Author + information
- Received January 8, 2016
- Revision received February 3, 2016
- Accepted February 3, 2016
- Published online April 1, 2016.
- Kshipra Hemala,
- Neha J. Pagidipati, MD, MPHa,
- Adrian Coles, PhDa,
- Rowena J. Dolor, MD, MHSa,b,
- Daniel B. Mark, MD, MPHa,
- Patricia A. Pellikka, MDc,
- Udo Hoffmann, MD, MPHd,
- Sheldon E. Litwin, MDe,
- Melissa A. Daubert, MDa,
- Svati H. Shah, MDa,b,
- Kevin Ariani, MDf,
- Renée P. Bullock-Palmer, MDg,
- Beth Martinez, BSa,
- Kerry L. Lee, PhDa and
- Pamela S. Douglas, MDa,∗ ()
- aDuke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- bDepartment of Medicine, Duke University School of Medicine, Durham, North Carolina
- cMayo Clinic College of Medicine, Rochester, Minnesota
- dMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- eDepartment of Medicine, Medical University of South Carolina, Charleston, South Carolina
- fNorthridge Hospital Medical Center, Northridge, California
- gDeborah Heart and Lung Center, Browns Mills, New Jersey
- ↵∗Reprint requests and correspondence:
Dr. Pamela S. Douglas, Duke University School of Medicine, 7022 North Pavilion DUMC, P.O. Box 17969, Durham, North Carolina 27715.
Objectives The aim of this study was 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 The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) 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 of age vs. 59.0 years of age) and were 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), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as “crushing/pressure/squeezing/tightness” in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging 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, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men.
Conclusions 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 for the evaluation of CAD.
The PROMISE trial was funded by National Heart, Lung, and Blood Institute grants R01 HL098237, R01 HL098236, R01 HL098305, and R01 HL098235. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this paper do not necessarily represent the official views of the National Heart, Lung, and Blood Institute. Dr. Mark has received personal fees from Medtronic, CardioDx, and St. Jude Medical; and grant support from Eli Lilly, Bristol-Myers Squibb, Gilead Sciences, AGA Medical, Merck, Oxygen Biotherapeutics, and AstraZeneca. Dr. Hoffmann has received grant support from Siemens Healthcare and HeartFlow. Dr. Douglas has received grant support from HeartFlow; and serves on a data and safety monitoring board for General Electric Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 8, 2016.
- Revision received February 3, 2016.
- Accepted February 3, 2016.
- American College of Cardiology Foundation