Sex differences in nonobstructive coronary artery disease: Recent insights and substantial knowledge gaps
Section snippets
Background
Ischemic heart disease (IHD) is the leading cause of mortality of women in all age groups [1]. At 50 years of age, the average lifetime risk of developing IHD in women is approximately 40% [2]. Overall, despite mortality from IHD in the United States steadily declining from the 1960s, the rate of mortality reduction in women has down-trended more slowly than that of men [1]. The exact factors contributing to poorer outcomes for women diagnosed with IHD have yet to be fully elucidated, but there
Challenges in detection
Among those with stable IHD, defined as chronic stable angina due to epicardial stenosis, microvascular dysfunction, vasospasm or symptomatic ischemic cardiomyopathy, nearly 60–70% of women and 30% of men have nonobstructive CAD [6]. However, it is challenging to determine the exact prevalence of nonobstructive CAD because of the aforementioned definitional heterogeneity as well as because the diagnosis has long been contingent on the performance of ICA. Studies have estimated a prevalence of
Assessment: Recent insights and shortcomings
As a consequence of the heterogeneity of definitions and the much greater attention to obstructive CAD, the assessment and risk stratification of nonobstructive CAD is far less elaborated. Nonobstructive CAD encompasses a wide spectrum of findings spanning minimal plaque to diffuse atherosclerosis. The risk of events appears to increase stepwise with the global atherosclerotic burden as defined by coronary segments with plaque by CCTA [28] or vessels diseased by ICA [7], although the
Treatment: More knowledge gaps than evidence
The substantial knowledge gaps regarding the ideal treatment of nonobstructive CAD have only recently gained wider attention. Overall, there are no specific guideline recommendations for this group of patients beyond risk factor modification. The preponderance of large secondary prevention trials required either anatomically obstructive CAD or a clinical event (e.g., myocardial infarction) for entry and excluded patients with nonobstructive disease. In contrast, trials specifically focusing on
Conclusions
After being overlooked for long, there is increasing appreciation of the clinical significance of nonobstructive CAD. Advances in both noninvasive and invasive testing will undoubtedly continue to challenge the paradigm that this is a “women׳s problem” while providing insights into meaningful sex differences. Although at present there are substantial knowledge gaps, it is hoped that ongoing research efforts will continue to improve the detection, assessment, and treatment of nonobstructive CAD
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Coronary artery disease in adults with anomalous aortic origin of a coronary artery
2022, JTCVS OpenCitation Excerpt :The decrease in CAD severity in the modern subcohort may be attributable to increased statin use and reduced tobacco use, though these associations were not directly explored in our analyses.24 The decrease in male predominance within the newer era also highlights the increased recognition and diagnosis of cardiovascular disease within women, a population with less frequent obstructive CAD and more microvascular disease.25 Our study, which is the largest single-center study on adult patients with AAOCA, demonstrates that the anomalous origin does not increase the stenosis severity of CAD in the anomalous vessel itself.
Ischemic heart disease and cardioprotection: Focus on estrogenic hormonal setting and microvascular health
2021, Vascular PharmacologyCitation Excerpt :Data obtained from patients undergoing coronary angiography, emphasize sex differences in the prevalence of INOCA that was 65% among women and 32% among men [7,9]. Importantly, INOCA and vascular dysfunction are the primary causes of worse outcomes and higher 1-year mortality in women than men, stressing over the need of a sex-specific diagnostic approach able to detect nonobstructive pathological conditions [10]. Moreover, evidences support differences in athero-thrombotic process between women and men; in particular, platelets from female patients show different fatty acid composition in the plasma membrane, and membrane receptors are more reactive to agonists [11,12].
Chest pain in the absence of obstructive coronary artery disease: A critical review of current concepts focusing on sex specificity, microcirculatory function, and clinical implications
2019, International Journal of CardiologyCitation Excerpt :At present many physicians use the latter term although the definitions still vary and it has not been proven that all cases have the same underlying mechanism [8,9]. In the last decade several excellent reviews on the coronary microcirculation and the role of the endothelium have been published [8,10–15]. In this paragraph we briefly review mechanisms involved in microvascular dysfunction and commonly used diagnostic parameters to allow a better understanding of the merits and limitations of published studies.
Sex-Related Differences in Vasomotor Function in Patients With Angina and Unobstructed Coronary Arteries
2017, Journal of the American College of CardiologyCitation Excerpt :The sex differences observed in the present paper might have several reasons. Prior studies have shown a greater burden of microvascular dysfunction among women (8,11–13,33,34). Several mechanisms have been proposed for this observation including smaller body size and myocardial mass (11).
Editorial commentary: Dissecting the gender differences in nonobstructive coronary artery disease: How do we bridge the gap?
2017, Trends in Cardiovascular MedicineSex differences in contributors to coronary microvascular dysfunction
2023, Frontiers in Cardiovascular Medicine
The authors have indicated that there are no conflicts of interest.