The Present and Future
State-of-the-Art Review
Emergence of Nonobstructive Coronary Artery Disease: A Woman’s Problem and Need for Change in Definition on Angiography

https://doi.org/10.1016/j.jacc.2015.08.876Get rights and content
Under an Elsevier user license
open archive

Abstract

Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.

Key Words

adverse outcomes
ischemia
sex-specific pathophysiology

Abbreviations and Acronyms

ACE
angiotensin-converting enzyme
ACS
acute coronary syndrome(s)
CAD
coronary artery disease
CI
confidence interval
CMD
coronary microvascular dysfunction
cMRI
cardiac magnetic resonance imaging
CTA
computed tomography angiography
CVD
cardiovascular disease
HR
hazard ratio
IHD
ischemic heart disease
IVUS
intravascular ultrasound
LV
left ventricular
MACE
major adverse cardiovascular event(s)
MI
myocardial infarction
NSTE
non–ST-segment elevation
NSTEMI
non–ST-segment elevation myocardial infarction
PET
positron emission tomography
STEMI
ST-segment elevation myocardial infarction
TCFA
thin-cap fibroatheromas

Cited by (0)

This work was supported by contracts N01-HV-68161, N01-HV-68162, N01-HV-68163, N01-HV-68164 from the National Heart, Lung, and Blood Institutes; grants U0164829, U01 HL649141, U01 HL649241, K23HL105787, T32HL69751, R01 HL090957, 1R03AG032631 from the National Institute on Aging; GCRC grant MO1-RR00425 from the National Center for Research Resources; the National Center for Advancing Translational Sciences Grants UL1TR000124 and UL1TR000064; and grants from the Gustavus and Louis Pfeiffer Research Foundation, Danville, NJ; The Women’s Guild of Cedars-Sinai Medical Center, Los Angeles; The Ladies Hospital Aid Society of Western Pennsylvania, Pittsburgh, PA; QMED, Inc., Laurence Harbor, NJ; the Edythe L. Broad and the Constance Austin Women’s Heart Research Fellowships; Cedars-Sinai Medical Center, Los Angeles; the Barbra Streisand Women’s Cardiovascular Research and Education Program, Cedars-Sinai Medical Center, Los Angeles; The Society for Women’s Health Research (SWHR), Washington, D.C.; The Linda Joy Pollin Women’s Heart Health Program; and the Erika Glazer Women’s Heart Health Project, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Light-McGroary is the principal investigator for several multicenter, pharmaceutical clinical trials in heart failure and pulmonary hypertension. Dr. Shah holds equity in Gilead Sciences. Dr. Bairey Merz has received lecture fees from consulting fees from Amgen, Medscape, Pfizer, and has served on the grand review committee for Gilead. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.