Coronary heart disease (CHD) is the leading cause of death in women in the United States. The recent proliferation of studies of woman and heart disease suggest that women may receive less aggressive treatment and thereby missing the important pre- and peri-CHD diagnostic phase. A recent vignette study confirmed a gender bis in proposed evaluation rather than actual practice information. No studies have addressed the possible the possible existence of gender differences in the critical pre- CHD diagnostic phase nor incorporated observed practice data across the total spectrum of primary to tertiary care. This study will focus on the important pre-diagnostic or differential diagnosis (hypothesis activation) phase. We will describe and compare the recorded CHD-related symptoms and their evaluation as well as timing of the CHD diagnosis in women and men during the ten years prior to their first acute myocardial infarction (AMI). In addition, we will describe and compare the evaluation and treatment of CHD risk factors in the ten years prior to the first AMI. These data will allow us to identify gender differences in timing of CHD diagnoses prior to AMI and differences in physician response to men and women's symptoms. Our extensive data collection will allow exploration of the association of other factors such as risk status, co-morbidity and age with gender differences in CHD-related testing or treatment. Control subjects (both men and women) who do not have known CHD will provide information on the role of prior probabilities on non-cardiac disease in gender differences in the evaluation of possible cardiac symptoms. The retrospective of look-back design starting at the time of the subject's first AMI, assures that subjects have CHD and will achieve greater efficiency in design than would be possible using a prospective cohort study. It also avoids the Hawthorne effect that might be observed in a clinical trial. Using a unique community population-based dataset maintained for > 70 years on all residents of Olmsted County avoids referral bias and will allow access to data from the entire spectrum of care, from primary ambulatory to tertiary hospital care. The information obtained will help fill important gaps in existing knowledge regarding gender differences in the recognition and evaluation of CHD. In addition, we will provide specific information on current gender-related practice patterns. This information can be used to inform future practice recommendations.
