Women's Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung and Blood Institute workshop: October 2-4, 2002: perspective: new frontiers in detection of ischemic heart disease in women.

Abstract

he prognostic implications of the diagnosis of ischemiavary dramatically in different clinical ischemic syn-dromes. At one extreme end, in unstable angina, the detectionof ischemia indicates the persistence or recurrence of insta-bility and hence carries much more severe prognostic impli-cations than in chronic stable angina. At the other extreme, inpatients with microvascular angina, the detection of ischemiadoes not indicate an increased risk of infarction or suddencardiac death and becomes clinically relevant only if itscauses can be understood and effectively treated.A typical condition in which the diagnosis of myocardialischemia is difficult is the so-calledcardiac syndrome X. Thissyndrome, which includes 60% to 70% of women (about 60%postmenopausal and 40% premenopausal) but also 30% to40% of men, is characterized by angina pectoris and normalcoronary angiography. Its incidence may vary from 10% to50% of patients submitted to coronary arteriography.Such broad inclusion criteria confuse the issue because ofthe likely inclusion of heterogeneous patients with andwithout a cardiac origin of pain. The selection of patients whopresent with specific patterns of clinical symptoms and withtransient ischemic ECG changes during chest pain would leadto more homogeneous subgroups, inasmuch as the associationof anginal pain with transient ECG changes indicates acardiac, although not necessarily ischemic, origin of pain.Moreover, distinct patterns of clinical presentation mightcorrespond with different specific pathogenetic mechanisms.