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
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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)