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The Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women

Abstract

It has been almost a quarter century since the first scientific statement on cardiovascular disease in women was published, yet cardiovascular disease remains the leading cause of death in women. Women often present with atypical symptoms which delays recognition, diagnosis and treatment. The complex interplay of gaps in knowledge, sparse sex-specific outcomes data, and limitations of current guidelines lead women to suffer poorer clinical outcomes, with higher cardiovascular morbidity and mortality. While efforts to increase awareness of differences in the presentation of heart disease in women have improved our ability to evaluate women with ischemic symptoms, sex-specific differences in the pathophysiology of heart disease continue to create diagnostic and therapeutic enigmas. As our knowledge of the differential impact of traditional risk factors in women continues to grow, a paucity of sex-specific outcomes data precludes the implementation of evidence-based interventions into clinical practice. More recently, emerging data on non-traditional risk factors unique to and/or more commonly found in women is also shedding new light on the increased burden of disease among younger women, and is an area for future research and interventions. Ultimately, there remains a need for sex and evidence-based diagnostic and therapeutic strategies to address the variances in disease presentation, pharmacokinetic and pharmacodynamics differences in women compared to men, and to identify prognostic markers that can be targets for long-term monitoring. In the interim, we need to ensure that available resources for anatomic and functional assessments of cardiovascular disease are not underutilized in women. This updated review discusses the current challenges of prevention, diagnosis and treatment of ischemic heart disease in women.

Keywords

  • Women
  • Ischemic heart disease
  • Coronary artery disease
  • Cardiovascular diseases
  • Epidemiology
  • Disparities
  • Cardiovascular risk
  • Diagnosis
  • Treatment

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Abbreviations

ACC:

American College of Cardiology

ACEI:

ACE inhibitors

ACS:

Acute coronary syndromes

AHA:

American Heart Association

ARB:

Angiotensin receptor blockers

ARIC:

Atherosclerosis Risk in Communities

ASCVD:

Atherosclerotic cardiovascular disease

ATP:

Adult Treatment Panel

CABG:

Coronary artery bypass grafting

CAC:

Coronary artery calcium

CAD:

Coronary artery disease

CASS:

Coronary Artery Surgery Study

CCTA:

Coronary computed tomographic angiography

CMR:

Cardiac magnetic resonance imaging

CONFIRM:

Coronary CT Angiography Evaluation for Clinical Outcomes

CVD:

Cardiovascular disease

CT:

Computed tomography

ECG:

Electrocardiogram

ELITE:

Early versus Late Intervention Trial with Estradiol

ETT:

Exercise treadmill test

FRS:

Framingham risk score

HERS:

Heart and Estrogen/Progestin Replacement Study

hsCRP:

High-sensitivity C-reactive protein

IHD:

Ischemic heart disease

IOM:

Institute of Medicine

ISCHEMIA:

International Study of Comparative Health Effectiveness and Invasive Approaches

KEEPS:

Kronos Early Estrogen Prevention Study

MACE:

Major adverse cardiac events

MHT:

Menopausal hormone therapy

MI:

Myocardial infarction

MPI:

Myocardial perfusion imaging

MVD:

Microvascular disease

NCDR:

National Cardiovascular Data Registry

NHANES:

National Health and Nutrition Examination Survey

NHLBI:

National Heart Lung and Blood Institute

PCE:

Pooled Cohort Equation

PCI:

Percutaneous coronary intervention

PCOS:

Polycystic ovarian syndrome

PET:

Positron emission tomography

PRHI:

Peripheral reactive hyperemia index

PROMISE:

Prospective Multicenter Imaging Study for Evaluation of Chest Pain

ROMICAT:

Rule Out Myocardial Infarction using Computer Assisted Tomography

SCORE:

Systematic Coronary Risk Evaluation

SPECT:

Single-photon emission computed tomography

WHI:

Women’s Health Initiative

WISE:

Women’s Ischemia Syndrome Evaluation

WOMEN:

What is the Optimal Method for Ischemia Evaluation in Women

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Acknowledgment

The authors are grateful to Mrs. Debra Ward and Mrs. Rebecca Olson for their precious assistance with chapter preparation. Dr. Brewer is supported by the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholars Program (award number K12 HD065987-07) from the National Institutes of Health (NIH) Office of Research on Women’s Health (ORWH), Mayo Clinic Women’s Health Research Center.

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Brewer, L.C., Adigun, R.O., Mulvagh, S.L. (2018). The Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women. In: Mehta, J., McSweeney, J. (eds) Gender Differences in the Pathogenesis and Management of Heart Disease. Springer, Cham. https://doi.org/10.1007/978-3-319-71135-5_12

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