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Management of coronary heart disease in women

Author
Pamela S Douglas, MD
Section Editor
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Deputy Editor
Gordon M Saperia, MD, FACC

INTRODUCTION

Cardiovascular diseases are the most common cause of death and disability in women in the United States [1,2]. Although there has been a reduction in the death rate from coronary heart disease (CHD) since 1980 (figure 1), CHD still accounted for 35 percent of all-cause mortality in women in 1995 [2]. Between the ages of 45 to 64, one in nine women develops symptoms of some form of cardiovascular disease. After age 65, the ratio climbs to one in three women, according to the National Center for Health Statistics.

There are significant differences between men and women in the epidemiology, diagnosis, treatment and prognosis of CHD that should be taken into account in the care of women with known or suspected disease (figure 2A-B). Unfortunately, data from clinical trials about the management of women with an acute coronary syndrome (myocardial infarction or unstable angina) are limited, since women are generally underrepresented in randomized controlled studies [3]. Furthermore, most available data suggest that women are not referred as often as men for appropriate diagnostic and/or therapeutic procedures. (See 'Coronary reperfusion' below.)

A repeating theme that will be described below is that unadjusted outcomes are often worse in women than men. However, with issues such as an early invasive strategy in non-ST elevation syndromes, fibrinolytic therapy or primary percutaneous coronary intervention in ST elevation myocardial infarction, and percutaneous coronary intervention in general, these differences are almost entirely due to confounding risk factors (eg, older age, more diabetes, more hypertension), not female sex [4-8].

The management of CHD in women will be reviewed here. The clinical features, including diagnosis of CHD in women, the outcome after acute myocardial infarction (AMI), and the problem of CHD in young women are discussed separately. (See "Clinical features and diagnosis of coronary heart disease in women" and "Coronary heart disease and myocardial infarction in young men and women".)

The success rate of therapy for CHD is similar in women and men; however, the complication rates differ, resulting in a sex specific profile of benefit (see below).

                     

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Literature review current through: Nov 2016. | This topic last updated: Tue Apr 28 00:00:00 GMT+00:00 2015.
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References
Top
  1. Eaker ED, Chesebro JH, Sacks FM, et al. Cardiovascular disease in women. Circulation 1993; 88:1999.
  2. Mosca L, Manson JE, Sutherland SE, et al. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1997; 96:2468.
  3. Lee PY, Alexander KP, Hammill BG, et al. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA 2001; 286:708.
  4. Lansky AJ, Hochman JS, Ward PA, et al. Percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the American Heart Association. Circulation 2005; 111:940.
  5. Blomkalns AL, Chen AY, Hochman JS, et al. Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. J Am Coll Cardiol 2005; 45:832.
  6. White HD, Barbash GI, Modan M, et al. After correcting for worse baseline characteristics, women treated with thrombolytic therapy for acute myocardial infarction have the same mortality and morbidity as men except for a higher incidence of hemorrhagic stroke. The Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Study. Circulation 1993; 88:2097.
  7. Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. N Engl J Med 1999; 341:226.
  8. Mehilli J, Ndrepepa G, Kastrati A, et al. Gender and myocardial salvage after reperfusion treatment in acute myocardial infarction. J Am Coll Cardiol 2005; 45:828.
  9. Scirica BM, Moliterno DJ, Every NR, et al. Differences between men and women in the management of unstable angina pectoris (The GUARANTEE Registry). The GUARANTEE Investigators. Am J Cardiol 1999; 84:1145.
  10. LaCroix AZ, Guralnik JM, Curb JD, et al. Chest pain and coronary heart disease mortality among older men and women in three communities. Circulation 1990; 81:437.
  11. Gan SC, Beaver SK, Houck PM, et al. Treatment of acute myocardial infarction and 30-day mortality among women and men. N Engl J Med 2000; 343:8.
  12. Shaw LJ, Miller DD, Romeis JC, et al. Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease. Ann Intern Med 1994; 120:559.
  13. Barakat K, Wilkinson P, Suliman A, et al. Acute myocardial infarction in women: contribution of treatment variables to adverse outcome. Am Heart J 2000; 140:740.
  14. Daly C, Clemens F, Lopez Sendon JL, et al. Gender differences in the management and clinical outcome of stable angina. Circulation 2006; 113:490.
  15. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998; 280:605.
  16. Grady D, Herrington D, Bittner V, et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA 2002; 288:49.
  17. Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 1994; 308:81.
  18. de Gaetano G, Collaborative Group of the Primary Prevention Project. Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general practice. Collaborative Group of the Primary Prevention Project. Lancet 2001; 357:89.
  19. Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005; 352:1293.
  20. Becker DM, Segal J, Vaidya D, et al. Sex differences in platelet reactivity and response to low-dose aspirin therapy. JAMA 2006; 295:1420.
  21. Clarke KW, Gray D, Keating NA, Hampton JR. Do women with acute myocardial infarction receive the same treatment as men? BMJ 1994; 309:563.
  22. Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet 1986; 2:57.
  23. Pfeffer MA, Braunwald E, Moyé LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med 1992; 327:669.
  24. Pedersen TR, Kjekshus J, Berg K, et al. Cholesterol lowering and the use of healthcare resources. Results of the Scandinavian Simvastatin Survival Study. Circulation 1996; 93:1796.
  25. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med 1996; 335:1001.
  26. Lewis SJ, Sacks FM, Mitchell JS, et al. Effect of pravastatin on cardiovascular events in women after myocardial infarction: the cholesterol and recurrent events (CARE) trial. J Am Coll Cardiol 1998; 32:140.
  27. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360:7.
  28. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004; 350:1495.
  29. Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008; 359:2195.
  30. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354.
  31. Lagerqvist B, Säfström K, Ståhle 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.
  32. Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina. Lancet 2002; 360:743.
  33. Glaser R, Herrmann HC, Murphy SA, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA 2002; 288:3124.
  34. Mueller C, Neumann FJ, Roskamm H, et al. Women do have an improved long-term outcome after non-ST-elevation acute coronary syndromes treated very early and predominantly with percutaneous coronary intervention: a prospective study in 1,450 consecutive patients. J Am Coll Cardiol 2002; 40:245.
  35. Hochman JS, Tamis-Holland JE. Acute coronary syndromes: does sex matter? JAMA 2002; 288:3161.
  36. Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 2002; 359:189.
  37. Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry. Arch Intern Med 1992; 152:972.
  38. Heer T, Schiele R, Schneider S, et al. Gender differences in acute myocardial infarction in the era of reperfusion (the MITRA registry). Am J Cardiol 2002; 89:511.
  39. Collins L, Douglas PS. Acute myocardial infarction in women. In: Acute Myocardial Infarction, 2nd ed, Gersh B, Rahimtoola S (Eds), Chapman & Hall, New York 1996.
  40. Gottlieb S, Harpaz D, Shotan A, et al. Sex differences in management and outcome after acute myocardial infarction in the 1990s: A prospective observational community-based study. Israeli Thrombolytic Survey Group. Circulation 2000; 102:2484.
  41. Vaccarino V, Parsons L, Every NR, et al. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med 1999; 341:217.
  42. Stone GW, Grines CL, Browne KF, et al. Comparison of in-hospital outcome in men versus women treated by either thrombolytic therapy or primary coronary angioplasty for acute myocardial infarction. Am J Cardiol 1995; 75:987.
  43. Woodfield SL, Lundergan CF, Reiner JS, et al. Gender and acute myocardial infarction: is there a different response to thrombolysis? J Am Coll Cardiol 1997; 29:35.
  44. Karnash SL, Granger CB, White HD, et al. Treating menstruating women with thrombolytic therapy: insights from the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO-I) trial. J Am Coll Cardiol 1995; 26:1651.
  45. Hannan EL, Racz MJ, Arani DT, et al. Short- and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2000; 36:1194.
  46. Vakili BA, Kaplan RC, Brown DL. Sex-based differences in early mortality of patients undergoing primary angioplasty for first acute myocardial infarction. Circulation 2001; 104:3034.
  47. Azar RR, Waters DD, McKay RG, et al. Short- and medium-term outcome differences in women and men after primary percutaneous transluminal mechanical revascularization for acute myocardial infarction. Am J Cardiol 2000; 85:675.
  48. Antoniucci D, Valenti R, Moschi G, et al. Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction. Am J Cardiol 2001; 87:289.
  49. Lansky AJ, Pietras C, Costa RA, et al. Gender differences in outcomes after primary angioplasty versus primary stenting with and without abciximab for acute myocardial infarction: results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Circulation 2005; 111:1611.
  50. Tamis-Holland JE, Palazzo A, Stebbins AL, et al. Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B) Angioplasty Substudy. Am Heart J 2004; 147:133.
  51. Mehilli J, Kastrati A, Dirschinger J, et al. Sex-based analysis of outcome in patients with acute myocardial infarction treated predominantly with percutaneous coronary intervention. JAMA 2002; 287:210.
  52. Stone GW, Grines CL, Cox DA, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002; 346:957.
  53. Hasdai D, Califf RM, Thompson TD, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol 2000; 35:136.
  54. Wong SC, Sleeper LA, Monrad ES, et al. Absence of gender differences in clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction. A report from the SHOCK Trial Registry. J Am Coll Cardiol 2001; 38:1395.
  55. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation 2007; 115:1481.
  56. Lehmann JB, Wehner PS, Lehmann CU, Savory LM. Gender bias in the evaluation of chest pain in the emergency department. Am J Cardiol 1996; 77:641.
  57. Kelsey SF, James M, Holubkov AL, et al. Results of percutaneous transluminal coronary angioplasty in women. 1985-1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry. Circulation 1993; 87:720.
  58. Weintraub WS, Wenger NK, Kosinski AS, et al. Percutaneous transluminal coronary angioplasty in women compared with men. J Am Coll Cardiol 1994; 24:81.
  59. Mehilli J, Kastrati A, Dirschinger J, et al. Differences in prognostic factors and outcomes between women and men undergoing coronary artery stenting. JAMA 2000; 284:1799.
  60. Rathore SS, Wang Y, Radford MJ, et al. Sex differences in cardiac catheterization after acute myocardial infarction: the role of procedure appropriateness. Ann Intern Med 2002; 137:487.
  61. Miller TD, Roger VL, Hodge DO, et al. Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease. J Am Coll Cardiol 2001; 38:690.
  62. Bertoni AG, Bonds DE, Lovato J, et al. Sex disparities in procedure use for acute myocardial infarction in the United States, 1995 to 2001. Am Heart J 2004; 147:1054.
  63. Ghali WA, Faris PD, Galbraith PD, et al. Sex differences in access to coronary revascularization after cardiac catheterization: importance of detailed clinical data. Ann Intern Med 2002; 136:723.
  64. Anand SS, Xie CC, Mehta S, et al. Differences in the management and prognosis of women and men who suffer from acute coronary syndromes. J Am Coll Cardiol 2005; 46:1845.
  65. King KM, Ghali WA, Faris PD, et al. Sex differences in outcomes after cardiac catheterization: effect modification by treatment strategy and time. JAMA 2004; 291:1220.
  66. Peterson ED, Lansky AJ, Kramer J, et al. Effect of gender on the outcomes of contemporary percutaneous coronary intervention. Am J Cardiol 2001; 88:359.
  67. Abramson JL, Veledar E, Weintraub WS, Vaccarino V. Association between gender and in-hospital mortality after percutaneous coronary intervention according to age. Am J Cardiol 2003; 91:968.
  68. Jacobs AK, Johnston JM, Haviland A, et al. Improved outcomes for women undergoing contemporary percutaneous coronary intervention: a report from the National Heart, Lung, and Blood Institute Dynamic registry. J Am Coll Cardiol 2002; 39:1608.
  69. Watanabe CT, Maynard C, Ritchie JL. Comparison of short-term outcomes following coronary artery stenting in men versus women. Am J Cardiol 2001; 88:848.
  70. Anderson ML, Peterson ED, Brennan JM, et al. Short- and long-term outcomes of coronary stenting in women versus men: results from the National Cardiovascular Data Registry Centers for Medicare & Medicaid services cohort. Circulation 2012; 126:2190.
  71. Jacobs AK. Coronary revascularization in women in 2003: sex revisited. Circulation 2003; 107:375.
  72. Schunkert H, Harrell L, Palacios IF. Implications of small reference vessel diameter in patients undergoing percutaneous coronary revascularization. J Am Coll Cardiol 1999; 34:40.
  73. Stefanini GG, Baber U, Windecker S, et al. Safety and efficacy of drug-eluting stents in women: a patient-level pooled analysis of randomised trials. Lancet 2013; 382:1879.
  74. O'Rourke DJ, Malenka DJ, Olmstead EM, et al. Improved in-hospital mortality in women undergoing coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 2001; 71:507.
  75. Fisher LD, Kennedy JW, Davis KB, et al. Association of sex, physical size, and operative mortality after coronary artery bypass in the Coronary Artery Surgery Study (CASS). J Thorac Cardiovasc Surg 1982; 84:334.
  76. Loop FD, Golding LR, MacMillan JP, et al. Coronary artery surgery in women compared with men: analyses of risks and long-term results. J Am Coll Cardiol 1983; 1:383.
  77. Weintraub WS, Wenger NK, Jones EL, et al. Changing clinical characteristics of coronary surgery patients. Differences between men and women. Circulation 1993; 88:II79.
  78. O'Connor GT, Morton JR, Diehl MJ, et al. Differences between men and women in hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. Circulation 1993; 88:2104.
  79. Brandrup-Wognsen G, Berggren H, Hartford M, et al. Female sex is associated with increased mortality and morbidity early, but not late, after coronary artery bypass grafting. Eur Heart J 1996; 17:1426.
  80. Edwards FH, Carey JS, Grover FL, et al. Impact of gender on coronary bypass operative mortality. Ann Thorac Surg 1998; 66:125.
  81. Hartz RS, Rao AV, Plomondon ME, et al. Effects of race, with or without gender, on operative mortality after coronary artery bypass grafting: a study using The Society of Thoracic Surgeons National Database. Ann Thorac Surg 2001; 71:512.
  82. Hogue CW Jr, Barzilai B, Pieper KS, et al. Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report. Circulation 2001; 103:2133.
  83. Guru V, Fremes SE, Austin PC, et al. Gender differences in outcomes after hospital discharge from coronary artery bypass grafting. Circulation 2006; 113:507.
  84. Vaccarino V, Abramson JL, Veledar E, Weintraub WS. Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women. Circulation 2002; 105:1176.
  85. O'Connor NJ, Morton JR, Birkmeyer JD, et al. Effect of coronary artery diameter in patients undergoing coronary bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation 1996; 93:652.
  86. Jacobs AK, Kelsey SF, Brooks MM, et al. Better outcome for women compared with men undergoing coronary revascularization: a report from the bypass angioplasty revascularization investigation (BARI). Circulation 1998; 98:1279.