Interpreting angina: symptoms along a gender continuum

Background ‘Typical’ angina is often used to describe symptoms common among men, while ‘atypical’ angina is used to describe symptoms common among women, despite a higher prevalence of angina among women. This discrepancy is a source of controversy in cardiac care among women. Objectives To redefine angina by (1) qualitatively comparing angina symptoms and experiences in women and men and (2) to propose a more meaningful construct of angina that integrates a more gender-centred approach. Methods Patients were recruited between July and December 2010 from a tertiary cardiac care centre and interviewed immediately prior to their first angiogram. Symptoms were explored through in-depth semi-structured interviews, transcribed verbatim and analysed concurrently using a modified grounded theory approach. Angiographically significant disease was assessed at ≥70% stenosis of a major epicardial vessel. Results Among 31 total patients, 13 men and 14 women had angiograpically significant CAD. Patients describe angina symptoms according to 6 symptomatic subthemes that array along a ‘gender continuum’. Gender-specific symptoms are anchored at each end of the continuum. At the centre of the continuum, are a remarkably large number of symptoms commonly expressed by both men and women. Conclusions The ‘gender continuum’ offers new insights into angina experiences of angiography candidates. Notably, there is more overlap of shared experiences between men and women than conventionally thought. The gender continuum can help researchers and clinicians contextualise patient symptom reports, avoiding the conventional ‘typical’ versus ‘atypical’ distinction that can misrepresent gendered angina experiences.

[1]  T. Dawber,et al.  II. Coronary Heart Disease in the Framingham Study , 1957 .

[2]  T. Dawber,et al.  Coronary heart disease in the Framingham study. , 1957, American journal of public health and the nation's health.

[3]  W. Proudfit,et al.  Selective Cine Coronary Arteriography: Correlation with Clinical Findings in 1,000 Patients , 1966, Circulation.

[4]  M. Bourassa,et al.  Clinical significance of selective coronary cinearteriography. , 1968, Canadian Medical Association journal.

[5]  A. Strauss,et al.  The discovery of grounded theory: strategies for qualitative research aldine de gruyter , 1968 .

[6]  W. Kannel,et al.  The Framingham study of coronary disease in women. , 1972, Medical times.

[7]  W. Kannel,et al.  Natural history of angina pectoris in the Framingham study. Prognosis and survival. , 1972, The American journal of cardiology.

[8]  L. Campeau Letter: Grading of angina pectoris. , 1976, Circulation.

[9]  Multiple risk factor intervention trial. Risk factor changes and mortality results. Multiple Risk Factor Intervention Trial Research Group. , 1982, JAMA.

[10]  Lippincott Williams Wilkins,et al.  Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. , 1983, Circulation.

[11]  de S Cameron What has gender got to do with sex , 1985 .

[12]  M. Lewis Older women and health: an overview. , 1986, Women & health.

[13]  Jennifer Coates,et al.  Some problems in the sociolinguistic explanation of sex differences , 1985 .

[14]  S. Pocock,et al.  High density lipoprotein cholesterol is not a major risk factor for ischaemic heart disease in British men. , 1986, British medical journal.

[15]  Sandra Harding,et al.  Feminism and Methodology: Social Science Issues , 1988 .

[16]  D. Gordon,et al.  High-density lipoprotein--the clinical implications of recent studies. , 1989, The New England journal of medicine.

[17]  D. Tannen You just don't understand: women and men in conversation. morrow , 1990 .

[18]  P. Eckert,et al.  Think Practically and Look Locally: Language and Gender as Community-Based Practice , 1992 .

[19]  V. Sommeren,et al.  Essays on Women, Medicine and Health , 1994 .

[20]  L. Chambless,et al.  Sex differences in mortality after myocardial infarction: is there evidence for an increased risk for women? , 1995, Circulation.

[21]  H. Krumholz,et al.  Sex differences in mortality after myocardial infarction. Is there evidence for an increased risk for women? , 1995, Circulation.

[22]  J. Holmes Women, Language and Identity , 1997 .

[23]  T. Lancet Assessing the odds , 1997, The Lancet.

[24]  A. Clarke,et al.  Women's Health: Complexities and Differences , 1998 .

[25]  K L Baird,et al.  The new NIH and FDA medical research policies: targeting gender, promoting justice. , 1999, Journal of health politics, policy and law.

[26]  P E N E L O P E E C K,et al.  New generalizations and explanations in language and gender research , 1999 .

[27]  J. Holmes,et al.  The Community of Practice: Theories and methodologies in language and gender research , 1999, Language in Society.

[28]  F Van de Werf,et al.  Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. , 1999, The New England journal of medicine.

[29]  K A Schulman,et al.  The effect of race and sex on physicians' recommendations for cardiac catheterization. , 1999, The New England journal of medicine.

[30]  Hugo A. Katus,et al.  Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. , 2000, European heart journal.

[31]  S. Gabriel,et al.  Sex differences in evaluation and outcome of unstable angina. , 2000, JAMA.

[32]  W. K. Jones,et al.  Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. American Heart Association Women's Heart Disease and Stroke Campaign Task Force. , 2000, Archives of family medicine.

[33]  L. Wallentin,et al.  Is early invasive treatment of unstable coronary artery disease equally effective for both women and men? FRISC II Study Group Investigators. , 2001, Journal of the American College of Cardiology.

[34]  J. Ayanian Increased Mortality among Middle-Aged Women after Myocardial Infarction: Searching for Mechanisms and Solutions , 2001, Annals of Internal Medicine.

[35]  T. Ryan,et al.  Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999. , 2002, Journal of the American College of Cardiology.

[36]  P. Austin,et al.  Biology or bias: practice patterns and long-term outcomes for men and women with acute myocardial infarction. , 2002, Journal of the American College of Cardiology.

[37]  H. Krumholz,et al.  Sex Differences in Cardiac Catheterization after Acute Myocardial Infarction: The Role of Procedure Appropriateness , 2002, Annals of Internal Medicine.

[38]  M. Mora Open Heart , 2003, Annals of Internal Medicine.

[39]  W. Ghali,et al.  Sex differences in outcomes after cardiac catheterization: effect modification by treatment strategy and time , 2004 .

[40]  C. Begley,et al.  ‘Add Women & Stir’—The Biomedical Approach to Cardiac Research! , 2004, European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology.

[41]  Constance K Haan,et al.  Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women , 2004, Circulation.

[42]  Constance K Haan,et al.  Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women , 2004, Arteriosclerosis, thrombosis, and vascular biology.

[43]  W. Ghali,et al.  Sex differences in outcomes after cardiac catheterization: effect modification by treatment strategy and time. , 2004, JAMA.

[44]  Kira Hall,et al.  Language and Identity , 2005 .

[45]  S. Yusuf,et al.  Differences in the management and prognosis of women and men who suffer from acute coronary syndromes. , 2005, Journal of the American College of Cardiology.

[46]  G. Mikhail Coronary revascularisation in women , 2006, Heart.

[47]  E. Brink,et al.  Constructing grounded theory : A practical guide through qualitative analysis , 2006 .

[48]  Fred S Apple,et al.  Universal definition of myocardial infarction. , 2007, Journal of the American College of Cardiology.

[49]  Is it possible to identify patient's sex when reading blinded illness narratives? An experimental study about gender bias , 2008, International journal for equity in health.

[50]  E. Barrett-Connor,et al.  Prevalence of Angina in Women Versus Men: A Systematic Review and Meta-Analysis of International Variations Across 31 Countries , 2008, Circulation.

[51]  C. Seale,et al.  The Interaction of Class and Gender in Illness Narratives , 2008 .

[52]  H. Russell Bernard,et al.  Analyzing Qualitative Data: Systematic Approaches , 2009 .

[53]  M. Walsh,et al.  ACC 2009 survey results and recommendations: Addressing the cardiology workforce crisis A report of the ACC board of trustees workforce task force. , 2009, Journal of the American College of Cardiology.

[54]  J. Pogue,et al.  Referrals in acute coronary events for CARdiac catheterization: The RACE CAR trial. , 2010, The Canadian journal of cardiology.

[55]  Clive Seale,et al.  Gender and the Language of Illness , 2010 .

[56]  Arlene S Bierman,et al.  Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes. , 2012, American heart journal.

[57]  S. Daskalopoulou,et al.  Sex differences in acute coronary syndrome symptom presentation in young patients. , 2013, JAMA internal medicine.

[58]  C. Held,et al.  Do clinical factors explain persistent sex disparities in the use of acute reperfusion therapy in STEMI in Sweden and Canada? , 2013, European heart journal. Acute cardiovascular care.

[59]  Sonia S Anand,et al.  Reconstructing angina: cardiac symptoms are the same in women and men. , 2013, JAMA internal medicine.

[60]  Penelope Eckert,et al.  The Problem with Binaries: Coding for Gender and Sexuality , 2014, Lang. Linguistics Compass.

[61]  I. Fischer You Just Don T Understand Women And Men In Conversation , 2016 .