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Updating terminology for women with heart disease may help refine diagnosis, treatment
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Ischemic heart disease may be a more appropriate term to use when referring to symptomatic women with heart disease than coronary artery disease or coronary heart disease, authors of a state-of-the-art paper suggested.
The authors reviewed evolving clinical evidence suggesting that sex-related differences between women and men should be taken into consideration when describing, diagnosing and treating different types of heart disease. According to the authors, paradoxical sex differences observed across many studies have suggested that women have less anatomical obstructive CAD and relatively preserved left ventricular ejection function, but have greater rates of myocardial ischemia and mortality when compared with similarly aged men. In addition, a greater absolute number of women die from IHD when compared with men.
“I would hope that this analysis would extend the things that are happening that are not sex-specific,” co-author C. Noel Bairey Merz, MD, director of the Women’s Heart Center at the Cedars-Sinai Medical Center in Los Angeles and a member of the Cardiology Today editorial board, said in an interview. “Women and heart disease is more or less the poster child for this issue of ischemia terminology. It is even broader than just sex, but sex is a good poster child because it gets people’s attention.”
According to data cited in the paper, more than 80% of midlife women have one or more traditional cardiac risk factors. On average, women tend to have greater levels of blood cholesterol after their fifth decade of life and have mild decreases in HDL after menopause. The authors contended that women also possess a number of novel risk factors and that traditional risk factors and the Framingham risk score often underestimate the risk for IHD in women. Women on average have higher levels of CRP, which correlates with a greater frequency of inflammatory-mediated autoimmune diseases and is suggestive of a prominent role for inflammation in IHD sex differences. The disruption of ovulatory cycling (indicated by hormonal abnormalities) in premenopausal women is also associated with an increased risk for coronary atherosclerosis and adverse CVD events.
The authors also suggested that the evaluation of women with symptoms suggestive of IHD may be further hampered by the definition of “typical” angina derived from study populations consisting largely of men. Women without obstructive CAD, for example, continue to exhibit signs and symptoms of IHD while consuming health care resources resulting from diagnostic uncertainty. Normal coronary angiograms, defined as angiograms with no visible obstructive CAD, are also reported more frequently in women with acute coronary syndromes than in men.
“What we are realizing in this decade of the management of CVD is that physiology almost trumps anatomy,” Bairey Merz said. “You need to be measuring ischemia and paying attention to things like flow, because things that go bump in the night are not necessarily related to plaque in the big arteries.”
Despite an increased risk for obstructive CAD among women, they continued to receive less guideline-indicated therapies than men. Citing the results of several studies of ACS in women, the authors noted differences in the reduction of the composite of death, MI or repeat ACS with an invasive treatment strategy among biomarker-positive and biomarker-negative women. An invasive strategy was associated with a 33% reduction in the risk for the composite endpoint in biomarker-positive women when compared with biomarker-negative women, and this difference was not apparent in men.
Although women and men derived similar benefits from drug-eluting stents, women tended to have overall greater mortality with percutaneous coronary intervention for both STEMI and non-STEMI. The overall clinical evidence analyzed in the paper suggested suboptimal treatment of proven obstructive CAD was more prevalent in women than in men, despite evidence and guidelines supporting risk reduction with acute, revascularization or chronic medical therapies.
“We can manage the ischemia and the impact of plaque with very aggressive anti-ischemic and anti-atherosclerotic methods, and it is time to start doing this,” Bairey Merz said. “We have the anatomy problem well in hand, as we know who benefits from bypass and angioplasty, as well as who does not. We would hope that this would impact treating physicians and force them to start putting their physiology hats back on. They have turned into plumbers, and we would like to change that.”
Ultimately, Bairey Merz and co-authors of the study hoped that the results of research conducted within the past two decades would help refine and enhance the sex-specific care of various types of heart disease.
“What we have seen in the past 15 years is that gaps have started to narrow, and we would hope that people would really take this to heart and continue to incorporate these relatively new findings into their practice to close gaps,” Bairey Merz said. “Everyone should have optimal care.” – by Eric Raible
Shaw LJ. J Am Coll Cardiol. 2009;54:1561-1575.