Women and Ischemic Heart Disease
Key result
Women with ischemic heart disease face worse outcomes despite less obstructive CAD, driven by microvascular dysfunction.
Why the study?
Knowledge regarding sex differences in coronary heart disease is evolving, particularly the paradox of lower obstructive CAD burden yet higher ischemia and near-term mortality in women.
Key Points
- To review sex-specific differences in the pathophysiology, risk assessment, and clinical management of ischemic heart disease, focusing on non-obstructive coronary mechanisms in women.
- Synthesized observational and clinical evidence on sex differences in ischemic heart disease from cohorts including the Women's Ischemia Syndrome Evaluation and Multi-Ethnic Study of Atherosclerosis.
- Evaluated the prognostic performance of traditional risk assessment models, inflammatory biomarkers such as high-sensitivity C-reactive protein, and vascular imaging modalities.
- Analyzed clinical management paradigms for non-ST elevation acute coronary syndromes and non-obstructive coronary artery disease.
- Women experience higher near-term mortality and ischemia despite lower obstructive disease burden, with 52% of women dying of sudden cardiac death prior to hospital arrival compared to 42% of men.
- An ankle brachial index ≤0.90 carries a hazard for death of 2.7 (95% CI, 2.0-3.6) in women versus 3.3 (95% CI, 2.7-4.1) in men, while a coronary artery calcification score ≥300 confers an annual event rate of 2.2%.
- The Framingham risk score classifies >90% of women as low risk, leaving 84% of women with significant coronary artery calcification categorized as low risk prior to incorporating novel markers or imaging.
Structured PICO
P
Population
Review detailing the pathophysiology, risk stratification, and management of ischemic heart disease in women, emphasizing the role of coronary microvascular dysfunction.
This review highlights the need to recognize female-specific pathophysiology in ischemic heart disease, particularly microvascular dysfunction, to improve risk stratification and clinical management in women.
Limitations
- Lack of randomized trials comparing therapies for risk reduction in women with angina/ischemia and normal coronary arteries
- Lack of randomized trials evaluating adverse outcomes for anti-anginal and anti-ischemic therapies in women with evidence of ischemia but no obstructive CAD
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“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.”
JWJanet WeiAssociate professor of cardiology, Cedars-Sinai Medical Center
“Women are often dismissed for angina or even heart attack when they present with chest discomfort in the setting of nonobstructive coronary artery disease. Our research team and others study the role of coronary microvascular dysfunction and coronary vasospasm in ischemic heart disease, heart attacks and heart failure with preserved ejection fraction, which is more prevalent in women than men.”
Implication
Supports consideration of microvascular dysfunction in symptomatic women without obstructive CAD; leaves open optimal therapeutic strategies pending randomized trials.
Abstract
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.
Discussion
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Cite This Study
Shaw et al. (2009) conducted a review in Ischemic heart disease in women. Female sex vs. Male sex was evaluated. Women with ischemic heart disease have lower rates of obstructive coronary artery disease but experience more symptoms, ischemia, and adverse outcomes than men, largely due to coronary microvascular dysfunction.