Angina and Cardiac Care

Differences in cardiac care according to gender have now been described for 20 years. As early as 1987, Tobin et al1 reported that 40% of male patients with abnormal exercise radionuclide scans were referred for cardiac catheterization, whereas only 4% of the female patients were referred for future testing. Since then, many investigations have continued to describe a less aggressive management strategy for coronary artery disease (CAD) in women than in men in a variety of settings, but predominantly in patients with acute coronary syndromes.2–11Article p 490 Women are normally protected against CAD as compared with men until elderly age, but once they experience an acute myocardial infarction (MI), they have poorer outcomes than their male counterparts, particularly if they are younger than 60 years.12,13 It is possible that underrecognition and undertreatment of CAD in its early phase in women is a contributory factor. This may lead to 2 possible scenarios: (1) a more advanced or complicated disease at the time of MI due to lack of preventive treatment, and (2) referral bias due to the fact that only the most severely affected or the most symptomatic women with CAD are eventually diagnosed and treated.Angina pectoris is the most common initial presentation of symptomatic CAD in women and therefore represents, in many cases, the starting point in the sequence of healthcare delivery events that may result in gender-related inequalities. If there is lower utilization of noninvasive diagnostic testing at this initial point of care, it may translate into delayed diagnosis, delayed initiation of therapeutic interventions, and ultimately worse outcomes. Recognition of such underutilization, therefore, would shed light on whether the more advanced level of symptom severity, comorbidity, and often worse outcomes of women at the time of an MI are due to earlier undertreatment or …