Chest
Pain in Women
.........................................................................................................................
Mazen Ahmad Asayreh, MD
From the department of Internal Medicine,
King Hussein Medical Center, Royal Medical Services,
Jordan
Correspondence:
P.O. Box 11343
Amman 11123 Jordan
E-mail: asayreh@yahoo.com
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ABSTRACT
Objective:
To characterize the clinical features,
investigations, and Prognosis of women
referred with chest pain, who subsequently
underwent coronary angiography.
Material and
methods:
A retrospective analysis of 500 women
with chest pain seen in emergency or outpatient
clinics in three hospitals belonging to
the Royal Medical Services in Jordan,
between January 2000 - January 2004) who
subsequently underwent coronary angiography.
Women were divided according to angiography
results as: division with normal coronaries,
and other, with coronary artery disease.
Results:
195/500 women had normal coronary angiograms,
and 305 of them have had coronary artery
disease. Diabetes mellitus was the most
common risk factor that was encountered
in women with coronary artery disease
(P=0.001). The specificity and positive
predictive value of exercise testing before
angiography were 68%, and 73% respectively.
Revascularization procedures were 216/305
(71%). Many patients with normal coronaries
had symptoms during follow up 146/195(75%)
and 44/195(23%) required readmission for
severe symptoms.
Conclusions:
In women referred with chest pain, a diagnosis
of normal coronary arteries was common.
Risk factor analysis and exercise stress
testing were of limited value in predicting
coronary artery disease in women. A diagnosis
of non-cardiac chest pain in patients
with normal coronaries is of little benefit
regarding morbidity.
Key words:
chest, pain, women
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Epidemiologic studies of
acute myocardial infarction have described gender
differences in the time of death after infarction,
with greater numbers of men dying before hospitalization
than women. Chest pain in women is a commonly
encountered condition which accounts for an
appreciable number of referrals to cardiologists
for further evaluation. Psychiatric illnesses
are presents in up to 50% of new patients attending
the cardiac clinic with chest pain. Patients
with recurrent chest pain who are free of significant
coronary artery disease (CAD) account for 10%
to 30% of patients who were undergoing coronary
angiography.
The accurate diagnosis of chest pain is often
difficult. Myocardial ischemia, aortic dissection,
pulmonary embolism, pericarditis, and gastroenterological
sources of chest pain are the most common differentials.
The symptom of chest pain has many causes -
some of them are cardiac and others are not.
The presence of common symptoms, such as heartburn
and regurgitation, usually make the diagnosis
of gastro esophageal reflux disease fairly straightforward.
Coronary angiography is the criterion for establishing
a diagnosis of CAD. Patients with positive results
on an exercise test are more likely to be further
investigated, but ST segment shift with exercise
is a less specific marker of CAD in women.
However, coronary angiography carries a small
but well documented risk of complications and
consequently should be for those patients most
likely to have chest pain of cardiac origin.
For many years research in CAD has been focused
on men, yet CAD is also the major cause of death
and an important cause of disability in women.
We studied the files of 500 women referred
to the cardiac center in King Hussein Medical
Center (KHMC) with chest pain for further investigation
over a four year period. Additionally we compared
the characteristics of women with CAD and women
with normal coronary arteries.
We reviewed the files of
500 women referred to the cardiac center
with chest pain who subsequently underwent coronary
angiography. Risk factors, results of exercise
testing and coronary angiography, intervention,
morbidity and mortality were recorded.
Patients were divided into two groups according
to the presence or absence of CAD identified
by coronary angiography. A diagnosis of CAD,
based on the cardiologist's reports, was made
if the diameter of stenosis in any coronary
artery exceeded 40%.
Patients were excluded if they were found to
have cardiac disease other than CAD. The presence
of recognized risk factors for CAD, which included
a family history (first degree relative with
CAD), hypercholesterolemia (random total cholesterol
more or equal than 6.5mmol/l or patient receiving
lipid lowering agent), hypertension requiring
specific treatment, history of smoking (current
or previous cigarette smoker), and diabetes
mellitus (requiring treatment by diet, oral
hypoglycemic, or insulin, were recorded).
The exercise test was analyzed as positive
or negative. Patient details were obtained from
the clinical notes, with follow up to present
day. Events during follow up including MI, hospital
readmission and death were recorded. Chi -square
was used for statistical analysis.
Of the 500 females who underwent coronary angiography,
305 (61%) had CAD and 195 (39%) had normal coronary
arteries. Women with CAD were older than women
with normal coronary arteries (mean SD 58.7(9.1)
year v 53.6(9.3); P 0.001). Only diabetes mellitus
was more frequently encountered in women with
CAD than women with normal coronary arteries
(39/305(13%) v 4/195(2%); P=0.01) (Table 1).
Hypertension and positive family history for
CAD were more frequently encountered in women
with CAD than in those with normal coronaries
(hypertension 156/305(51%) v 106/305 (35%),
P=0.003; family history, 216/305 (71%) v 155/195(51%),
P= 0.01.
Smoking was not a common risk factor for CAD
in both groups (70/305 (23%) v 33/195 (17%)).
Exercise test results were correlated with the
presence or absence of CAD. The test was positive
in 50/195 (26%) in women with normal coronary
arteries and 201/305 (66%) in women with CAD.
The sensitivity of exercise testing was (63%)
and the specificity was (74%). In 103/305 (34%)
had single vessel disease, 88/305 (29%) had
two vessel disease, and 118/305 (39%) had triple
vessel disease .No correlation was found between
the results of exercise test and numbers of
diseased vessels.
Follow up details were obtained in 91% of patient.
Mean follow up time was 3.6 years.
Patients with normal coronary arteries
Table ll shows the outcome in the 195 women
with normal coronary arteries. Three women died
from non-cardiac causes, and three women died
suddenly of unknown cause. Table lll shows outcome
in the 305 women found to have CAD.
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Table
1 Risk
factor profile in patient with chest pain |
|
Patient group |
Family history of (CAD) |
Hyper-cholesterolaemia |
Hypertension |
Smoking |
Diabetes mellitus |
|
Coronary artery disease(CAD) |
216 (71%) |
146(48%) |
156(51%) |
70(23%) |
39(13%) |
|
Normal coronary arteries |
155(51%) |
79(41%) |
106(35%) |
33(17%) |
4(2%) |
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Table
2 Outcome
in 195 patients referred to hospital with
chest pain and found to have normal coronary
arteries |
|
Outcome |
Women number and percent |
|
Continued chest pain |
146(75%) |
|
Further treatment for angina |
56(29%) |
|
Readmission to hospital due to chest pain |
87(45%) |
|
Myocardial infarction |
3(1.5%) |
|
Death from non-cardiac cause |
3(1.5%) |
|
Sudden death |
3(1.5%) |
There is growing interest
in research into women with suspected or documented
coronary artery disease which, until recently,,
has been little studied. Coronary artery disease
is the main cause of death in women in the Western
world. Whether the results from these studies
can be applied to all women is unknown.
Consequently, the aim of our study was to
characterise women referred with chest pain
to a cardiac centre since they represent an
important clinical problem. Standard risk factors
for coronary artery disease and the results
of exercise testing were of limited value in
distinguishing women with coronary artery disease
from those with chest pain from non-cardiac
causes. Despite a diagnosis of noncardiac chest
pain, many patients continued to have symptoms
and seemed to have derived little benefit from
cardiac investigation. Furthermore, cardiac
events were no more frequent during the follow
up period. Women represented the minority of
patients referred with a clinical diagnosis
of angina for further investigation. 39% of
women referred with chest pain for further investigation,
were subsequently found to have normal coronary
arteries, which is in keeping with the coronary
artery surgery study, in which 46% of women
referred with chest pain for angiography had
normal coronary arteries.
Studies examining the importance of risk factors
in the development of coronary artery disease
have shown that hypertension, smoking, raised
serum concentrations of lipids, diabetes mellitus,
and a family history of coronary artery disease
are all important in predicting the development
of the disease. Other than diabetes mellitus,
however, risk factors for coronary artery disease
in women were poor discriminators in our study.
The reason(s) why only diabetes mellitus discriminated
between women with and without coronary artery
disease is uncertain. Smoking is not a common
risk factor for coronary artery disease in Jordan
because of social restrictions. In one study
the relative risk of fatal coronary artery disease
in diabetic compared with non-diabetic patients
was 3.3 in women after adjustment for age, systolic
blood pressure, cholesterol, body mass index,
and cigarette smoking. Positive results on the
exercise test were found in 26% of women subsequently
shown on angiography to have normal coronary
arteries, which is comparable with other studies.
Some patients may have abnormalities of coronary
flow reserve, which could account for their
symptoms.
Our data indicates that the vast majority
of patients with normal coronary arteries continue
to experience chest pain. Perhaps this is not
surprising since the cause of the patient's
symptoms may remain undiagnosed, despite further
non-cardiological investigation. Alternatively,
patients may continue to believe that their
pain is cardiac in origin, a possible explanation
in some, since about a third continued antianginal
treatment during follow up. Although these findings
are not new, the implication is that doctors
communicate poorly with patients and reassurance
is inadequate. Furthermore, the situation is
perpetuated by the continued prescription of
antianginal drugs in the knowledge that the
patient does not have coronary artery disease.
Perhaps cardiologists spend disproportionately
little time counseling patients with normal
coronary arteries compared with patients with
coronary artery disease.
The results of this study indicate that chest
pain in women referred for coronary angiography
is often non-cardiac in origin, and standard
criteria used to determine the likelihood of
coronary artery disease in men are of limited
value in women. Current limitations on health
care resources emphasise the need for better
identification of those women most likely to
have coronary artery disease before referral
for invasive assessment.
Although establishing a diagnosis of normal
coronary arteries may be reassuring for the
patient's physician, such a diagnosis does little
to relieve the symptoms experienced by these
patients, who, in the absence of an alternative
diagnosis, continue to place a considerable
drain on health care resources.
Chest pain in women is
common and may or may not have a cardiac cause.
In this study 39% of women referred with chest
pain who subsequently underwent coronary angiography
were found to have normal coronary arteries.
Despite a diagnosis of normal coronary arteries,
morbidity was considerable; an appreciable proportion
continued to have chest pain and to take anti-anginal
drugs.
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