Coronary heart disease (CHD) remains the leading cause of death in the United States, accounting for 26.6% of all deaths in 2005, with an age-adjusted male to female mortality ratio of 1.5.1 Although the CHD mortality rate has steadily declined since its peak in the 1960s, morbidity from CHD has shown opposite trends, with increasing rates of revascularization and an increasing prevalence of angina pectoris, now estimated at 9.1 million (4.6 million women [3.9%]; 4.4 million men [4.4%]).2 In stark contrast to CHD mortality rates, age-adjusted prevalence rates for angina in the United States are higher among women than men.2 Anginal symptoms tend to persist despite medical therapy and revascularization, lead to substantial functional disability, and be associated with high healthcare costs even in the absence of obstructive coronary artery disease (CAD).3,4 Article p 1526 In 1990, Kalin and Zumoff showed in a large ecological study that the male:female CHD mortality ratio was quite constant across countries despite widely varying CHD mortality rates between countries, suggesting an inherent gender difference.5 Similar data for angina have not been available. The study by Hemingway et al6 in this issue was thus undertaken to determine whether differences in angina rates by gender are similarly constant in countries that greatly differ in the prevalence of CHD risk factors and prevalence of CHD. The authors conducted a meta-analysis of cross-sectional and prospective cohort studies of 74 populations within 31 countries encompassing around 40 000 individuals (nearly 50% women). All studies ascertained angina by Rose questionnaire. Countries were categorized by their male:female myocardial infarction mortality ratio, their geographical region, and their level of economic development. Angina prevalence varied approximately 20-fold between countries, ranging from 0.73% to 14.4% in women and 0.76% to 15.1% in men. Female and male angina prevalence …