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  • Review Article
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Presentation, management, and outcomes of ischaemic heart disease in women

Nature Reviews Cardiology volume 10, pages 508–518 (2013)Cite this article

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Abstract

Scientific interest in ischaemic heart disease (IHD) in women has grown considerably over the past 2 decades. A substantial amount of the literature on this subject is centred on sex differences in clinical aspects of IHD. Many reports have documented sex-related differences in presentation, risk profiles, and outcomes among patients with IHD, particularly acute myocardial infarction. Such differences have often been attributed to inequalities between men and women in the referral and treatment of IHD, but data are insufficient to support this assessment. The determinants of sex differences in presentation are unclear, and few clues are available as to why young, premenopausal women paradoxically have a greater incidence of adverse outcomes after acute myocardial infarction than men, despite having less-severe coronary artery disease. Although differential treatment on the basis of patient sex continues to be described, the extent to which such inequalities persist and whether they reflect true disparity is unclear. Additionally, much uncertainty surrounds possible sex-related differences in response to cardiovascular therapies, partly because of a persistent lack of female-specific data from cardiovascular clinical trials. In this Review, we assess the evidence for sex-related differences in the clinical presentation, treatment, and outcome of IHD, and identify gaps in the literature that need to be addressed in future research efforts.

Key Points

  • Important differences exist between women and men in clinical presentation, recognition of symptoms by patients and physicians, outcome, and response to treatment for ischaemic heart disease (IHD)

  • Among patients with IHD, environmental or behavioural causes of sex-related differences in outcomes might be more important than biological factors

  • Onset of IHD in women, manifesting as an acute myocardial infarction before the age of 65 years, is associated with adverse outcomes compared with men of a similar age

  • A traditional diagnostic strategy, focusing on detection of severe coronary stenoses, is likely to be inadequate in women

  • Additional invasive testing aimed at determining endothelial coronary dysfunction might be useful to risk-stratify women with chest pain and minimal or no obstructive coronary artery disease

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Figure 1: Differences in presentation of AMI among 1,143,513 patients (481,581 of whom were women) in the National Registry of Myocardial Infarction (1994–2006).
Figure 2: Underestimation of stenosis by angiography in a woman aged 65 years.
Figure 3: Intracoronary imaging with optical coherence tomography in a woman aged 55 years.
Figure 4: Acetylcholine testing in a woman aged 55 years.
Figure 5: Temporal trends in hospital mortality by sex and age.

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Acknowledgements

The authors of this Review are members of the European Society of Cardiology Working Group on Coronary Pathophysiology and Microcirculation, and acknowledge the European Society of Cardiology for financial support. Dr Vaccarino is supported by the National Institutes of Health, grant K24HL077506.

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Authors and Affiliations

  1. Emory University Rollins School of Public Health and School of Medicine, USA

    Viola Vaccarino

  2. Cardiovascular Research Centre, CSIC-ICCC, Spain

    Lina Badimon

  3. University Hospital, Zurich, Switzerland

    Roberto Corti

  4. Institut für Physiologie, Universität zu Lübeck, Germany

    Cor de Wit

  5. Floreasca Emergency Hospital, Romania

    Maria Dorobantu

  6. University of Pecs, Pécs, Hungary

    Akos Koller

  7. Charité-Universitätsmedizin Berlin, Germany

    Axel Pries

  8. Department of Experimental, Diagnostics and Specialized Medicine, Section of Cardiology, Policlinico Sant'Orsola-Malpighi, Bologna, 40138, Italy

    Olivia Manfrini, Edina Cenko & Raffaele Bugiardini

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  1. Viola Vaccarino
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Contributions

V. Vaccarino, R. Corti, O. Manfrini, E. Cenko, and R. Bugiardini researched data for the article. V. Vaccarino, L. Badimon, M. Dorobantu, O. Manfrini, A. Pries, E. Cenko, and R. Bugiardini contributed substantially to the discussion of content. The article was written by V. Vaccarino, R. Corti, and R. Bugiardini. V. Vaccarino, L. Badimon, R. Corti, C. de Wit, M. Dorobantu, O. Manfrini, A. Koller, E. Cenko, and R. Bugiardini reviewed/edited the manuscript before submission.

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Correspondence to Raffaele Bugiardini.

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Vaccarino, V., Badimon, L., Corti, R. et al. Presentation, management, and outcomes of ischaemic heart disease in women. Nat Rev Cardiol 10, 508–518 (2013). https://doi.org/10.1038/nrcardio.2013.93

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