The Yentl syndrome is alive and well

This editorial refers to ‘Are we using cardiovascular medications and coronary angiography appropriately in men and women with chest pain?’[†][1], by N. Johnston et al. , on page 1331 and ‘Factors influencing underutilization of evidence-based therapies in women’[‡][2], by R. Bugiardini et al. , on page 1337 More women than men die annually from ischaemic heart disease (IHD) in the developed world. This represents a reversal of fortune from previous decades and places women firmly as the new majority now impacted.1 Notably, the adverse IHD gender gap is the widest in relatively young women, where myocardial infarction (MI) mortality is 2-fold higher in women under 50 years compared with age-matched men.2 While it is now clear that there are many gender differences in IHD outcomes, including more frequent angina diagnosis, more office visits, more avoidable hospitalizations, higher MI mortality, and higher rates of heart failure in women compared with men,1 the aetiologies contributing to these differences are less clear. A number of paradoxes are evident with regard to sex differences in IHD.2 First, women have a higher prevalence of angina compared with men, yet have an overall lower prevalence of obstructive coronary artery disease (CAD). Secondly, symptomatic women undergoing coronary angiography have less extensive and severe obstructive CAD, despite being older with a higher risk factor burden compared with men. Thirdly, despite relatively less obstructive CAD, women have a more adverse prognosis compared with men. We have hypothesized an alternative, female-specific pattern of IHD due to the relatively high frequency of microvascular coronary dysfunction (MCD) in symptomatic women with and without obstructive CAD3−5 which we have … [1]: #fn-2 [2]: #fn-3