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: Section 1: diagnosis of stable ischemia and ischemic heart disease.

Abstract

The WISE workshop was convened to review results from the Women’s Ischemic Syndrome Evaluation (WISE) study and other studies of ischemic heart disease to examine the nature and scope of gender differences in both chronic and acute cardiac ischemia, in terms of clinical manifestations, detection, and treatment. This section addresses research needs in improved diagnosis of myocardial ischemia in women. The chronic stable ischemia syndrome was traditionally viewed as reversible myocardial ischemia and obstructive macrovascular coronary artery disease (CAD) that limits blood flow during periods of increased myocardial oxygen demand. The symptom, typical angina pectoris, usually had a predictable, effort-induced threshold for provocation and a characteristic chest discomfort. Unless they had diabetes, women were thought to be generally spared from this syndrome until they became elderly.1 Relatively “fixed” stenoses were central to this syndrome, and dynamic changes in coronary size were believed infrequent and contributing to only occasional variability in the threshold for ischemia provocation. Finally, the smaller arteries and arterioles were thought to be relatively spared from disease, and hence, they were not likely to participate in the pathophysiology of the ischemic syndrome. Our more contemporary view includes both men and women (with the latter being more prevalent2,3) who have variable thresholds for ischemia and symptoms that may be typical or atypical for angina pectoris. This view also includes patients (more frequently women, but also men) who have symptoms but no flow-limiting large-vessel coronary stenoses. The pathophysiology of this variability, as well as of ischemia without flow-limiting stenoses, has now been confirmed to be due to dynamic changes in coronary size that also include the microcirculation.4 These findings often involve dysfunctional endothelium and have the potential to limit flow, causing ischemia …