Chest pain in Women without Obstructive Coronary Artery Disease: Patient-reported outcomes, diagnostic accuracy, and healthcare contacts after a first diagnosis of angina or nonspecific chest pain

Chest pain in women without obstructive coronary artery disease (CAD) may be caused by non-obstructive/diffuse CAD, microvascular angina, or vasospastic angina. Accurately diagnosing women with chest pain without obstructive CAD is challenging, and women are often given diagnoses that do not require invasive treatment in the cardiology department. As a result, women are often discharged without a structured treatment approach despite suffering from a high symptom burden, and currently, no standardised follow-up strategy exists. Although international guidelines recognise the importance of understanding the health challenges associated with living with persistent chest pain in women without obstructive CAD, little is known about the patient's clinical trajectory following their first diagnostic evaluation. Therefore, this ph.d. project will investigate the characteristics of women discharged with chest pain without obstructiveCAD, including differences among those with a diagnosis related to symptoms of angina (presumed cardiac cause) and those with a diagnosis related to more nonspecific chest pain (presumed due to non-cardiac causes), the women’s health status at discharge, and consume of healthcare services. Through a national cross-sectional study, a validation study, and a national prospective cohort study, the ph.d. project aimed to investigate i) The women’s self-reported health at discharge and factors associated with adverse outcomes (with three years of register-based follow-up), ii) The diagnostic accuracy of diagnostic codes related to symptoms of angina or nonspecific chest pain, and iii) The women’s use of primary and secondary health care contacts following a first diagnosis of chest pain and factors associated with higher use within three years of follow-up (register-based).
In Study 1, differences in patient-reported outcomes at discharge were investigated among 931 women with angina and 839 women with nonspecific chest pain. Data were collected through the nationwide cross-sectional study DenHeart, where self-reported instruments related to health status, anxiety and depression, health-related quality of life, and symptom burden were distributed to patients via a paper-based survey. The association between poor patient-reportedoutcomes and adverse outcomes was also examined.
In study 2, the accuracy of 557 ICD-10 diagnostic codes related to angina and nonspecific chest pain was examined using electronic medical patient records.
In Study 3, a national registry-based prospective cohort of 17,836 women with angina and 42,832 women with nonspecific chest pain - the WOMANOCA cohort - was established. The study compared the use of healthcare contacts between the two groups following a first-ever diagnosis of angina or nonspecific chest pain to a background reference population of 303,247 asymptomatic women.
The DenHeart study (Study 1) found that women with angina reported significantly worse self-reported health on most instruments compared to women with nonspecific chest pain. Adverse outcomes, including unplanned cardiac readmissions and revascularisations (PCI/CABG), varied between groups, with the angina groups experiencing the most outcomes. Several self-reported measurements were associated with adverse outcomes among both groups, indicatingthat chest pain of any kind can lead to health challenges in women (Paper I). The validation study (Study 2) found that diagnosing angina in women based solely on symptoms might be challenging, with an overall PPV of 64% for women with angina and 81% for women with nonspecific chest pain (Paper II). The WOMANOCA study (Study 3) found that both women with angina and women with nonspecific chest pain had higher use of healthcare contacts than the reference population. Overall, women with angina had a higher risk of cardiac- related healthcare contacts during follow-up, whereas women with nonspecific chest pain had a higher risk of more general healthcare contacts (Paper III).
The findings call for better diagnostic accuracy, clinical management, and follow-up strategies for women discharged with chest pain without obstructive coronary artery disease, whether through cardiology departments for women withangina or general practitioner for women with nonspecific chest pain. A multidisciplinary intervention focusing on an individualised patient-centered approach is crucial, as “one size does not fit all.”