Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries

Abstract

Ischemic heart disease (IHD) is the leading cause of mortality in women. While traditional cardiovascular risk factors play an important role in the development of IHD in women, women may experience sex-specific IHD risk factors and pathophysiology, and thus female-specific risk stratification is needed for IHD prevention, diagnosis, and treatment. Emerging data from the past 2 decades have significantly improved the understanding of IHD in women, including mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries. Despite this progress, sex differences in IHD outcomes persist, particularly in young women. This review highlights the contemporary understanding of coronary arterial function and disease in women with no obstructive coronary arteries, including coronary anatomy and physiology, mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries, noninvasive and invasive diagnostic strategies, and management of IHD.

Imaging of heart disease in women: review and case presentation

“…In addition, women more frequently report non-traditional CVRFs, such as mental stress and depression [ 13 ]. Mechanistically, plaque composition differs between sexes with women presenting more often with plaque erosion during an acute coronary syndrome (ACS) (as compared to plaque rupture in men), less necrotic core, and less plaque calcification [ 24 ]. These sex differences in plaque composition could account for the higher prevalence of ischemia with non-obstructive CAD in women [ 24 ], a central feature in the female population of both acute and chronic coronary syndromes (CCS).…”

A Scientific Imperative as Seen Through a Sharpened Lens: Sex, Gender, and the Cardiovascular Condition

“…[6][7][8] In fact, certain apparently similar ischemic syndromes (eg, chest pain or leg claudication) can arise from relatively distinct pathophysiology in females compared to males. 6,8 This fact leads us to Circulation Research. 2022;130:433-435.…”

“…6–8 In fact, certain apparently similar ischemic syndromes (eg, chest pain or leg claudication) can arise from relatively distinct pathophysiology in females compared to males. 6,8 This fact leads us to recent guidelines 9 encouraging avoidance of the term ‘atypical’ to describe symptoms in females where the preferred adjective should perhaps more accurately be ‘understudied’. Not surprisingly, a related theme is the persistent disparities experienced by females compared to males in rates of diagnosis, treatment, and control of conventionally defined cardiovascular conditions, attributable to many factors, including delayed or missed recognition.…”

“…Not surprisingly, a related theme is the persistent disparities experienced by females compared to males in rates of diagnosis, treatment, and control of conventionally defined cardiovascular conditions, attributable to many factors, including delayed or missed recognition. 3,[5][6][7][8] Finally, and concerningly, is the consistent finding that available cardiovascular interventions are often not similarly effective in females compared with males, likely due to a combination of factors including sex differences in biological response, gender differences in patterns of prescribing or titrating therapies, and available therapies themselves being functionally inadequate or mismatched for the treatment of femalespecific cardiovascular conditions. [3][4][5][6]10,11 The scientific imperative is now ever clear.…”

“…One persistent theme is how prevalent cardiac diseases with common features, including heart failure, arrhythmias, and valvular disorders, tend to present phenotypically differently in females compared with males 3–5 ; similarly, prevalent vascular diseases tend to manifest differently when involving each of the major coronary, cerebrovascular, and peripheral arterial vascular beds. 6–8 In fact, certain apparently similar ischemic syndromes (eg, chest pain or leg claudication) can arise from relatively distinct pathophysiology in females compared to males. 6,8 This fact leads us to recent guidelines 9 encouraging avoidance of the term ‘atypical’ to describe symptoms in females where the preferred adjective should perhaps more accurately be ‘understudied’.…”