Coronary artery disease is now the commonest cause of death in women in many countries, including Britain and the United States.1 Its incidence increases with age, rising rapidly after the menopause2: by 65 cardiovascular disease is equally common in men and women. As the proportion of older women in the population increases so the incidence of cardiovascular disease will increase. In the United States cardiovascular disease now kills proportionately more women than men.3 Before the age of 65 coronary artery disease is half as common in women as men, affecting affecting one in nine women aged 45 to 64. But coronary artery disease also affects premenopausal women - a quarter of the deaths from myo-cardial infarction in women under 65 occur in women under 45.

The first hurdle in assessing coronary artery disease in women is to increase awareness of its existence - both among doctors and among women themselves. Women with coronary artery disease usually present differently from men.4 They present more commonly with angina than infarction. Furthermore, their symptoms are more likely to have atypical features and are more often attributed to non-cardiac causes - especially in younger women, in whom coronary artery disease is uncommon. Exercise testing is as useful in women as men when they are aged 65 or over (when the incidence of coronary artery disease is the same), but in younger women, with a lower incidence of coronary artery disease, the rate of false positive results is likely to be higher. (This may explain the finding that women with chest pain are five times more likely to have normal coronary arteries than men.5,6)

Assessing chest pain in women, Sullivan et al confirmed the limited value of exercise testing in predicting coronary artery disease in women …