Abstract
Chest pain is a common symptom with significant diagnostic challenges, particularly as its presentation and associated outcomes can vary by sex and age. This retrospective cohort study examined 10,220 patients referred to a UK Rapid Access Chest Pain Clinic between 2018 and 2024 to explore differences in presentation, investigation pathways and coronary artery disease (CAD) severity. Patients were categorised by sex, age group and chest pain type (typical, atypical or non-cardiac), and the type of investigation or management they received was assessed. Men were more likely to report typical chest pain and undergo invasive angiography, while women more often presented atypically and were managed with non-invasive imaging. In patients with typical chest pain, men were significantly more likely to have severe CAD on angiography, especially in older age groups. These findings support risk-based models that incorporate sex and age, such as the European Society of Cardiology (ESC) risk factor-weighted clinical likelihood approach, rather than a one-size-fits-all computed tomography coronary angiography (CTCA)-first pathway recommended by the National Institute for Health and Care Excellence (NICE). The study highlights the importance of using sex- and age-specific strategies in the triage of chest pain to improve diagnostic accuracy, reduce delays, and ensure timely identification of patients at highest risk of significant coronary disease.