Dr. Eugenia Trisvetova
A woman complaining of chest pains might have a compromised anamnestic record, systolic arterial hypertension, abdominal obesity, diabetes, lipid metabolism disturbances, a habit of smoking, psychosocial factors, plaque erosion and atherosclerosis pathogenetic mechanisms as risk factors.Read here a review of some differences and likely features of female coronary artery disease.
While women appear to be at lower risk for coronary artery disease the search for "coronary artery disease in women" in the pubmed database revealed 50 publications in 1980, 500 in 1995 and nearly 1000 in 2013. Many of these publications have shown that the process is delayed by 10 years, rather than avoided. Initiatives such as Women at Heart aimed at increasing awareness that cardiovascular disease is the cause of death in 55% of women compared to 43% of men.Aspects such as clinical course features, symptoms, main pathogenetic mechanisms, effects of pharmaceutical substances have been proven to a certain extent gender-specific and differences should be taken into account during primary and secondary prevention of coronary artery disease (CAD). Fertile age, menopause, oral contraceptives, hormonal and metabolic disorders during pregnancy, labor and therapeutic abortion as well as physiological differences are specific to women (1,2,3).
During post-menopausal years traditional risk factors in woman tend to become very present and increase a woman's risk for coronary artery disease.In women, and relative to their male counterparts:
Female centered findings:
B) Other risk factorsPsychosocial factors, anatomical characteristics and atherosclerosis pathogenetic mechanisms are also important.Relative to their male counterparts:
Coronary artery disease diagnostics in women are challenging because a typical course will be to show "atypical" pain syndrome and intact coronary arteries (15).The following investigations apply to diagnostics of CAD: rest ECG, stress tests (treadmill test, bicycle ergometry), pharmacologic tests, Holter ECG, rest and stress echocardiography, radionuclide techniques, coronary angiography, MRI, positron emission tomography, blood biomarkers identification. Relative to their male counterparts:
Female centered findings:
The same non-pharmacological, and pharmacological interventions are used in the treatment of both women and men with CAD. Nevertheless, relative to their male counterparts:
Regarding endovascular and surgical treatment of CAD, intervention in women has some distinct features:
Regarding secondary prevention of CAD:
Gender differences in the structure of organs, physiological reactions, and hormonal background determine certain peculiarities in clinical manifestations, course of the disease in women and men. As in men, symptoms specific to CAD in women need prompt recognition for determination of risk groups and development of preventive measures. The full range of diagnostic measures should be put in place for women taking into account the low sensitivity and specificity of non-invasive methods, according to the latest guidelines on management of coronary artery disease. Women have been underrepresented in cardiovascular clinical trials, especially in the field of coronary artery disease (23). Clinical trials enrolling a significant proportion of women will allow for pre-specified gender analysis and those performed in women only will also better address their specific needs. The iPOWER study for example will include 2,000 women with suspected CAD and CAD who will be followed for 5 years for cardiovascular outcomes. The study will provide information on methods to diagnose coronary microvascular dysfunction and determine the prognostic value of routine non-invasive assessment of microvascular function.
1 - Cardiovascular diseases in women: a statement from the policy conference of the European Society of CardiologyStramba-Badiale M, Fox KM, Priori SG, Collins P, Daly C, Graham I, Jonsson B, Schenck-Gustafsson K, Tendera M Eur Heart J 2006;27:994–1005. 2 - Coronary Artery Disease in Women Kavita Sharma, Martha Gulati Global Heart 2013;8(2):105; DOI:10.1016/j.gheart.2013.02.001 3 - Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries Hemingway H, Langenberg C, Damant J, Frost C, Pyorala K, Barrett-Connor E Circulation 2008;117:1526–1536. 4 - 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).Mancia G1, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F; Task Force Members. J Hypertens. 2013 Jul;31(7):1281-357. doi: 10.1097/01.hjh.0000431740.32696.cc.5 - Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up studyJiang H., Ogden M., Bazzano L. et al. Arch Intern Med. 2001; 161: 996-1002.6 - Triglycerides + high-density-lipoprotein-cholesterol dyslipidaemia, a coronary risk factor in elderly women: the CArdiovascular STudy in the ELderly Mazza A, Tikhonoff V, Schiavon L, Casiglia E. Intern Med J 2005;35(10):604-10. 7 - Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular eventsJespersen L, Hvelplund A, Abildstrøm SZ et al. Eur Heart J 2012;33:734–744. 8 - Frequent nut consumption and risk of coronary heart disease in women: prospective cohort study Hu FB, Stampfer MJ, Rimm EB, et al. BMJ 1998;317:1341. 9 - Estrogen receptor-alpha variants are associated with lipoprotein size distribution and particle levels in women: the Framingham Heart Study Demissie S, Cupples LA, Shearman AM, Gruenthal KM, Peter I, Schmid CH, et al. Atherosclerosis 2006;185(1):210-8. 10 - Sex differences in coronary artery size assessed by intravascular ultrasound Sheifer SE, Canos MR, Weinfurt KP et al. Am Heart J 2000;139:649-653. 11 - Angina with “normal” coronary arteries: a changing philosophy Bugiardini R, Bairey Merz CN. JAMA 2005;293:477–484.12 - Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries Hemingway H, Langenberg C, Damant J, Frost C, Pyorala K, Barrett-Connor E. Circulation 2008;117:1526–1536. 13 - Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. Anderson GL, Limacher M, Assaf AR, et al. JAMA 2004;291(14):1701-12. 14 - Evidence-based guidelines for cardiovascular disease prevention in women Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, et al. Circulation 2004;109(5):672-93.15 - 2013 ESC guidelines on the management of stable coronary artery diseaseThe Task Force on the management of stable coronary artery disease of the European Society of Cardiology.
Mancia G et al. J Hypertens. 2013 Jul;31(7):1281-35716 - Do men and women respond differently to blood pressure-lowering treatment? Results of prospectively designed overviews of randomized trials Turnbull F, Woodward M, Neal B, Barzi F, Ninomiya T, Chalmers J, et al. Eur Heart J 2008;29(21):2669-80.17 - CASS Principal Investigaters and their Associates Coronary Artery Surgery Study (CASS): a randomized trial of coronary artery bypass surgery, quality of life in patients randomly assigned to treatment groups. Circulation 1983;5(68):951–960.18 - Sex and racial differences in pharmacological responseWhere is the evidence? Pharmacogenetics, pharmacokinetics, and pharmacodinamics Anderson GD. J Womens Health 2005;14:19-29. 19 - Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S) Scandinavian Simvastatin Survival Study Group. Lancet 1994;344 (8934):1383–1389. 20 - MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Heart Protection Study Collaborative Group Lancet. 2002;6;360(9326):7-22. 21 - Baseline characteristics of participants in the JUPITER trial,a randomized placebo-controlled primary prevention trial of statin therapy among individuals with low low-density lipoprotein cholesterol and elevated high-sensitivity C-reactive protein Ridker PM, Fonseca FA, Genest J, Gotto AM, Kastelein JJ, Khurmi NS, Koenig W, Libby P, Lorenzatti AJ, Nordestgaard BG, Shepherd J, Willerson JT, Glynn RJ; JUPITER Trial Study Group. Am J Cardiol 2007;100:1659 - 1664. 22 - Improving diagnosis and treatment of women with angina pectoris and microvascular disease: The iPOWER study design and rationaleAm Heart J. 2014 Apr;167(4):452-8. doi: 10.1016/j.ahj.2014.01.003. Epub 2014 Jan 15. Prescott E et al.23 - Women and research on cardiovascular diseases in Europe: a report from the European Heart Health Strategy (EuroHeart) projectStramba-Badiale M. Eur Heart J. 2010 Jul;31(14):1677-81d).
Eugenia TrisvetovaOlga PatorskayaBelarusian State Medical UniversityAv. Dzerzhinsky 83, Minsk 220116Telephone: +375-29-679-791
Four 2012 ESC conference presentations on heart disease in womenE-journal articles on cardiovascular disease and pregnancy, peripheral artery disease and cardiovascular diseases in women.Authors' disclosures: None declared
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