What is the clinical evidence from this study?

Study design: Cohort. Population: Chest pain suspected of coronary artery disease (n=2331). Intervention: Female sex vs. Male sex. Primary outcome: Diagnostic value (Area Under the Curve) of clinical symptoms and cardiovascular risk factors for proven CAD (p=0.11).

January 15, 2015Open Access

The Diagnostic Value of Clinical Symptoms in Women and Men Presenting with Chest Pain at the Emergency Department, a Prospective Cohort Study

MMManon G. van der MeerUniversity Medical Center Utrecht BBBarbra E. BackusCardiac Imaging YGYolanda van der GraafGeneral / Preventive / Lipids

Key Result

The diagnostic value of clinical symptoms and cardiovascular risk factors for predicting coronary artery disease was high and not significantly different between women (AUC 0.79) and men (AUC 0.75).

Study Design

Type

Cohort (n=2,331)

Multicenter

Yes

Structured PICO

Does the diagnostic value of clinical symptoms and cardiovascular risk factors for predicting coronary artery disease differ between women and men presenting with chest pain at the emergency department?

Population

2,331 patients presenting to the emergency department with chest pain without ST-elevation, followed for 6 weeks to determine the diagnostic value of clinical symptoms for coronary artery disease.

Exposure

Assessment of 12 clinical symptoms and 7 cardiovascular risk factors to predict coronary artery disease.

Comparator

Comparison of diagnostic value between women and men.

Outcome

Proven coronary artery disease (CAD), defined as a significant stenosis at angiography requiring percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) or medical treatment, or a definite diagnosis of a Non-ST-elevation myocardial infarction (NSTEMI) or cardiovascular death within six weeks after presentation.composite

Clinical symptoms and cardiovascular risk factors have a high and comparable diagnostic value for predicting coronary artery disease in both women and men presenting to the emergency department with chest pain.

Main Result

Absolute Event Rate: 0.79% vs 0.75%

p-value: p=0.11

Limitations

Results cannot be extrapolated to primary care patients as only patients presenting at the emergency department were included.
Pragmatic use of a combination of clinical diagnoses and treatments as the reference standard instead of coronary angiography for all patients, potentially leading to differential verification bias.
No evaluation of underlying microvascular disease as only obstructive CAD was evaluated.
No information collected about chest pain duration.

Abstract

BACKGROUND: Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking. METHODOLOGY: Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes. RESULTS: A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11). CONCLUSION: The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

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