Ischemic Heart Disease in Women

Abstract

After at least 2 decades of growing awareness on coronary heart disease in women, we are left with many questions, few answers, and plenty of opinions. Review articles, books, sessions at scientific meetings, and commentaries regarding various aspects of heart disease in women have proliferated. These reports have highlighted important sex differences in the pathophysiology, presentation, and treatment of ischemic heart disease and have denounced pervasive sex-related disparities in referral and treatment for heart disease as a major reason for outcome differences between the sexes. Such activities have been useful in driving attention to heart disease in women, an area largely ignored by the scientific community and the public just 15 to 20 years ago. However, we must recognize that to date, limited data substantiate many of these statements; such recognition is important to guide future research efforts. A careful look at recently published literature reveals only modest advancements toward clarifying sex-based differences in the pathophysiology of ischemic heart disease and sex-based differences in outcome. At the same time, key questions concerning strategies for prevention and treatment of heart disease in women remain unanswered, and cardiovascular clinical trials continue to include fewer women than men.1 A fundamental question is whether the mechanisms underlying ischemic heart disease in women differ from those in men. This is an important question because if pathophysiology differs in women, such differences can inform strategies for prevention, detection, and treatment that would be most effective for women. That pathophysiology may differ in women compared with men is suggested by several factors. First, despite having more symptoms and physical limitations,2,3 women have less obstructive coronary heart disease than men along the entire spectrum of acute coronary syndromes4 and when referred for revascularization.5,6 Second, the syndrome of chest pain without obstructive coronary artery disease …