Why do female patients less frequently present with classic ischemic chest pain?

Why Women Less Frequently Present with Classic Ischemic Chest Pain

Women actually experience chest pain with the same frequency as men during acute coronary syndrome (87–92%), but they are significantly more likely to present with multiple accompanying symptoms that can overshadow or be mistaken for non-cardiac causes, leading to systematic underdiagnosis. 1

The Core Misconception

The widespread belief that women have "atypical" presentations is partially a myth. Chest pain remains the predominant symptom in women with ACS, occurring at rates equal to men. 1 However, the critical difference lies in the pattern and accompanying symptoms:

• Women report ≥3 associated symptoms significantly more often than men 1
• 32% of women vs 23% of men present with nausea/vomiting 1
• 10% of women vs 4% of men report jaw pain 1, 2
• Women more frequently describe neck pain, back pain, epigastric discomfort, fatigue, dyspnea, and diaphoresis alongside chest symptoms 1

Biological & Pathophysiologic Mechanisms

Hormonal & Vascular Factors

Post-menopausal loss of estrogen eliminates vascular endothelial protective effects (antioxidative, vasodilatory via nitric oxide, prostaglandin regulation, smooth muscle proliferation inhibition), explaining why women develop ACS 8–10 years later than men but with more complex presentations. 1

Alternative Ischemic Mechanisms

Women have a higher proportion of ACS caused by non-classical mechanisms rather than typical plaque rupture: 3, 4

• Plaque erosion
• Coronary microvascular dysfunction (INOCA)
• Coronary vasospasm
• Spontaneous coronary artery dissection
• Takotsubo (stress-related) cardiomyopathy

These mechanisms produce ischemia without obstructive coronary disease on angiography, yet cause real symptoms and worse outcomes. 3, 4, 5

Neurologic & Pain Processing Differences

Sex differences in autonomic nervous system reactivity, visceral innervation, and central pain processing contribute to divergent symptom patterns. 4 Women demonstrate:

• Greater psychological susceptibility to pain
• Different visceral pain referral patterns
• More prodromal symptoms before acute events 1

Clinical Presentation Patterns

Symptom Descriptors

Women use different language to describe cardiac pain: 3, 6

• More likely to report "pressure," "tightness," "heaviness," or "burning" rather than "crushing"
• More frequently describe neck and throat pain
• Characterize pain as "intense," "sharp," or "burning" more often than men

Timing & Triggers

Women's ischemic symptoms are more often precipitated by mental/emotional stress and less frequently by physical exertion compared to men. 1

Women present to the hospital approximately 1 hour later after symptom onset (median 300 min vs 238 min in men). 1, 2

The Diagnostic Trap: Systematic Underdiagnosis

Physician Bias & Risk Score Failures

Traditional risk assessment tools and physician gestalt systematically underestimate cardiac risk in women and misclassify them as having non-ischemic chest pain. 1 This occurs because:

• Risk scores were developed primarily in male populations
• Accompanying symptoms are dismissed as "anxiety" or "non-cardiac"
• The focus on obstructive CAD misses microvascular disease 5

Consequences of Missed Diagnosis

Women are less likely to undergo coronary angiography (73.8% vs 84.3% in men) despite similar or higher symptom burden. 1

Women receive less aggressive treatment: 1

• Lower rates of aspirin, β-blockers, statins, ACE inhibitors
• Reduced utilization of primary PCI and fibrinolysis
• Delayed time to reperfusion

Troponin Threshold Issues

Using universal troponin cut-offs misses approximately 30% of women with STEMI. 1, 2 Sex-specific thresholds (>16 ng/L for women vs >34 ng/L for men) are essential but underutilized. 1, 2

High-Risk Populations for Atypical Presentation

Beyond female sex, these groups have increased likelihood of non-chest-pain presentations: 2, 7

• Older adults (especially >75 years): isolated dyspnea, syncope, delirium, unexplained falls
• Diabetic patients: autonomic neuropathy blunts pain perception
• Patients with heart failure, chronic kidney disease, COPD, or prior stroke
• Patients with permanent pacemakers: masked ECG changes

Critical Clinical Approach

Mandatory Actions

Obtain 12-lead ECG within 10 minutes and high-sensitivity troponin immediately in any woman with chest discomfort or concerning accompanying symptoms. 1, 8

Actively inquire about accompanying symptoms during history-taking: 1

• Jaw, neck, or back pain
• Nausea, vomiting, or epigastric discomfort
• Fatigue or generalized weakness
• Dyspnea or palpitations
• Diaphoresis

Terminology Matters

Never use the term "atypical chest pain" in women—it perpetuates dismissal of cardiac causes. 1, 8 Instead, classify presentations as "cardiac," "possibly cardiac," or "non-cardiac." 1, 8

Common Pitfalls to Avoid

• Do not dismiss accompanying symptoms as anxiety or gastroesophageal reflux without objective cardiac testing 1
• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac pain (esophageal spasm also responds) 1, 8
• Do not assume normal physical examination excludes ACS (uncomplicated MI can present with entirely normal findings) 8
• Do not assume younger age (<50 years) excludes ACS in women 3

The Bottom Line

Women are not "less likely to feel ischemic chest pain"—they feel it at equal rates but experience it differently due to biological sex differences in vascular pathophysiology, pain processing, and disease mechanisms. 1, 4 The real problem is systematic clinical underrecognition of these sex-specific patterns, leading to delayed diagnosis, less aggressive treatment, and worse outcomes. 1 Assume cardiac etiology in women with chest symptoms plus accompanying features until proven otherwise. 1