Sex Differences in Coronary Function Test Results in Patient With Angina and Nonobstructive Disease

Abstract

Introduction: Invasive coronary function testing (CFT) has become the recommended diagnostic tool to assess the various endotypes of coronary vasomotor dysfunction in patients with angina and no obstructive coronary artery disease (ANOCA), which has implications for therapy and prognosis. Although the expanding performance of CFT is leading to increased knowledge of coronary vasomotor dysfunction, little is known about sex-related differences in the results of comprehensive CFT.Methods: We conducted a prospective study of all consecutive patients with ANOCA that underwent clinically indicated CFT in a tertiary interventional from February 2019 to February 2021. CFT consisted of acetylcholine testing to diagnose epicardial or microvascular spasm, and adenosine testing to diagnose CMD. CMD was defined as an index of microvascular resistance (IMR) ≥ 25 and/or coronary flow reserve (CFR) < 2.0.Results: In total, 228 women and 38 men underwent CFT. No differences in traditional risk factors were seen, but women had a higher prevalence of migraine (45 vs. 14%, p = 0.001). Men more often had a history of percutaneous coronary intervention (12 vs. 49%, p = 0.001). We found no difference in clinical presentation. Coronary vasomotor dysfunction was present in 95% of men and 88% of women (p = 0.25), but males show more often epicardial spasm and less microvascular spasm than women (63 vs. 42% and 29 vs. 40% respectively, p = 0.039). Impaired CFR was more prevalent among females (6 vs 20%, p = 0.033). IMR [median of 23 (15–32) vs. 19 (13–25), p = 0.08] did not differ between the sexes.Conclusion: Men undergoing CFT show a comparable prevalence of coronary vascular dysfunction as women. However, men have a higher prevalence of epicardial spasm and a lower prevalence of microvascular spasm compared with women. An impaired CFR was more often present in women, with an equally impairment of IMR.

Meta-analysis and systematic review of coronary vasospasm in ANOCA patients: Prevalence, clinical features and prognosis

“…The total study population had a mean age of 58.2 years of which 44.2% were women ( n = 7.064). Twelve studies ( n = 4.287) described Western World populations (mean age 57.7; 40.3% women) ( 8 – 10 , 12 – 14 , 20 – 22 , 26 – 28 ) and 13 studies ( n = 11.688) described Asian populations (mean age 58.4; 42.0% women) ( 11 , 15 – 19 , 23 , 25 , 29 – 32 ).…”

“…The prevalence of epicardial spasm in ANOCA patients was reported in 17 studies, including 11.762 ANOCA patients with a mean age of 58.1 years of which 52.2% were women ( Supplementary Table S5 ) ( 8 , 9 , 11 , 12 , 14 , 17 – 20 , 22 – 25 , 27 , 28 , 30 , 31 ). Studies reported an incidence of epicardial spasm between 16%–73% and an overall prevalence of epicardial spasm ( n = 5.614) of 43% [95% confidence interval (CI), 33%–53%], based on random effects analysis ( Figure 2 ).…”

“…Studies reported an incidence of epicardial spasm between 16%–73% and an overall prevalence of epicardial spasm ( n = 5.614) of 43% [95% confidence interval (CI), 33%–53%], based on random effects analysis ( Figure 2 ). When studies only using Ach as diagnostic agent and using similar diagnostic criteria (i.e., 75% or 90% epicardial vasoconstriction with ischemic ECG changes and symptoms) were included in a separate random effects analysis, studies reported an overall prevalence of 44% (95% CI, 30%-58%) ( Supplementary Figure S1 ) ( 8 , 9 , 14 , 22 , 23 , 25 , 27 ). In addition, Supplementary Figure S2 shows the prevalence of epicardial spasm in studies published the past five years, reporting a prevalence of 50% (95% CI, 36%-64%).…”

“…Furthermore, a separate analysis including studies within the funnel-plot ( Supplementary Figure S3 ) was performed, reporting a prevalence of 42% (95% CI, 36%-48%) ( Supplementary Figure S5 ). The prevalence of microvascular spasm was reported in 10 studies ( n = 4,403 ANOCA patients) with a mean age of 61.9 years of which 51.6% were women( 8 , 9 , 14 , 17 , 19 , 22 – 24 , 27 , 30 ). Based on random effects analysis, studies reported an overall prevalence of 25% (95% CI, 16%–36%) ( Figure 3 ).…”

Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies

“…Men have been shown to have a comparable prevalence of coronary vascular dysfunction to women. However, they probably have a higher prevalence of epicardial spasm and a lower prevalence of microvascular spasm than women [ 19 ].…”