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Gender Disparities in CAD: Women and Ischemic Heart Disease

  • Women and Ischemic Heart Disease (A. Maran, Section Editor)
  • Published:
Current Atherosclerosis Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The goal of this article is to review the disparities that exist for women who present for treatment of ischemic heart disease.

Recent Findings

It is well known that women are more likely to present with ischemic heart disease at an advanced age with more comorbidities when compared to male counterparts. Despite correction of risk factors, women experience worse outcomes, even in the absence of obstructive coronary artery disease. A review of the literature highlights the importance of a thoughtful approach to medical therapy and revascularization.

Summary

While most recommendations applied to women are derived mostly from male data, further study of sex-specific differences may lead to approaches which can ultimately reduce disparities for the treatment of ischemic heart disease in women.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. “State-specific mortality from sudden cardiac death --- United States, 1999.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/mmwr/preview/mmwrhtml/mm5106a3.htm. Accessed 25 Aug 2008.

  2. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association [published correction appears in Circulation. 2011;123:e240]. Circulation. 2011;123:e18–e209.

    Article  PubMed  Google Scholar 

  4. Centers for Disease Control and Prevention. Racial/ethnic disparities in prevalence, treatment, and control of hypertension—United States, 1999–2002. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5401a3.htm. Accessed 25 Aug 2008. 17. Murphy SL. Death: final data for 1998. Natl Vital Stat Rep 2000;48: 1–105.

  5. • Melloni C, et al. Representation of women in randomized clinical trials of cardiovascular disease prevention. Circ Cardiovasc Qual Outcomes. 2010;(3, 2):135–42. https://doi.org/10.1161/circoutcomes.110.868307. This was a great article which highlights the lack of involvement of women and cardiology clinical trials.

    Google Scholar 

  6. Hecht HS, Superko HR. Electron beam tomography and National Cholesterol Education Program guidelines in symptomatic women. J Am Coll Cardiol. 2001;37:1506–11.

    Article  CAS  PubMed  Google Scholar 

  7. Shaw LJ, Lewis JF, Hlatky MA, et al. Women’s ischemic syndrome evaluation: current status and future research directions, report of the National Heart Lung Blood Institute (NHLBI) Workshop, October 2–4, 2002: section 5: gender-related risk factors for ischemic heart disease. Circulation. 2004a;109:56e–8e.

    Article  Google Scholar 

  8. Pasternak RC, Abrams J, Greenland P, Smaha LA, Wilson PW, Houston-Miller N. 34th Bethesda Conference: task force #1—identification of coronary heart disease risk: is there a detection gap? J Am Coll Cardiol. 2003;41:1863–74.

    Article  PubMed  Google Scholar 

  9. Michos ED, Nasir K, Braunstein JB, Rumberger JA, Budoff MJ, Post WS, et al. Framingham risk equation underestimates subclinical atherosclerosis risk in asymptomatic women. Atherosclerosis. 2006;184:201–6.

    Article  CAS  PubMed  Google Scholar 

  10. Lakoski SG, Greenland P, Wong ND, Schreiner PJ, Herrington DM, Kronmal RA, et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as “low risk” based on Framingham risk score: the Multi-Ethnic Study of Atherosclerosis (MESA). Arch Intern Med. 2007;167:2437–42.

    Article  PubMed  Google Scholar 

  11. Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. JAMA. 2007;297:611–9.

    Article  CAS  PubMed  Google Scholar 

  12. Nasir K, Michos ED, Blumenthal RS, Raggi P. Detection of high-risk young adults and women by coronary calcium and National Cholesterol Education Program Panel III guidelines. J Am Coll Cardiol. 2005;46:1931–6.

    Article  PubMed  Google Scholar 

  13. Messerli FH, Williams B, Ritz E. Essential hypertension. Lancet. 2007;370:591–603.

    Article  CAS  PubMed  Google Scholar 

  14. Gu Q, Burt VL, Paulose-Ram R, Dillon CF. Gender differences in hypertension treatment, drug utilization patterns, and blood pressure control among us adults with hypertension: data from the national health and nutrition examination survey 1999–2004. Am J Hypertens. 2008;21:789–98.

    Article  PubMed  Google Scholar 

  15. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–e245.

    Article  PubMed  Google Scholar 

  16. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937–52.

    Article  PubMed  Google Scholar 

  17. Stone NJ, Robinson J, Lichtenstein AH, et al. ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2013;2013

  18. Kostis WJ, Cheng JQ, Dobrzynski JM, Cabrera J, Kostis JB. Meta-analysis of statin effects in women versus men. J Am Coll Cardiol. 2012;59:572–82.

    Article  CAS  PubMed  Google Scholar 

  19. Bhattacharjee S, Findley PA, Sambamoorthi U. Understanding gender differences in statin use among elderly Medicare beneficiaries: an application of decomposition technique. Drugs Aging. 2012;29:971–80.

    Article  CAS  PubMed  Google Scholar 

  20. Bhardwaj S, Selvarajah S, Schneider EB. Muscular effects of statins in the elderly female: a review. Clin Interv Aging. 2013;8:47–59.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332:73–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gregg EW, Gu Q, Cheng YJ, Venkat Narayan KM, Cowie CC. Mortality trends in men and women with diabetes, 1971 to 2000. Ann Intern Med. 2007;147:149–55.

    Article  PubMed  Google Scholar 

  23. Kalyani RR, Lazo M, Ouyang P, Turkbey E, Chevalier K, Brancati F, et al. Sex differences in diabetes and risk of incident coronary artery disease in healthy young and middle-aged adults. Diabetes Care. 2014;37:830–8.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Golden SH, Brown A, Cauley JA, Chin MH, Gary-Webb TL, Kim C, et al. Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an endocrine society scientific statement. J Clin Endocrinol Metab. 2012;97:E1579–639.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Njolstad I, Arnesen E, Lund-Larsen PG. Smoking, serum lipids, blood pressure, and sex differences in myocardial infarction. A 12-year follow-up of the Finnmark Study. Circulation. 1996;93:450–6.

    Article  CAS  PubMed  Google Scholar 

  26. Teo KK, Ounpuu S, Hawken S, Pandey MR, Valentin V, Hunt D, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:647–58.

    Article  PubMed  Google Scholar 

  27. Paixao AR, Berry JD, Neeland IJ, et al. Coronary artery calcification and family history of myocardial infarction in the Dallas heart study. JACC Cardiovasc Imaging. 201447.

  28. Kim C, Chang HJ, Cho I, Sung JM, Choi D, Jeong MH, et al. Impact of family history on the presentation and clinical outcomes of coronary heart disease: data from the Korea acute myocardial infarction registry. Korean J Intern Med. 2013;28:547–56.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Mehta PK, Wei J, Wenger NK. Ischemic heart disease in women: a focus on risk factors. Trends Cardiovasc Med. 2015;25(2):140–51. https://doi.org/10.1016/j.tcm.2014.10.005.

    Article  PubMed  Google Scholar 

  30. Tullos BW, Sung JH, Lee JE, Criqui MH, Mitchell ME, Taylor HA. Ankle-brachial index (ABI), abdominal aortic calcification (AAC), and coronary artery calcification (CAC): the Jackson Heart Study. Int J Card Imaging. 2013;29:891–7.

    Article  Google Scholar 

  31. Reis SE, Olson MB, Fried L, Reeser V, Mankad S, Pepine CJ, et al. Mild renal insufficiency is associated with angiographic coronary artery disease in women. Circulation. 2002;105:2826–9.

    Article  PubMed  Google Scholar 

  32. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296–305.

    Article  CAS  PubMed  Google Scholar 

  33. Wilson BJ, Watson MS, Prescott GJ, Sunderland S, Campbell DM, Hannaford P, et al. Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study. BMJ. 2003;326:845.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Wenger NK. Recognizing pregnancy-associated cardiovascular risk factors. Am J Cardiol. 2014;113:406–9.

    Article  PubMed  Google Scholar 

  35. Ahmed R, Dunford J, Mehran R, Robson S, Kunadian V. Pre-eclampsia and future cardiovascular risk among women: a review. J Am Coll Cardiol. 2014;63:1815–22.

    Article  PubMed  Google Scholar 

  36. Jay JG, Vermeulen MJ, Schull MJ, et al. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet. 2005;366:1797–803.

    Article  Google Scholar 

  37. Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007;335:974.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Zhang J, Chen L, Delzell E, Muntner P, Hillegass WB, Safford MM, et al. The association between inflammatory markers, serum lipids and the risk of cardiovascular events in patients with rheumatoid arthritis. Ann Rheum Dis. 2014;73:1301–8.

    Article  CAS  PubMed  Google Scholar 

  39. Nilsson G, Holmberg L, Garmo H, Duvernoy O, Sjögren I, Lagerqvist B, et al. Distribution of coronary artery stenosis after radiation for breast cancer. J Clin Oncol Off J Am Soc Clin Oncol. 2012;30:380–6.

    Article  Google Scholar 

  40. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation. 2008;118:1080–111.

    Article  PubMed  Google Scholar 

  41. Quintana-Gallego E, Carmona-Bernal C, Capote F, Sánchez-Armengol Á, Botebol-Benhamou G, Polo-Padillo J, et al. Gender differences in obstructive sleep apnea syndrome: a clinical study of 1166 patients. Respir Med. 2004;98:984–9.

    Article  PubMed  Google Scholar 

  42. McSweeney JC, Cody M, O’Sullivan P, et al. Women’s early warning symptoms of acute myocardial infarction. Circulation, American Heart Association, Inc., 25 Nov. 2003, circ.ahajournals.org/content/108/21/2619.long.

  43. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA Internal Medicine, American Medical Association, 22 Feb 2012, jamanetwork.com/journals/jama/fullarticle/1355992.

  44. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update; a report from the American Heart Association. http://Circ.ahajournals.org/Content/125/1/e2.Full, 3 Jan. 2012, circ.ahajournals.org/content/125/1/e2.full.

  45. • Shaw LJ, Bugiardini R, Merz CN. Women and ischemic heart disease: evolving knowledge. J Am Coll Cardiol. 2009;54:1561–75. This provides a thorough review of ischemic heart disease in women.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Woodfield SL, Lundergan CF, Reiner JS, Thompson MA, Rohrbeck SC, Deychak Y, et al. Gender and acute myocardial infarction: is there a different response to thrombolysis? J Am Coll Cardiol. 1997;29:35–42.

    Article  CAS  PubMed  Google Scholar 

  47. Becker RC, Burns M, Every N, Maynard C, Frederick P, Spencer FA, et al. Early clinical outcomes and routine management of patients with non-ST-segment elevation myocardial infarction: a nationwide perspective. Arch Intern Med. 2001;161:601–7.

    Article  CAS  PubMed  Google Scholar 

  48. Bairey Merz CN, Shaw LJ, Reis SE. Ischemic heart disease in women: insights from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study. Part II: gender differences in presentation, diagnosis, and outcome with regard to sex-based pathophysiology of atherosclerosis, macro- and micro-vascular CAD. J Am Coll Cardiol. 2006;47 Suppl:21s–9s.

    Article  Google Scholar 

  49. Shaw LJ, Bairey Merz CN, Reis SE, WISE Investigators, et al. Ischemic heart disease in women: insights from the NHLBI-sponsored Women’s ischemia Syndrome Evaluation (WISE) study. Part I: sex differences in traditional and novel risk factors, symptom evaluation and gender-optimized diagnostic strategies. J Am Coll Cardiol. 2006;47:S4–20.

    Article  PubMed  Google Scholar 

  50. Humphries KH, Pu A, Gao M, Carere RG, Pilote M. Angina with “normal” coronary arteries: sex differences in outcomes. Am Heart J. 2008;155:375–81.

    Article  PubMed  Google Scholar 

  51. Reynolds HR, Farkouh ME, Lincoff AM, Hsu A, Swahn E, Sadowski ZP, et al. Impact of female sex on death and bleeding after fibrinolytic treatment of myocardial infarction in GUSTO V. Arch Intern Med. 2007;167:2054–60.

    Article  PubMed  Google Scholar 

  52. Blomkalns AL, Chen AY, Hochman JS, Peterson ED, Trynosky K, Diercks DB, et al. Gender disparities in diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. J Am Coll Cardiol. 2005;45:832–7.

    Article  PubMed  Google Scholar 

  53. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med. 1999;341:217–25.

    Article  CAS  PubMed  Google Scholar 

  54. Hemingway H, McCallum A, Shipley M, Manderbacka K, Martikainen P, Keskimäki I. Incidence and prognostic implications of stable angina pectoris among women and men. JAMA. 2006;295:1404–11.

    Article  CAS  PubMed  Google Scholar 

  55. Marinescu MA, Loffler AI, Ouellette M, Smith L, Kramer CM, Bourque JM. Coronary microvascular dysfunction, microvascular angina, and treatment strategies. JACC Cardiovasc Imaging. 2015;8:210–20. This systematic review was recently published and of great importance as it illustrates the lack of data to support current therapy for MVA and that there is no established definition for defining CMD.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Kohan AA, Levy Yeyati E, De Stefano L, Dragonetti L, Pietrani M, Perez de Arenaza D, et al. Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature. Cardiovasc Diagn Ther. 2014;4:138–46.

    PubMed  PubMed Central  Google Scholar 

  57. Pelliccia F, Greco C, Vitale C, Rosano G, Gaudio C, Kaski JC. Takotsubo syndrome (stress cardiomyopathy): an intriguing clinical condition in search of its identity. Am J Med. 2014;127:699–704.

    Article  PubMed  Google Scholar 

  58. Summers MR, Prasad A. Takotsubo cardiomyopathy: definition and clinical profile. Heart Fail Clin. 2013;9:111–22. vii

    Article  PubMed  Google Scholar 

  59. Pärkkä JP, Niemi P, Saraste A, Koskenvuo JW, Komu M, Oikonen V, et al. Comparison of MRI and positron emission tomography for measuring myocardial perfusion reserve in healthy humans. Magn Reson Med. 2006;55:772–9.

    Article  PubMed  Google Scholar 

  60. •• Löffler AI, Bourque JM. Coronary microvascular dysfunction, microvascular angina, and management. Curr Cardiol Rep. 2016;18:1. This was a great review on microvascular dysfunction which is a potential sex-specific mechanism that is common in women that may lead to worse outcomes.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Gulati M, Cooper-DeHoff RM, McClure C, et al. Adverse cardiovascular outcomes in women with nonobstructive coronary artery disease: a report from the Women’s Ischemia Syndrome Evaluation Study and the St James Women Take Heart Project. Arch Intern Med. 2009;169:843–50.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Alexander KP, Chen AY, Newby LK, Schwartz JB, Redberg RF, Hochman JS, et al. Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative. Circulation. 2006;114:1380–7.

    Article  CAS  PubMed  Google Scholar 

  63. Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97.

    Article  PubMed  Google Scholar 

  64. Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart. 2009;95:20–6.

    Article  CAS  PubMed  Google Scholar 

  65. Glaser R, Herrmann HC, Murphy SA, Demopoulos LA, DiBattiste P, Cannon CP, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA. 2002;288:3124–9.

    Article  PubMed  Google Scholar 

  66. Lagerqvist B, Safstrom K, Stahle E, et al. Is early invasive treatment of unstable coronary artery disease equally effective for both women and men? FRISC II Study Group Investigators. J Am Coll Cardiol. 2001;38:41–8.

    Article  CAS  PubMed  Google Scholar 

  67. Dolor RJ, Melloni C, Chatterjee R, et al. Treatment strategies for women with coronary artery disease. comparative effectiveness review no. 66. Rockville, MD: Agency for healthcare Research and Quality. 2012. AHRQ publication no. 12-EHC070-EF. Available at: http://www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed 30 July 2014.

  68. Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol. 2006;48:1319–25.

    Article  PubMed  Google Scholar 

  69. Clayton TC, Pocock SJ, Henderson RA, et al. Do men benefit more than women from an interventional strategy in patients with unstable angina or non-ST-elevation myocardial infarction? The impact of gender in the RITA 3 trial. Eur Heart J. 2004;25:1641–50.

    Article  CAS  PubMed  Google Scholar 

  70. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e139–228.

    Article  PubMed  Google Scholar 

  71. Jneid H, Fonarow GC, Cannon CP, Hernandez AF, Palacios IF, Maree AO, et al. Sex differences in medical care and early death after acute myocardial infarction. Circulation. 2008;118:2803–10.

    Article  PubMed  Google Scholar 

  72. Bukkapatnam RN, Yeo KK, Li Z, Amsterdam EA. Operative mortality in women and men undergoing coronary artery bypass grafting (from the California Coronary Artery Bypass Grafting Outcomes Reporting Program). Am J Cardiol. 2010;105:339–42.

    Article  PubMed  Google Scholar 

  73. Kim C, Redberg RF, Pavlic T, Eagle KA. A systematic review of gender differences in mortality after coronary artery bypass graft surgery and percutaneous coronary interventions. Clin Cardiol. 2007;30:491–5.

    Article  PubMed  PubMed Central  Google Scholar 

  74. Shaw LJ, Bugiardini R, Merz CN. Women and ischemic heart disease: evolving knowledge. J Am Coll Cardiol. 2009;54:1561–75.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Jeremy D. Rier.

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Rhian E. Davies and Jeremy D. Rier declare no conflict of interest.

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This article is part of the Topical Collection on Women and Ischemic Heart Disease

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Davies, R.E., Rier, J.D. Gender Disparities in CAD: Women and Ischemic Heart Disease. Curr Atheroscler Rep 20, 51 (2018). https://doi.org/10.1007/s11883-018-0753-7

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