Author Affiliations: Department of Social and Behavioral Sciences, Human Development and Health, Harvard School of Public Health, Harvard University, Boston, Massachusetts (Dr Kreatsoulas); Departments of Clinical Epidemiology and Biostatistics (Drs Shannon, Giacomini, and Anand) and Medicine (Drs Velianou and Anand), Faculty of Health Sciences, Centre for Health Economics and Policy Analysis (Dr Giacomini), and Chanchlani Research Centre (Dr Anand), McMaster University, Hamilton, Ontario, Canada; and Interventional Cardiology, Hamilton Health Science, Hamilton General Hospital (Dr Velianou), Hamilton.
Coronary artery disease (CAD) is the leading cause of mortality in the Western world. The prevalence of angina and proportion of deaths from CAD is higher among women than men.1,2 Despite this, the perception that CAD is a man's disease prevails.3- 5 Historic faulty assumptions in the construct of angina, failure to systematically include women in clinical studies, and differences in age-specific incidence rates have perpetuated this perception.5,6 As a result, the term typical angina has evolved to describe symptoms in men, whereas atypical angina is applied to women. This lack of clarity has been a source of controversy in understanding CAD in women.
We developed a new theory and construct of angina by scaling symptom expression according to sex and gender along a continuum. The objective of this study was to quantify male-typical vs female-typical angina symptoms as they range along a continuum among patients with obstructive CAD.
We studied patients with suspected CAD and/or angina and at least 1 prior abnormal cardiac test result who underwent their first coronary angiogram. A previously developed validated standardized cardiac assessment tool captured patient risk factors and symptoms. An experienced angiographer blinded to patient identifiers interpreted the angiographic findings. Obstructive CAD was defined as the presence of at least 1 vessel 2.0 mm or larger in diameter with at least 70% stenosis.
Baseline characteristics including age, cardiac risk factors, and coronary anatomy were compared between women and men. Symptoms were analyzed according to sex/gender and obstructive CAD angiographic results. Continuous and dichotomous variables were compared using 2-tailed t tests and χ2 tests, respectively (IBM SPSS19, IBM). A predetermined sample size of 210 was estimated to provide 80% power at P < .05 (2-sided).
From June through November 2010, 128 men and 109 women were enrolled. Traditional risk factors were present in 118 participants (50% of the sample). Women were slightly older (mean [SD] age, 67.5 [10.8] vs 64.5 [11.5] years; P = .06), more likely to have normal coronary arteries (22 of 109 [20%] vs 10 of 128 [8%]; P = .004), and less likely to have obstructive CAD (50 of 109 [46%] vs 89 of 128 [70%]; P < .001) when compared with men. Men were more likely to be past smokers (77 of 128 [60%] vs 45 of 109 [41%]; P < .001).
We mapped reported symptoms onto a continuum according to sex and gender (Figure). The most common descriptors used by men and women with obstructive CAD included “chest pain” (71 of 87 [82%] vs 42 of 50 [84%]; P = .72), “pressure” (47 of 87 [54%] vs 29 of 50 [58%]; P = .65), and “tightness” (37 of 87 [43%] vs 29 of 50 [58%]; P = .08), respectively. Women used certain descriptions approximately twice as often as men, including “discomfort” (23 of 50 [46%] vs 24 of 87 [28%]; P = .03), “crushing” (12 of 50 [24%] vs 8 of 87 [9%;]; P = .02), “pressing” (14 of 50 [28%] vs 12 of 87 [14%]; P = .04), and “bad ache” (15 of 50 [30%] vs 13 of 87 [15%]; P = .04).
Figure. Continuum of symptoms according to sex and gender among patients with obstructive coronary artery disease. *Women vs men, P < .05; no significant differences in symptoms between men and women with shared experiences.
Men and women reported pain in the same areas outside the chest region, including the arms (37 of 87 [43%] vs 25 of 50 [50%]; P = .40), back (23 of 87 [26%] vs 15 of 50 [30%]; P = .65), and shoulders (28 of 87 [32%] vs 13 of 50 [26%]; P = .45), respectively.
Other symptoms reported by men and women included shortness of breath (58 of 87 [67%] vs 38 of 50 [76%]; P = .25), fatigue (49 of 87 [56%] vs 31 of 50 [62%]; P = .52), sweating (42 of 87 [48%] vs 23 of 50 [46%]; P = .80), and weakness (28 of 87 [32%] vs 23 of 50 [46%]; P = .11), respectively. Women were more likely to report dry mouth (17 of 50 [34%] vs 16 of 87 [18%]; P = .04), whereas men did not report any symptoms significantly more often than women.
By mapping reported symptoms along a continuum, we have shown that angina-type symptoms are remarkably similar among men and women with obstructive CAD. This suggests that the clinical construct of “atypical angina” in women is incorrect. Furthermore, the descriptors more commonly expressed by women were not unique to women; men expressed them also. The choice of terms used to describe a symptom may be a function of gendered language rather than of conventionally portrayed biological sex difference. In contrast, among the seemingly biological symptoms, such as non–chest localization of pain, we observed no differences between men and women. The continuum thus allows for the gendered expression of a symptom while not constraining the symptom to a particular sex.
Previous studies have focused on establishing differences in symptoms between men and women, between typical and atypical angina. Our data show the predominance of similar symptoms between men and women. By presenting these terms on a continuum, our study demonstrates the commonalities in cardiac symptomatology for men and women, while also allowing for gendered differences in how these experiences may be expressed, providing more meaningful diagnostic information than conventional “typical” vs “atypical” distinctions.
Our study is internally valid because symptoms were validated against the gold standard, coronary angiography. Our modest sample size is sufficiently powered; in addition, our study represents “real-world” practice and is one of the few prospective studies of cardiac symptoms to date.
In conclusion, the symptom continuum according to sex and gender has empirically demonstrated the substantial overlap of shared symptoms between men and women with obstructive CAD. This information can help clinicians to better contextualize symptoms associated with obstructive CAD rather than adhering to the conventional “typical” and “atypical” angina distinction. Future studies should seek to test and validate the symptom continuum according to gender in diverse patient populations.
Correspondence: Dr Kreatsoulas, Department of Social and Behavioral Sciences, Human Development and Health, Harvard School of Public Health, Harvard University, 1137 Massachusetts Ave (37), Cambridge, MA 02138 (email@example.com).
Published Online: April 8, 2013. doi:10.1001/jamainternmed.2013.229
Author Contributions: Dr Kreatsoulas had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition of data: Kreatsoulas and Velianou. Analysis and interpretation of data: Kreatsoulas, Shannon, Giacomini, and Anand. Drafting of the manuscript: Kreatsoulas and Anand. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kreatsoulas and Shannon. Administrative, technical, and material support: Velianou. Study supervision: Shannon, Giacomini, and Anand.
Conflict of Interest Disclosures: None reported.
Additional Information: Dr Kreatsoulas holds a Fulbright Scholarship and a Heart and Stroke of Ontario Research Fellowship. Dr Anand holds the Eli Lilly Canada–May Cohen Chair in Women's Health, Michael DeGroote–Heart and Stroke Foundation of Ontario Endowed Chair in Population Health Research, and Canada Research Chair in Ethnicity and Cardiovascular Disease.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Internal Medicine editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 6
Customize your page view by dragging & repositioning the boxes below.
Users' Guides to the Medical Literature
Users' Guides to the Medical Literature
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.