[Sportschosun, Jang Jong-ho] When evaluating the heart of patients with chest pain, noninvasive functional tests such as exercise electrocardiographic stress testing are recommended before invasive coronary angiography.
Exercise electrocardiographic stress testing is widely available and relatively inexpensive. It also has the advantage of assessing not only the degree of arterial narrowing, but also whether ischemia is actually occurring in the heart. However, there has been little evidence on how often, and in which patients, the test is used in real-world practice.
A research team led by Professors Yoo Ha-young and Park Sung-mi of the Cardiology Department at Korea University Anam Hospital recently identified the real-world use of exercise electrocardiographic stress testing before coronary angiography in chest pain patients, as well as gender differences, using large-scale multicenter data from Korea.
The team analyzed 2,517 patients who underwent elective coronary angiography for chest pain and were registered in the Korean Women’s Chest Pain Registry (KoROSE) from 2013 to 2023. The median age was 64, and women accounted for 62.5% of the total. The researchers also examined the proportion of patients who received exercise electrocardiographic stress testing before coronary angiography and the factors that influenced its use.
The results showed that only 58.4% of patients who underwent coronary angiography had previously received exercise electrocardiographic stress testing, indicating that noninvasive functional testing was not being used sufficiently.
A clear gender gap was especially evident in test use. The testing rate was 69.5% among men, compared with 51.7% among women. Even in the intermediate-risk group, where the need for testing is considered high, 71.2% of men were tested, while only 54.1% of women received the test.
After adjusting for cardiovascular risk factors such as age, underlying diseases, and lifestyle habits, women were still less likely than men to undergo exercise electrocardiographic stress testing.
The analysis found that women were about 40% less likely to receive the test, suggesting that the gender gap cannot be explained solely by patient age or risk factors.
Test use also showed a mismatch with actual vascular status. Among patients with obstructive coronary artery disease, in which the coronary arteries were narrowed by 50% or more, 48.4% had undergone exercise electrocardiographic stress testing. By contrast, the rate was higher, at 65.3%, among patients without significant stenosis. Overall, 40.8% of the patients were found to have obstructive coronary artery disease.
Even when major coronary arteries do not appear severely narrowed on angiography, nonobstructive coronary ischemia, or INOCA, can occur because of microvascular dysfunction and other causes that prevent enough blood from reaching the heart muscle. If this is missed, the underlying cause may not be properly identified, delaying additional tests and treatment. The fact that this condition is more common in women, yet diagnostic exercise electrocardiographic stress testing was performed less often in women than in men, suggests that necessary tests are not being adequately provided for female patients and that ischemia may be overlooked or risk assessment may be incomplete during diagnosis.
Professor Park Sung-mi explained, "Even though women had a similar level of risk to men, they were clearly less likely to undergo exercise testing, and the gap remained even after accounting for age and other factors. If we skip functional testing like this, we may miss ischemia in the tiny microvessels of the heart, even when the major arteries are not severely narrowed. These microvascular problems are especially common in women."
She added, "This study confirms, using large-scale domestic data, that gender disparities exist in the diagnostic process for chest pain patients. It should provide evidence for improving clinical workflows and risk assessment methods so that functional testing is used more actively in intermediate-risk patients and women."
The study was supported by the National Institute of Health under the Korea Disease Control and Prevention Agency (KDCA). The paper, "Real-World Practice of Exercise Electrocardiographic Stress Testing for the Evaluation of Chest Pain," was published in JACC: Asia, the official international journal of the American College of Cardiology.
Jang Jong-ho, bellho@sportschosun.com
This article has been translated by GripLabs Mingo AI.
