Coronary artery disease in women: understanding the diagnostic and management pitfalls.

Coronary artery disease kills more women than all cancers combined, yet the clinical picture in women is different enough from men that the diagnosis can be missed or delayed. A cardiologist highlights these gender-based differences and explains why certain diagnostic tests are better than others at identifying CAD in women. Coronary artery disease (CAD) is the leading killer of women in the US. After menopause, mortality rates from CAD in women nearly equal those of men. Yet the clinical picture in women is different enough from that in men that it can obscure the correct diagnosis. Women are 10 years older than men, on average, when presenting with CAD, possibly due to delayed diagnosis or presentation. Differences in symptomatology between men and women are important to note. For example, other diseases, such as arthritis or osteoporosis, can obscure CAD symptoms. Further, compared with men, women's chest pain is more often associated with abdominal pain, dyspnea, nausea, and fatigue. More women than men with CAD have diabetes, hypertension, hypercholesterolemia, and a family history of CAD. Clinicians need to know how to assess the gender-specific pretest likelihood of CAD in women, starting with a careful review of the patient's chest pain history. Other risk factors, including smoking, abdominal obesity, and certain comorbidities, should be taken into consideration. The diagnostic accuracy of exercise testing is slightly lower for women than men. Certain diagnostic tests, particularly exercise echocardiography and exercise thallium/sestamibi testing, offer more prognostic information than traditional exercise electrocardiographic studies without imaging. Mortality associated with interventional procedures--such as angioplasty and coronary artery bypass grafting (CABG)--is slightly higher in women, although long-term survival rates are similar for both sexes. Detection of CAD at an earlier stage in women may result in earlier referrals for CABG, with the benefit of lower associated mortality rates.