woman at risk for IHD recommends testing for the full spectrum of IHD ( Figure 3).…”

Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain

“…4 All trials, including this cohort, had a low CAD prevalence with overestimation of the individual probability of disease by conventional prediction rules for both men and women. 13,14,22 In CRESCENT, the CAD prevalence was 9% in women, whereas the predicted probability by the Diamond and Forrester method was 38%. For men, the prevalence was 12%, whereas the predicted probability was 54%.…”