Review
Ischemic Heart Disease in Women: A Review for Primary Care Physicians
Abstract
Ischemic heart disease (IHD) is the leading cause of death among women in the Western world, and its prevalence is growing. The pathophysiology of heart disease in women differs from that in men. Women with chest pain and abnormal stress tests are less likely than men to have critical stenosis of coronary arteries, a phenomenon attributed to endothelial dysfunction. Hypertension, intimal injury, and cholesterol are among the various factors that contribute to endothelial dysfunction. The presenting symptoms of IHD also differ in women. Women are more likely to describe neck and throat pain and to characterize the pain as intense, sharp, or burning. A history of coronary or other vascular disease, diabetes, or chronic kidney disease places patients at high risk for IHD. Risk factor modification can be tailored based on each patient's risk. Hormone replacement therapy, antioxidants, folic acid, and aspirin in healthy women under 65 years of age have recently been shown to be ineffective in the prevention of IHD.
Key Points
* Women with ischemic heart disease are more likely than men to have endothelial dysfunction.
* Established coronary artery disease, other vascular disease, chronic kidney disease, and diabetes mellitus place women at high risk for ischemic heart disease.
* Hormone replacement therapy, antioxidants, folic acid, and aspirin (in healthy women under 65 years of age) are ineffective in preventing ischemic heart disease.
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References
1. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol 2007;49:1230–1250.
2. Roger VL, Jacobsen SJ, Pellikka PA, et al. Gender differences in use of stress testing and coronary heart disease mortality: a population-based study in Olmsted County, Minnesota. J Am Coll Cardiol1998;32:345–352.
3. Hu FB, Stampfer MJ, Manson JE, et al. Trends in the incidence of coronary heart disease and changes in diet and lifestyle in women. N Engl J Med 2000;343:530–537.
4. Vittinghoff E, Shlipak MG, Varosy PD, et al. Risk factors and secondary prevention in women with heart disease: the Heart and Estrogen/progestin Replacement Study. Ann Intern Med 2003;138:81–89.
5. Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation 2010;121:948–954.
6. Merz CN, Kelsey SF, Pepine CJ, et al. The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report. J Am Coll Cardiol 1999;33:1453–1461.
7. Kucher N, Lipp E, Schwerzmann M, et al. Gender differences in coronary artery size per 100 g of left ventricular mass in a population without cardiac disease. Swiss Med Wkly 2001;131:610–615.
8. Anderson HV, Stokes MJ, Leon M, et al. Coronary artery flow velocity is related to lumen area and regional left ventricular mass. Circulation 2000;102:48–54.
9. Buchthal SD, den Hollander JA, Merz CN, et al. Abnormal myocardial phosphorus-31 nuclear magnetic resonance spectroscopy in women with chest pain but normal coronary angiograms. N Engl J Med 2000;342:829–835.
10. Camici PG, Crea F. Coronary microvascular dysfunction. N Engl J Med 2007;356:830–840.
11. Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation 1995;92:657–671.
12. Bellasi A, Raggi P, Merz CN. New insights into ischemic heart disease in women. Cleve Clin J Med 2007;74:585–594.
13. Arnold AL, Milner KA, Vaccarino V. Sex and race differences in electrocardiogram use (the National Hospital Ambulatory Medical Care Survey). Am J Cardiol 2001;88:1037–1040.
14. Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome of unstable angina. JAMA 2000;283:646–652.
15. Shaw LJ, Vasey C, Sawada S, et al. Impact of gender on risk stratification by exercise and dobutamine stress echocardiography: long-term mortality in 4234 women and 6898 men. Eur Heart J2005;26:447–456.
16. Maynard C, Litwin PE, Martin JS, et al. Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry. Arch Intern Med 1992;152:972–976.
17. Daly C, Clemens F, Lopez Sendon JL, et al. Gender differences in the management and clinical outcome of stable angina. Circulation 2006;113:490–498.
18. Bell MR, Berger PB, Holmes DR Jr, et al. Referral for coronary artery revascularization procedures after diagnostic coronary angiography: evidence for gender bias? J Am Coll Cardiol 1995;25:1650–1655.
19. Sullivan AK, Holdright DR, Wright CA, et al. Chest pain in women: clinical, investigative, and prognostic features. BMJ 1994;308:883–886.
20. Johnson BD, Shaw LJ, Pepine CJ, et al. Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NLHBI-sponsored Women's Ischaemia Syndrome Evaluation (WISE) study. Eur Heart J 2006;27:1408–1415.
21. Gulati M, Cooper-DeHoff RM, McClure C, et al. Adverse cardiovascular outcomes in women with nonobstructive coronary artery disease: a report from the Women's Ischemia Syndrome Evaluation Study and the St James Women Take Heart Project. Arch Intern Med 2009;169:843–850.
22. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:618–626.
23. Cohen MG, Fonarow GC, Peterson ED, et al. Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines—Coronary Artery Disease Program. Circulation 2010;121:2294–2301.
24. Bransford TL, Ofili E. The paradox of coronary heart disease in African-American women. J Natl Med Assoc 2000;92:327–333.
25. Williams RA. Cardiovascular disease in African American women: a health care disparities issue. J Natl Med Assoc 2009;101:536–540.
26. Bugiardini R, Bairey Merz CN. Angina with “normal” coronary arteries: a changing philosophy. JAMA 2005;293:477–484.
27. Johnson BD, Shaw LJ, Buchthal SD, et al. Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease: results from the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation 2004;109:2993–2999.
28. Ridker PM, Buring JE, Rifai N, et al. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. JAMA 2007;297:611–619.
29. Reis SE, Olson MB, Fried L, et al. Mild renal insufficiency is associated with angiographic coronary artery disease in women. Circulation 2002;105:2826–2829.
30. Lee WL, Cheung AM, Cape D, et al. Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies. Diabetes Care 2000;23:962–968.
31. Juutilainen A, Kortelainen S, Lehto S, et al. Gender difference in the impact of type 2 diabetes on coronary heart disease risk. Diabetes Care 2004;27:2898–2904.
32. Prescott E, Hippe M, Schnohr P, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ 1998;316:1043–1047.
33. Gierach GL, Johnson BD, Bairey Merz CN, et al. Hypertension, menopause, and coronary artery disease risk in the Women's Ischemia Syndrome Evaluation (WISE) Study. J Am Coll Cardiol 2006;47:S50–S58.
34. Bass KM, Newschaffer CJ, Klag MJ, et al. Plasma lipoprotein levels as predictors of cardiovascular death in women. Arch Intern Med 1993;153:2209–2216.
35. The Emerging Risk Factors Collaboration, Di Angelantonio E, Sarwar N, et al. Major lipids, apolipoproteins, and risk of vascular disease. JAMA 2009;302:1993–2000.
36. Pischon T, Boeing H, Hoffmann K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med 2008;359:2105–2120.
37. Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA 2007;297:1465–1477.
38. Wilson PW, D'Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837–1847.
39. Melander O, Newton-Cheh C, Almgren P, et al. Novel and conventional biomarkers for prediction of incident cardiovascular events in the community. JAMA 2009;302:49–57.
40. O'Keefe JH, Carter MD, Lavie CJ. Primary and secondary prevention of cardiovascular diseases: a practical evidence-based approach. Mayo Clin Proc 2009;84:741–757.
41. Autier P, Gandini S. Vitamin D supplementation and total mortality: a meta-analysis of randomized controlled trials. Arch Intern Med 2007;167:1730–1737.
42. Milani RV, Lavie CJ, Mehra MR. Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol 2004;43:1056–1061.
43. Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2009;150:405–410.
