Background: To examine sex differences in pain and associated symptoms in patients with exercise-related ischemia, as well as the independence of these findings from other clinical factors. Methods: Prospective study of 482 women and 425 men(mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging(MPI). Analyses were performed on 38 women and 94 men with both angina and MPI evidence of ischemia during exercise. Measures: Chest pain localization, extension, intensity, quality, and presence of various non-pain-related symptoms. Results: Women rated their pain as more intense, used different words to describe it, and reported more non-pain-related symptoms than men(P< .05). They experienced pain and other sensations in the neck area more frequently(P< .05). Most of these differences remained after controlling for clinical or psychological variables, with the exception of pain intensity measures. Conclusions: Sex differences in the experience of symptoms associated with MPI evidence of myocardial ischemia may complicate timely and accurate diagnosis of ischemia in women. Background: To examine sex differences in pain and associated symptoms in patients with exercise-related ischemia, as well as the independence of these findings from other clinical factors. Methods: Prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging (MPI). Analyzes were performed on 38 women and 94 men with both angina and MPI evidence of ischemia during exercise. Measures: Chest pain localization, extension, intensity, quality, and presence of various non-pain- related symptoms. Results: Women rated their pain as more intense, used different words to describe it, and reported more non-pain-related symptoms than men (P <.05). They experienced pain and other sensations in the neck area more frequently (P <.05). Most of these differences remained after controlling for clinical or psychological variables, with the exception of pain intensity measures. Conclusions: Sex differences in the experience of symptoms asso ciated with MPI evidence of myocardial ischemia may complicate timely and accurate diagnosis of ischemia in women.