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Introduction to Diagnosis

Evaluation of CHD in women presents a unique and difficult challenge for clinicians due to their vague presenting symptoms and lower prevalence of obstructive CAD demonstrated by coronary angiography as compared with men [8].  Unfortunately, women have also been shown to have more adverse outcomes compared to males despite demonstrating lower angiographic disease burden and preserved left ventricular function .

Steps for successful diagnosis of men and women with cardiac ischemia:

  1. A careful clinical history with an emphasis on defining chest pain characteristics. Pay close attention to presenting symptoms. Women have a tendency to exhibit more subtle symptoms compared to men.  These include pain in the neck, shoulders, upper back or jaw, shortnes of breath, flu-like symptoms (nausea, claminess, cold sweats) and feelings of anxiety, discomfort or fatigue. 

  2. Take into consideration that risk factors may have stronger predictive value in women than in men. Consider factors such as: age,  hypertension, smoking, diabetes mellitus and hyperlipidemia.

  3. Choose the appropriate diagnostic test. Testing is usually most beneficial for patients with intermediate pre-test likelihood of disease[1].

Among women with low probability of CAD i.e. pre-menopausal women, non-invasive testing could bring about false positive results and should be avoided as it can lead to multiple unnecessary tests [1].  However, in women with higher risk for CAD, the most cost effective strategy is to directly proceed to catheterization.  If an initial exercise stress test is negative, the patient should be observed and followed closely. A positive or non-diagnostic exercise test should be followed by referral for coronary angiography[4].

Current diagnostic tests can help in determining the needs of patients, when taken in consideration with other factors such as history, risk factors, and age.

The Canadian Cardiovascular Society’s suggestions for clinical diagnosis are as follows:

  1. Physicians should be aware that women are more likely to have angina rather than MI as their initial presentation of CAD. Typical features of coronary artery disease, both in the acute and chronic situation, do occur in women, however, women have a higher likelihood of presenting with atypical symptoms than do men. Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI. (Grade C, Level III).

  2. Prior to exercise testing patients should be clinically stratified into low, moderate or high probability based on the chest pain algorithm. The cost-effectiveness of a diagnostic strategy varies with the pretest probability. (Grade C, Level III).

  3. Women with a low probability profile (<20% likelihood of CAD) should not undergo stress testing. (Grade B, Level II).

  4. Women with intermediate probability profile (20-80% likelihood of disease) who can exercise with a normal baseline ECG should undergo exercise testing with Duke treadmill score. Stress imaging (nuclear or echo) should be performed if the patient cannot exercise maximally, has a nondiagnostic exercise test or has baseline ECG abnormalities. (Grade B, Level II).

  5. Women with a high probability of disease (>>80% likelihood) should undergo stress testing with Duke treadmill score or coronary angiography. (Grade B, level II).

  6. Physicians should consider that the indications for stress imaging are similar in men and women. Electrically positive ECG stress tests in women on estrogen may be considered a sex-specific indication for stress imaging.


1. Redberg, R.F., (1998) Coronary Artery Disease in Women: Understanding the Diagnostic and Management Pitfalls. Medscape Women’s Health, 3:1.

4. Kim, C., Kwok, Y.S., Saha, S., Redberg, R.F., (1999) Diagnosis of Suspected Coronary Artery Disease in Women: a Cost-effectiveness Analysis. Am Heart J, 137 (6): 1019-27.

8. Shaw, L.J. et al. Insights from the NHLBI Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study. Part I-Gender Differences in Traditional and Novel Risk Factors, Symptom Evaluation and Gender-Optimized Diagnostic Strategies. Journal of the American College of Cardiology, 2006; 47(3) 4S-20S.

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