Examination of Gender Bias in the Evaluation andTreatment of Angina Pectoris by Cardiologists

Michael Blum, MD, Martin Slade, MPH, Donna Boden, RN, Henry Cabin, MD, andTeresa Caulin-Glaser, MD

One hundred fifty-eight patients (76 men and 82women) presenting to an outpatient cardiology clinicwith a new complaint of angina were prospectivelyfollowed to determine if there was a gender bias inthe management of suspected coronary artery dis-ease when physicians trained in cardiology managedtheir care. Overall, there were no differences in thepercentage of women who underwent noninvasiveevaluation, invasive evaluation, and treatment of sus-pected coronary artery disease compared withmen. �2004 by Excerpta Medica, Inc.

(Am J Cardiol 2004;93:765–767)

A lthough previous reports have suggested thatgender independently influences the manner in

which physicians manage patients with chest pain,the influence of provider training has not been stud-ied and may be an important factor.1–4 The primaryobjective of this preliminary study is to assesswhether gender bias is apparent when physicianstrained in cardiovascular medicine evaluate andmanage ambulatory patients presenting for theirfirst evaluation of potentially ischemic chest pain.

• • •After approval was obtained from the Yale Uni-

versity School of Medicine Human Subjects Com-mittee, we conducted this study at the suburbanlocation of the Yale University Faculty PracticeCardiology outpatient clinic. Informed consent wasobtained from all patients. Seven board-certifiedcardiologists (6 men, 1 woman), who are membersof the Yale University School of Medicine faculty,staff the clinic. All patients who underwent aninitial evaluation of a chief symptom of chest, arm/shoulder/neck/jaw, or epigastric pain or discomfort,nausea, or shortness of breath were evaluated foreligibility. Patients who had a history of any car-diovascular, cerebrovascular, or peripheral vasculardisease, or who had a prior evaluation of chest painwere excluded. Eligible patients were prospectivelyenrolled and followed from January 1998 to De-cember 2000.

For a 3-year period beginning in January 1998,

data were collected on patients upon presentation tothe cardiology clinic and at 6- and 12-month fol-low-up visits. An experienced cardiac nurse datacollector reviewed study criteria for all new patientspresenting to the clinic. Data on demographics,presenting symptoms, cardiac risk factors, noninva-sive testing, invasive testing, and outcome at 6 and12 months were obtained from patient questionnaireand by review of medical records. Providers at theclinic were unaware of the study aims.

All data analyses, unless otherwise specified,were conducted at the p � 0.05 level of signifi-cance. Fisher’ s exact test was used to determine ifsignificant baseline demographic differences ex-isted between genders in the study population. Ad-ditionally, Fisher’ s exact test was used to evaluateany significant differences based on gender in pre-senting complaints, referrals for noninvasive diag-

From the Division of Cardiovascular Medicine, Yale University Schoolof Medicine, New Haven, Connecticut, and the McConnell HeartHealth Center, Riverside Methodist Hospital, Columbus, Ohio. Dr.Caulin-Glaser was supported by Grant K08 HL03372-02 from theNational Heart, Lung, and Blood Institute, National Institutes of Health,Bethesda, Maryland. Dr. Caulin-Glaser’s address is: McConnell HeartHealth Center, Riverside Methodist Hospital, 3773 Olentangy RiverRoad, Columbus, Ohio 43214-6907. E-mail: tcauling@ ohiohealth.com. Manuscript received July 8, 2003; revised manuscript receivedand accepted December 2, 2003.

TABLE 1 Demographic, Clinical Characteristics, andMedications Prescribed

Characteristic/MedicationMen

(n � 76)Women(n � 82)

pValue

Mean age (yrs) 53 � 11 54 � 15 0.8Body mass index �25 kg/m2 49 (64%) 69 (84%) 0.005Exercise 3x/wk 31 (41%) 31 (38%) 0.8Hypertension 24 (32%) 34 (41%) 0.2Diabetes mellitus 8 (11%) 7 (9%) 0.6Smoker 18 (24%) 10 (12%) 0.1Total cholesterol (mg/dl) 0.8

�200 20 (26%) 20 (24%)201–250 33 (43%) 40 (49%)�250 24 (32%) 22 (27%)

High-density lipoprotein (mg/dl) 0.0220–30 13 (17%) 0 (0%)31–40 32 (42%) 16 (20%)51–60 12 (16%) 25 (30%)�60 8 (11%) 17 (21%)

Low-density lipoprotein (mg/dl) 0.7�100 2 (3%) 8 (10%)101–130 21 (28%) 21 (26%)131–160 34 (45%) 31 (38%)�160 21 (28%) 21 (26%)

Triglycerides (mg/dl) 0.01�150 25 (33%) 53 (65%)151–100 47 (62%) 18 (22%)�300 4 (5%) 10 (12%)

Aspirin 14 (18%) 15 (18%) 0.8Angiotensin-converting

enzyme inhibitor8 (11%) 9 (11%) 1.0

� blocker 8 (11%) 15 (18%) 0.3Angiotensin receptor blocker 0 (0%) 2 (2%) 0.5Calcium channel blocker 1 (1%) 9 (11%) 0.02Diuretic 2 (3%) 14 (17%) 0.005Statin 5 (7%) 12 (15%) 0.1Other lipid-altering agent 1 (1%) 0 (0%) 0.5Nitrates 1 (1%) 1 (1%) 1.0

765©2004 by Excerpta Medica, Inc. All rights reserved. 0002-9149/04/$–see front matterThe American Journal of Cardiology Vol. 93 March 15, 2004 doi:10.1016/j.amjcard.2003.12.007

nostic testing, invasive diagnostic testing, detectionof epicardial coronary artery disease by catheteriza-tion, myocardial infarction and death, and medicalmanagement. Finally, 2 cardiovascular outcomes,acute coronary syndrome and death, were evaluatedusing Fisher’ s exact test.

Consecutive patients (n � 302) with a new chiefcomplaint suggestive of angina were evaluated. Ofthose, 197 (65%) were eligible based on inclusionand exclusion criteria; 23 patients declined the in-vitation to participate in the study, and 16 patientswere lost to follow-up. Ultimately, 158 patientscompleted participation. The study population con-sisted of 76 men (mean age 53 years) and 82 women(mean age 54 years) for whom complete data werecollected; they comprised 80% of the eligible pa-

tients. Baseline demographic andclinical characteristics of thepopulation were analyzed to ac-count for any potential confound-ing differences in cardiac riskprofile. There were no significantdifferences in age (Figure 1).Table1 data indicate that there were nosignificant differences in the tradi-tional cardiac risk factors of hyper-tension, diabetes mellitus, familyhistory, smoking, total cholesterol,or low-density lipoprotein levelsbased on gender. The women inthe study were found to have sig-nificantly greater high-density li-poprotein levels and significantlylower triglyceride levels than themen. Also, a significantly higherproportion of women had a bodymass index �25 kg/m2 (p �0.005). Overall, there was no sig-nificant gender difference in themedical treatment recommended bythe cardiologists given the patients’initial presenting complaints (Table1). However, women were morelikely to be prescribed calciumchannel blockers (p �0.01) and di-uretics (p �0.005) than men.

Chest pain or discomfort was themost common presenting complaintfor men and women (Figure 2). Signif-icantly more women presented withnon–chest pain/discomfort symptoms,including dyspnea (p �0.05) and gas-trointestinal distress (p �0.05). Al-though not statistically significant,women more frequently reported arm,back, and neck pain or discomfort.

There was no statistically signifi-cant difference in the number of menand women evaluated with noninva-sive studies (Figure 3). However, menpresenting with chest pain or discom-fort were significantly more likely to

undergo an exercise treadmill stress test without addi-tional imaging (73% vs 49%, p � 0.004). It shouldbe noted that there was also a borderline significantdifference in the ordering of an echocardiogramgiven a presenting complaint of chest pain or dis-comfort, with a greater percentage of women un-dergoing the study (17% vs 7%, p � 0.05).

There was no statistically significant difference inthe number of men and women who underwent coro-nary angiography (25% vs 19%, p � 0.4). After un-dergoing cardiac catheterization, 67% of patients werereferred for coronary revascularization; 54% under-went percutaneous revascularization, and 13% under-went coronary artery bypass surgery. There were nosignificant differences between men and women inreferral for a revascularization procedure.

FIGURE 1. For age, there were no significant differences between men and women.

FIGURE 2. Although chest pain was the most common complaint regardless of gender, asignificant number of women presented with symptoms of dyspnea (p <0.05) and/orgastrointestinal discomfort (p <0.05) compared with men. GI � gastrointestinal.

766 THE AMERICAN JOURNAL OF CARDIOLOGY� VOL. 93 MARCH 15, 2004

At the 6- and 12-month follow-up, there were nomyocardial infarctions or deaths in any of the patients.

• • •Several reports over the last decade have suggested

that the evaluation and management of women withchest pain is not as thorough as that of men.1,3,5,6

Studies have demonstrated lower use of diagnostictesting, coronary revascularization, and standard anti-ischemic medical therapy in women.2,7–9 In contrast,this prospective preliminary study suggests that gen-

der does not independently influencethe overall assessment and manage-ment of patients presenting for initialevaluation of possible angina pecto-ris, when appropriately trained phy-sicians with a heightened awarenessas to the degree, presentation, andprevalence of coronary artery diseasein women perform the evaluation.

1. Beery TA. Gender bias in the diagnosis and treatmentof coronary artery disease. Heart Lung 1995;24:427–435.2. Kudenchik PJ, Maynard C, Martin JS, Wirkus M,Weaver WD. Comparison of presentation, treatment,and outcome of acute myocardial infarction in menversus women. Am J Cardiol 1996;78:9–14.3. Wegner NK. Coronary heart disease in women: gen-der differences in diagnostic evaluation. J Am MedWomens Assoc 1994;49:181–185.4. Yarzebski J, Col N, Pagely P, Savageau J, Gore J,Goldberg R. Gender differences and factors associatedwith the receipt of thrombolytic therapy in patients withacute myocardial infarction: a community-wide per-spective. Am Heart J 1996;131:43–50.5. Weitzman S, Cooper L, Chambless L, Rosamond W,Clegg L, Marcucci G, Romm F, White A. Gender,racial, and geographic differences in the performance ofcardiac diagnostic and therapeutic procedures for hos-pitalized acute myocardial infarction in four states. Am JCardiol 1997;79:722–726.6. Schulman KA, Berlin JA, Harless W, Kerner JF,

Sistrunk S, Gersh BJ, Dube R, Taleghani CK, Burke JC, Williams S, et al. Theeffect of race and sex on physicians’ recommendations for cardiac catheteriza-tion. N Engl J Med 1999;340:618–626.7. Shaw LJ, Miller DD, Romeis JC, Kargl G, Younis LT, Chaitman BR. Genderdifferences in the noninvasive evaluation and management of patients withsuspected coronary artery disease. Ann Intern Med 1994;120:559–566.8. Giles WH, Anda RF, Casper ML, Escobedo LG, Taylor HA. Race and sexdifferences in rates of invasive cardiac procedures in US hospitals: data from thenational hospital discharge survey. Arch Intern Med 1995;155:318–324.9. Hachamovitch R, Berman DS, Kiat H, Bairey-Merz N, Cohen I, Cabico JA,Friedman JD, Germano G, Van Train KF, Diamond GA. Gender-related differ-ences in clinical management after exercise nuclear testing. J Am Coll Cardiol1995;26:1457–1464.

FIGURE 3. Men were more frequently referred for exercise treadmill testing (ETT)compared with women (p <0.05). There were no differences based on gender forevaluation with stress imaging, echocardiography, and coronary angiography. An-gio � coronary angiography; ECHO � echocardiography; ETT-ECHO � exercisetreadmill stress testing at rest and during stress echocardiography; ETT-MIBI � exer-cise treadmill stress testing with nuclear imaging using sestamibi.

BRIEF REPORTS 767