Women’s Ischemic Syndrome Evaluation

Abstract

Endorsed by the American College of Cardiology Foundation T he concomitant effects of aging, traditional risk factors, and a lack of endogenous estrogen promote the sequelae of arterial dysfunction, inflammation, and atheromatous plaque deposition in women. The challenges for improved diagnosis of coronary artery disease (CAD) in women include the more complex and multifactorial nature of the disease process; small artery size; and vascular and metabolic abnormalities that have yet to be thoroughly elucidated with existing imaging technology. Conditional risk markers, such as high-sensitivity C-reactive protein (hs-CRP), may provide greater insight into the arterial insult and underlying risk burden. Conventional ischemia testing, aimed primarily at detection of obstructive lesions, has provided disappointing results in women. Perhaps as a result of vascular remodeling, symptomatic women more often have nonobstructive atherosclerotic disease and, in some cases, evidence of metabolic or vascular dysfunction. Imaging accuracy in women is also hampered by technical problems and differences in body habitus. In addition, studies assessing diagnostic accuracy of imaging methods have often included small numbers of women subjects. In larger female samples, stress echocardiography and single photon emission computed tomography (SPECT) have yielded positive results in terms of estimating clinical outcomes. Newer technology, such as magnetic resonance spectroscopy (MRS) and perfusion imaging (MRI), has revealed intriguing findings indicating reductions in both subendocardial flow and high-energy phosphates that are suggestive of myocardial ischemia during stress testing in symptomatic women without obstructive CAD. This section reviews the evidence for gender differences in traditional and novel risk factors and explores the use of conventional and innovative myocardial methods to detect myocardial ischemia. Clinical Application and Evidence Traditional Risk FactorsThe Atherosclerosis Risk In Communities (ARIC) study assessed traditional risks (age, cholesterol, blood pressure, smoking, and diabetes) for CAD events in 15 792 middleaged, black and white women and men. These traditional risk factors can be integrated into a global risk score to predict 10-year risk of CAD events. Most men and many women have a 10-year CAD risk of greater than 10%. Results from the ARIC study reveal that these risk equations have higher predictive value in women than in men. 1 The addition of nontraditional risk factors and subclinical atherosclerosis measures improves prediction in men but not in women. 1

Carotid Atherosclerosis Is a Stronger Predictor of Myocardial Infarction in Women Than in Men

“…Sex-related differences are becoming increasingly recognized as potentially important factors in atherosclerosis. 31 Whereas the prevalence of angina pectoris is similar among men and women, men have a higher incidence of MI and myocardial death than women at any age. 32 This divergence in sex ratios between angina pectoris and MI remains unexplained.…”

Retinal Arteriolar Dilation Predicts Retinopathy in Adolescents With Type 1 Diabetes

“…The reasons for this observation are not apparent. Although epidemiological studies offer inconsistent evidence that the risk of diabetic retinopathy differs by sex, it has long been hypothesized that women are more susceptible to microvascular disease development than men (21). Moreover, hormonal changes associated with puberty have been suggested to contribute to the development of diabetic retinopathy (14,(22)(23)(24).…”

How does hypertension affect your eyes?

“…50,57 Emerging evidence also indicates that risk for coronary heart disease may be higher in women who were previously deemed 'low risk' by traditional risk factors. 57,58 In the Multi-Ethnic Study of Atherosclerosis cohort, retinopathy was shown to have significant correlation with increased coronary artery calcium scores. 59 Retinal arteriolar narrowing and decreased myocardial blood flow and perfusion reserve are also found to be closely linked.…”