Sudden Cardiac Death in Women With Suspected Ischemic Heart Disease, Preserved Ejection Fraction, and No Obstructive Coronary Artery Disease: A Report From the Women's Ischemia Syndrome Evaluation Study

Abstract

BackgroundSudden cardiac death (SCD) is often the first presentation of ischemic heart disease; however, there is limited information on SCD among women with and without obstructive coronary artery disease (CAD). We evaluated SCD incidence in the WISE (Women's Ischemia Syndrome Evaluation) study.Methods and ResultsOverall, 904 women with suspected ischemic heart disease with preserved ejection fraction and core laboratory coronary angiography were followed for outcomes. In case of death, a death certificate and/or a physician or family narrative of the circumstances of death was obtained. A clinical events committee rated all deaths as cardiovascular or noncardiovascular and as SCD or non‐SCD. In total, 96 women (11%) died over a median of 6 years (maximum: 8 years). Among 65 cardiovascular deaths, 42% were SCD. Mortality per 1000 person‐hours increased linearly with CAD severity (no CAD: 5.8; minimal: 15.9; obstructive: 38.6; P<0.0001). However, the proportion of SCD was similar across CAD severity: 40%, 58%, and 38% for no, minimal, and obstructive CAD subgroups, respectively (P value not significant). In addition to traditional risk factors (age, diabetes mellitus, smoking), a history of depression (P=0.018) and longer corrected QT interval (P=0.023) were independent SCD predictors in the entire cohort. Corrected QT interval was an independent predictor of SCD in women without obstructive CAD (P=0.033).Conclusions SCD contributes substantially to mortality in women with and without obstructive CAD. Corrected QT interval is the single independent SCD risk factor in women without obstructive CAD. In addition to management of traditional risk factors, these data indicate that further investigation should address mechanistic understanding and interventions targeting depression and corrected QT interval in women.

The role of imaging in women with ischemic heart disease

“…In addition, young women (<55 years old) with IHD with an acute myocardial infarction have a worse prognosis, with higher mortality compared to their male counterparts . Early identification of women at risk for IHD is critical, especially given that sudden cardiac death contributes substantially to mortality in women with and without obstructive coronary artery disease (CAD), and is often the first manifestation of CAD in a significant proportion of women …”

“…1 Early identification of women at risk for IHD is critical, especially given that sudden cardiac death contributes substantially to mortality in women with and without obstructive coronary artery disease (CAD), and is often the first manifestation of CAD in a significant proportion of women. 5,6 Contemporary and novel diagnostic imaging techniques have now assumed an expanded role in the evaluation of symptomatic women to detect not only focal epicardial coronary stenosis, but also nonobstructive atherosclerosis along with the identification of ischemia resulting from endothelial and microvascular dysfunction. [7][8][9] Incorporating the full spectrum of IHD, additional investigation to include imaging beyond standard stress tests is often necessary to define the etiology of symptoms in women.…”

Assessment of Vascular Dysfunction in Patients Without Obstructive Coronary Artery Disease

“…When studied using specific tests, MVA and VSA are common findings; up to 4 in 5 patients with INOCA may be affected ( 11 , 12 , 13 ). They are mostly women, and prognosis ( 14 , 15 , 16 , 17 , 18 ) and quality of life ( 7 , 19 , 20 , 21 ) are impaired. Vasospasm may also be a primary cause of myocardial infarction (MI) with no obstructive coronary disease and type 2 MI.…”

Advances in Precision Health and Emerging Diagnostics for Women

“…When women lose the protection of E 2 in early menopause, they have a 33% higher risk of coronary heart disease and stroke [47]. The Women’s Ischemia Syndrome Evaluation found that women’s arteries can appear healthy on angiogram, but can have microvascular dysfunction [48,49]. Recent developments in biomarkers for risk stratification and improved diagnostic tests allow for more sensitive detection of cardiovascular disease among women [44,46,49].…”