Women experience more symptoms, ischemia, and adverse outcomes despite lower rates of obstructive coronary artery disease compared to men, likely due to coronary microvascular dysfunction.
Women with ischemic heart disease frequently present without obstructive CAD but with microvascular dysfunction, requiring specific diagnostic and therapeutic strategies to improve outcomes.
Evolving knowledge regarding sex differences in coronary heart disease (CHD) is emerging. Given the lower burden of obstructive coronary artery disease (CAD) and preserved systolic function in women contrasted by higher rates of myocardial ischemia and near-term mortality compared to men, we propose the term ischemic heart disease (IHD) as appropriate for this discussion specific to women, rather than CAD or CHD. This paradoxical difference where women have lower rates of anatomical CAD but more symptoms, ischemia, and outcomes appear linked to coronary reactivity which includes microvascular dysfunction. Novel risk factors can improve the Framingham risk score, including inflammatory markers and reproductive hormones, as well as noninvasive imaging and functional capacity measurements. Risk for women with obstructive CAD is elevated compared to men, yet women are less likely to receive guideline-indicated therapies. In the setting of non-ST elevation acute myocardial infarction, interventional strategies are equally effective in biomarker positive women and men, while conservative management is indicated for biomarker negative women. For women with evidence of ischemia but no obstructive CAD, anti-anginal and anti-ischemic therapies can improve symptoms, endothelial function, and quality of life; however trials evaluating adverse outcomes are needed. We hypothesize that women experience more adverse outcomes compared to men because obstructive CAD remains the current focus of therapeutic strategies. Continued research is indicated to devise therapeutic regimens to improve symptom burden and reduce risk in women with IHD.
“We have hypothesized an alternative, female-specific pattern of ischemic HD due to the relatively high frequency of microvascular coronary dysfunction in symptomatic women with and without obstructive CAD, which we have linked with symptoms, ischemia and adverse outcomes. This alternative 'female-pattern' of ischemic HD is not easily recognized, given our male-pattern strategies aimed at detection and treatment of obstructive CAD.”
Shaw et al. (2009) conducted a review in Ischemic Heart Disease. Women experience more symptoms, ischemia, and adverse outcomes despite lower rates of obstructive coronary artery disease compared to men, likely due to coronary microvascular dysfunction.