Noninvasive testing in women presenting with chest pain: evidence for diagnostic uncertainty

To gain insight into the diagnostic utility of exercise stress testing in women.

Observational prospective cohort study.

The Victoria General Hospital, Halifax, Nova Scotia.

Consecutive women with chest pain referred by cardiologists or internists for exercise stress testing between May 30, 1992 and November 30, 1992 and followed prospectively to February 28, 1993.

The proportion of patients subsequently referred for thallium scintigraphy and/or coronary angiography and their clinical profiles were determined.

Of 183 patients studied, stress testing was positive in 48 (26.2%), negative in 48 (26.2%) and nondiagnostic in 87 (47.5%). Women with negative results were more likely to have had normal baseline electrocardiograms (ECGs) (P = 0.002) and least likely to have undergone prior angiography (P = 0.0003). Subsequent thallium scintigraphy and/or coronary angiography was undertaken in 33.3%, 18.8% and 27.6% with positive, negative and nondiagnostic index stress tests, respectively. None of chest pain, cardiac risk factors, previous cardiac investigations or baseline ECG discriminated 33 patients with negative or nondiagnostic stress results who had additional tests from 102 who did not.

Exercise stress testing poorly screens women with chest pain for coronary artery disease (diagnostic in only 52.5%). Further study was undertaken in 27.6% with nondiagnostic tests and, surprisingly, in 18.8% with negative results. Why certain women with nondiagnostic, and so many with negative, stress tests were referred for further investigation was unclear. These results suggest diagnostic uncertainty when females presenting with chest pain are assessed.