Sex Differences in the Pathophysiology, Treatment, and Outcomes in IHD

Current Atherosclerosis Reports, May 2015

Heart disease is the number one killer of women. Although there are many similarities between men and women, the evolving understanding of ischemic heart disease in women allow us to emphasize the important differences that need to be recognized. These differences, including symptoms at presentation, importance of particular risk factors, pathophysiology of disease, and treatments/outcomes, will be discussed in this review.

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Sex Differences in the Pathophysiology, Treatment, and Outcomes in IHD

Curr Atheroscler Rep Sex Differences in the Pathophysiology, Treatment, and Outcomes in IHD Monika Sanghavi 0 1 Martha Gulati 0 1 0 Department of Internal Medicine (Cardiology) and Department of Clinical Public Health (Epidemiology), The Ohio State University , Columbus, OH , USA 1 Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center , 5323 Harry Hines Blvd, Dallas, TX 75390-8830 , USA Heart disease is the number one killer of women. Although there are many similarities between men and women, the evolving understanding of ischemic heart disease in women allow us to emphasize the important differences that need to be recognized. These differences, including symptoms at presentation, importance of particular risk factors, pathophysiology of disease, and treatments/outcomes, will be discussed in this review. Ischemic heart disease; Women; Microvascular dysfunction; Cardiovascular disease; Risk factors - Women in the USA are more likely to die of cardiovascular disease (CVD) than any other cause [1 ]. In fact, cardiovascular disease claims the life of a woman every minute [1 ]. The statistics are staggering; however, almost 50 % of white women and three fourths of Hispanic and black women are still unaware that this is their greatest risk [2]. Among cardiovascular diseases, coronary heart disease (CHD) makes up the majority of events for both men and women below 75 years of age [1 ]. The incidence of CHD in women lags behind men by 10 years, suggesting a protective effect in women that is lost with advanced age, particularly after the onset of menopause. The overall incidence of CHD is lower in women; however, across all age strata, a myocardial infarction (MI) is more likely to be fatal in women, particularly in younger women (under 55 years of age) [1 ]. Although the overall trends suggest a decrease in incident CHD events and CHD-related deaths over the past 20 25 years in both men and women, the only exception is younger women (3544 years of age) for whom the mortality has increased [3]. Previously it was assumed that heart disease in women was the same as in men, and the underrepresentation of women in research studies prevented any alternate sex-specific conclusions. With the emergence of new sex-specific studies and data, the landscape of heart disease is changing. We now know that certain risk factors are stronger predictors of heart disease in women, there are sex differences in symptoms, and there are differences in the underlying pathophysiology. With the new understanding of the pathophysiologic differences come changes in diagnostic testing and treatment strategies. CHD is traditionally characterized by obstructive atherosclerosis in the epicardial coronary arteries resulting in ischemia or decreased myocardial blood flow. However, with the recognition that there are a variety of disorders that result in ischemia and ischemic symptoms in women, not just coronary heart disease, the more-inclusive term ischemic heart disease (IHD) is considered fitting for this discussion [4]. IHD is a broader term that encompasses any disorder or disease that results in myocardial ischemia; this includes Cardiac Syndrome X, a term used to describe patients with symptoms and evidence of ischemia but no obstructive coronary artery disease [5] and is noted to be more common in women. More recently, this syndrome has been labeled as female-specific IHD. The following review article will discuss the sex differences in IHD with a focus on the pathophysiology, treatment, and outcomes. Symptoms/Clinical Presentation Angina pectoris is the most common symptom of myocardial ischemia. The description of Btypical^ angina was based the presence of classic characteristics of obstructive coronary disease which included retrosternal chest pressure, exacerbation with activity, and relief with rest or nitroglycerin, defined in a population of predominantly men. Of note, other causes of myocardial ischemia may not present with the same characteristic presentation, for example, patients with coronary vasospasm often report pain at rest. The distinction of Btypical^ vs. Batypical^ angina, based on the number of classic characteristics present, was used by Diamond and Forrester to help determine the pretest probability of atherosclerotic disease [6]. More recently, the term Batypical angina^ is often used when describing symptoms in women since some women can have prodromal symptoms of shortness of breath, fatigue, and weakness with ischemia [7] or other nonclassic descriptions of pain. However, even though women are more likely to have atypical symptoms when compared to men, the most common presentation in acute coronary syndrome is still typical angina [8]. In a study evaluating anginal symptoms in men and women with confirmed obstructive coronary artery disease, there was no difference in the presenting symptoms [9]. In general, women have a higher prevalence of angina (...truncated)


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Monika Sanghavi, Martha Gulati. Sex Differences in the Pathophysiology, Treatment, and Outcomes in IHD, Current Atherosclerosis Reports, 2015, pp. 34, Volume 17, Issue 6, DOI: 10.1007/s11883-015-0511-z