Why does chest pain present atypically in women?

Why Chest Pain Presentation Differs in Women

The premise that chest pain is "atypical" in women is actually a misconception based on male-centered symptom definitions—women present with chest pain just as frequently as men (87-92% of cases), but they more commonly report additional accompanying symptoms alongside chest pain. 1

The Core Misunderstanding

The term "atypical" is fundamentally problematic because it uses male symptom patterns as the reference standard. Women are not presenting atypically; rather, the medical definition of "typical" was derived predominantly from male patients. 1, 2

• Chest pain remains the predominant symptom in women with acute coronary syndrome (ACS), occurring with equal frequency to men (89.5% vs 87% in patients ≤55 years; 91-92% across all ages). 1
• The 2021 ACC/AHA guidelines explicitly recommend avoiding the term "atypical chest pain" and instead describing presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misclassification of symptoms as benign. 1, 3

What Actually Differs: Accompanying Symptoms

Women are significantly more likely to present with chest pain plus additional symptoms rather than chest pain alone:

• Jaw and neck pain: 10% in women vs 4% in men 1
• Nausea/vomiting: 32% in women vs 23% in men 1
• Epigastric symptoms, palpitations, and pain between shoulder blades: 61.9% in women vs 54.8% in men 1
• Back pain: More common in postmenopausal women (63-72%) 4
• Dyspnea, fatigue, and shortness of breath: More frequently reported by women 1

Why This Pattern Exists

Biological Factors

Women with ACS are typically 8-10 years older than men at presentation, with median age 69 vs 62 years. 1 This age difference relates to:

• Loss of estrogen's vascular protective effects after menopause (antioxidative, vasodilatory, prostaglandin regulatory, and smooth muscle proliferation inhibitory properties). 1
• Higher rates of microvascular dysfunction rather than obstructive epicardial coronary disease, which may produce different symptom patterns. 5

Hormonal Influences

Premenopausal women actually report atypical chest symptoms more frequently than postmenopausal women (57% vs 22-31%), independent of age. 4 Postmenopausal women more commonly report:

• Substernal chest pain (78-83% vs 44% in premenopausal) 4
• Indigestion-like discomfort (50-56% vs 22%) 4
• Sudden fatigue (89% vs 53-61%) 4

Pathophysiologic Differences

Women have weaker correlation between symptoms and significant luminal obstruction at coronary angiography compared to men. 1 This reflects:

• Higher prevalence of microvascular angina (MVA) in women—chest pain with ischemia on stress testing but no obstructive CAD on angiography. 5
• Endothelial dysfunction and abnormal coronary reactivity as primary mechanisms rather than fixed stenoses. 5

Clinical Consequences of This Misunderstanding

The mislabeling of women's symptoms as "atypical" leads to systematic underdiagnosis and undertreatment:

• Women are less likely to undergo coronary angiography (73.8% vs 84.3% in men) even when presenting with chest pain. 1
• Traditional risk assessment tools underestimate cardiac risk in women and misclassify them as having nonischemic chest pain. 1
• Women present to hospital approximately 1 hour later after symptom onset (median 300 vs 238 minutes), potentially due to both patient and provider delays in recognizing cardiac etiology. 1
• Women receive less aggressive treatment including lower rates of antiplatelets, beta-blockers, statins, and revascularization. 1

Key Algorithmic Approach

When evaluating chest pain in women:

1. Assume cardiac etiology until proven otherwise—women are at high risk for underdiagnosis. 1

2. Obtain 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin immediately. 1, 3

3. Specifically ask about accompanying symptoms: jaw/neck pain, nausea, fatigue, dyspnea, back pain, palpitations, and epigastric discomfort. 1

4. Use sex-specific troponin thresholds (>16 ng/L for women vs >34 ng/L for men with hs-cTnI), which reclassify 30% of women as having STEMI who would be missed with universal thresholds. 1

5. Do not dismiss symptoms based on "atypical" features—the presence of additional symptoms alongside chest pain is the norm in women, not an exception. 1, 2

Common Pitfalls to Avoid

• Never use nitroglycerin response as a diagnostic criterion—esophageal spasm and other conditions respond similarly. 1, 3
• Do not assume younger women or those without traditional risk factors are low-risk—women are underdiagnosed across all age groups. 1
• Avoid attributing symptoms to anxiety or non-cardiac causes without objective testing, as this perpetuates diagnostic delays. 1
• Recognize that sharp or pleuritic pain does not exclude ACS—13% of patients with pleuritic features have acute myocardial ischemia. 3