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STATE-OF-THE-ART PAPER

Women and Ischemic Heart Disease

Evolving Knowledge

Leslee J. Shaw, PhD, Raffaelle Bugiardini, MD and C. Noel Bairey Merz, MD^_*,_*

^_* Women's Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Emory Program in Cardiovascular Outcomes Research and Epidemiology, Emory University School of Medicine, Atlanta, Georgia
Department of Internal Medicine, Cardio-Angiology and Hepatology, University of Bologna, Bologna, Italy

Manuscript received February 13, 2009; revised manuscript received April 20, 2009, accepted April 27, 2009.

^_* Reprint requests and correspondence: Dr. C. Noel Bairey Merz, Cedars-Sinai Medical Center, Department of Medicine, 444 S. San Vicente Boulevard, Suite 600, Los Angeles, California 90048 (Email: merz{at}cshs.org).

Evolving knowledge regarding sex differences in coronary heart disease is emerging. Given the lower burden of obstructive coronary artery disease (CAD) and preserved systolic function in women, which contrasts with greater rates of myocardial ischemia and near-term mortality compared with men, we propose the term "ischemic heart disease" as appropriate for this discussion specific to women rather than CAD or coronary heart disease (CHD). This paradoxical difference, where women have lower rates of anatomical CAD but more symptoms, ischemia, and adverse outcomes, appears linked to abnormal coronary reactivity that 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 increased compared with men, yet women are less likely to receive guideline-indicated therapies. In the setting of non–ST-segment elevation acute myocardial infarction, interventional strategies are equally effective in biomarker-positive women and men, whereas conservative management is indicated for biomarker-negative women. For women with evidence of ischemia but no obstructive CAD, antianginal and anti-ischemic therapies can improve symptoms, endothelial function, and quality of life; however, trials evaluating impact on adverse outcomes are needed. We hypothesize that women experience more adverse outcomes compared with 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 ischemic heart disease.

Key Words: ischemic heart disease • sex differences • women

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   ACS = acute coronary syndrome   CAC = coronary artery calcium   CAD = coronary artery disease   CCTA = coronary computed tomographic angiography   CHD = coronary heart disease   cIMT = carotid intima-media thickness   CMR = cardiac magnetic resonance   CRP = C-reactive protein   CVD = cardiovascular disease   FRS = Framingham Risk Score   hsCRP = high-sensitivity C-reactive protein   IHD = ischemic heart disease   MET = metabolic equivalent   MI = myocardial infarction   PCI = percutaneous coronary intervention   PET = positron emission tomography   STEMI = ST-segment myocardial infarction

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