Stress testing in women: sexual discrimination or equal opportunity?

Abstract

This editorial refers to ‘Impact of gender on risk stratification by exercise and dobutamine stress echocardiography: long-term mortality in 4234 women and 6898 men’† by L.J. Shaw et al ., on page 447 Cardiovascular disease is the leading cause of death among women in the majority of industrialized countries, accounting for 54% of total cardiovascular mortality in the United States.1 Between the ages of 45 and 64, one in nine women develops symptoms of some form of cardiovascular disease; the ratio climbs to one in three women after age 65.2 The number of cardiovascular deaths is increasing in women but declining in men. Most of this is due to ischaemic heart disease and stroke. In particular, the 49% of overall mortality due to coronary artery disease (CAD) is observed in the female population.1 This problem is expected to increase according to population aging, as obesity, metabolic syndrome, as well as diabetes disproportionately affect women, and CAD generally becomes clinically evident at least 10 years later in women as compared with men. Women demonstrate more symptoms and non-invasive test findings suggesting ischaemia, yet have a lower prevalence of luminal obstructive coronary disease on angiography. However, once presenting with obstructive coronary disease, women will have more adverse outcomes than men, particularly if coronary revascularization is needed as bypass surgery is associated with approximately two-fold increased mortality in women compared to age-matched men. Several reasons may explain poor outcomes observed in women. First, an incomplete understanding of the disease and its pathophysiological mechanisms which include more microvascular involvement, perhaps more inflammation, and still undefined vascular and metabolic abnormalities different to that seen in the usual … *Corresponding author. Tel: +39 02 50323002; fax: +39 02 50323001. E-mail address : Riccardo.Bigi{at}unimi.it