Sex Difference in Chest Pain After Drug-Eluting Stents

Study Questions:

Do chest pain symptoms differ by sex after percutaneous coronary intervention (PCI) with newer generation drug-eluting stents (DES)?


This was a pooled analysis of patient-level data from two randomized trials. Data from the TWENTE study (Real-World Resolute Versus Xience V Drug-Eluting Stent Study in Twente) conducted between June 2008 and August 2010, and the DUTCH PEERS trial (Durable Polymer-Based STent CHallenge of Promus Element versus ReSolute Integrity in an All Comers Population) conducted between November 2010 and May 2012, were used to examine patient-reported chest pain symptoms in men and women at 1 and 2 years of follow-up. All subjects were admitted for PCI with either stable coronary artery disease or acute coronary syndromes. In both trials, the majority of patients were treated for complex target lesions and had off-label indications for DES use. Additional outcomes included adverse events at 1 and 2 years.


A total of 3,202 patients were included in this analysis, of which 871 (27.2%) were women. Women were older (67.5 vs. 62.8) and more likely to have cardiovascular disease risk factors including diabetes and hypertension. At 1- and 2-year follow-up, women reported more clinically relevant chest pain (16.3% vs. 10.5%; p < 0.001, and 17.2% vs. 11.1%; p < 0.001, respectively). Female sex was independently associated with chest pain at 1 and 2 years of follow-up, including chest pain occurring with daily activities and with minimum physical exertion or at risk, after controlling for possible confounders (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.4; p = 0.002 [for daily activities at 1 year]; and OR, 1.8; 95% CI, 1.3-2.5; p < 0.001 [for minimum activities/rest at 1year]). Chest pain symptoms were also associated with female sex at 2-year follow-up (OR, 1.8; 95% CI, 1.3-2.6; p < 0.001 [for daily activities] and adjusted OR, 1.7; 95% CI, 1.3-2.3; p = 0.001 [for minimum activities/rest]). In terms of adverse outcomes (including death, myocardial infarction, stent thrombosis, and revascularization), no difference between males and females was observed at 2 years.


The investigators concluded that although the incidence of adverse cardiovascular events was low and similar for both sexes, women reported significantly more chest pain.


The data from these two trials support prior observations of higher rates of chest pain among women. Further research is warranted to understand the mechanisms behind this difference in chest pain symptoms.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Interventions and ACS, Hypertension

Keywords: Acute Coronary Syndrome, Chest Pain, Diabetes Mellitus, Drug-Eluting Stents, Hypertension, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Physical Exertion, Polymers, Risk Factors, Sex Characteristics, Thrombosis

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