UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical features and diagnosis of coronary heart disease in women

Authors
Pamela S Douglas, MD
Neha Pagidipati, MD, MPH
Section Editors
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Patricia A Pellikka, MD, FACC, FAHA, FASE
Deputy Editor
Gordon M Saperia, MD, FACC

INTRODUCTION

There are significant differences between men and women in the epidemiology, diagnosis, treatment, and prognosis of coronary heart disease (CHD). These should be taken into account in the care of women with known or suspected disease.

The clinical features and diagnosis of CHD in women will be reviewed here. The management of CHD in women in general and specific information regarding young women are discussed separately. (See "Management of coronary heart disease in women" and "Coronary heart disease and myocardial infarction in young men and women".)

EPIDEMIOLOGY

Cardiovascular disease, including coronary heart disease (CHD), is 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 CHD since 1980, it accounted for 22 percent of all-cause mortality in women in 2013 [3]. Between the ages of 45 to 64, one in nine women develop 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. Additional epidemiologic information and issues related to prognosis are found elsewhere. (See "Epidemiology of coronary heart disease".)

CLINICAL PRESENTATION

The initial presentation of coronary heart disease (CHD) in women and men is more often than not similar. It may be a stable pattern of chest pain (stable angina), an acute coronary syndrome, heart failure (HF), or sudden cardiac death (SCD). Rarely, there are no symptoms and the initial presentation is an abnormal cardiac test such as an electrocardiogram or echocardiogram ordered for another reason.

This section will discuss how female sex may lead to presentation and diagnosis that differs somewhat from those in men. The broad discussions of presentations and diagnosis of CHD are found elsewhere. (See "Stable ischemic heart disease: Overview of care", section on 'Clinical manifestations' and "Criteria for the diagnosis of acute myocardial infarction", section on 'Third universal definition of MI' and "Evaluation of the patient with suspected heart failure", section on 'Clinical presentation' and "Evaluation of the survivor of sudden cardiac arrest", section on 'Initial evaluation'.)

           
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 07, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
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. Leading Causes of Death in Females, 2013 United States. Centers for Disease Control and Prevention, 2013. https://www.cdc.gov/women/lcod/2013/index.htm (Accessed on June 14, 2017).
  4. Stangl V, Witzel V, Baumann G, Stangl K. Current diagnostic concepts to detect coronary artery disease in women. Eur Heart J 2008; 29:707.
  5. Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation 2005; 111:499.
  6. 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.
  7. Poon S, Goodman SG, Yan RT, et al. Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes. Am Heart J 2012; 163:66.
  8. Jneid H, Fonarow GC, Cannon CP, et al. Sex differences in medical care and early death after acute myocardial infarction. Circulation 2008; 118:2803.
  9. Wenger NK. You've come a long way, baby: cardiovascular health and disease in women: problems and prospects. Circulation 2004; 109:558.
  10. Kreatsoulas C, Shannon HS, Giacomini M, et al. Reconstructing angina: cardiac symptoms are the same in women and men. JAMA Intern Med 2013; 173:829.
  11. Chen W, Woods SL, Puntillo KA. Gender differences in symptoms associated with acute myocardial infarction: a review of the research. Heart Lung 2005; 34:240.
  12. Canto JG, Canto EA, Goldberg RJ. Time to standardize and broaden the criteria of acute coronary syndrome symptom presentations in women. Can J Cardiol 2014; 30:721.
  13. Hemal K, Pagidipati NJ, Coles A, et al. Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients With Suspected Coronary Artery Disease: Insights From the PROMISE Trial. JACC Cardiovasc Imaging 2016; 9:337.
  14. Tamura A, Naono S, Torigoe K, et al. Gender differences in symptoms during 60-second balloon occlusion of the coronary artery. Am J Cardiol 2013; 111:1751.
  15. Mackay MH, Ratner PA, Johnson JL, et al. Gender differences in symptoms of myocardial ischaemia. Eur Heart J 2011; 32:3107.
  16. Alexander KP, Shaw LJ, Shaw LK, et al. Value of exercise treadmill testing in women. J Am Coll Cardiol 1998; 32:1657.
  17. Pepine CJ, Abrams J, Marks RG, et al. Characteristics of a contemporary population with angina pectoris. TIDES Investigators. Am J Cardiol 1994; 74:226.
  18. McSweeney JC, Cody M, O'Sullivan P, et al. Women's early warning symptoms of acute myocardial infarction. Circulation 2003; 108:2619.
  19. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA 2012; 307:813.
  20. Rubini Gimenez M, Reiter M, Twerenbold R, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med 2014; 174:241.
  21. Goldberg RJ, O'Donnell C, Yarzebski J, et al. Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J 1998; 136:189.
  22. Khan NA, Daskalopoulou SS, Karp I, et al. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med 2013; 173:1863.
  23. Jónsdóttir LS, Sigfusson N, Sigvaldason H, Thorgeirsson G. Incidence and prevalence of recognised and unrecognised myocardial infarction in women. The Reykjavik Study. Eur Heart J 1998; 19:1011.
  24. Shlipak MG, Elmouchi DA, Herrington DM, et al. The incidence of unrecognized myocardial infarction in women with coronary heart disease. Ann Intern Med 2001; 134:1043.
  25. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163.
  26. 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.
  27. Gurevitz O, Jonas M, Boyko V, et al. Clinical profile and long-term prognosis of women < or = 50 years of age referred for coronary angiography for evaluation of chest pain. Am J Cardiol 2000; 85:806.
  28. Mendes LA, Davidoff R, Cupples LA, et al. Congestive heart failure in patients with coronary artery disease: the gender paradox. Am Heart J 1997; 134:207.
  29. Bibbins-Domingo K, Lin F, Vittinghoff E, et al. Predictors of heart failure among women with coronary disease. Circulation 2004; 110:1424.
  30. Kannel WB, Wilson PW, D'Agostino RB, Cobb J. Sudden coronary death in women. Am Heart J 1998; 136:205.
  31. Albert CM, Chae CU, Rexrode KM, et al. Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women. Circulation 2005; 111:480.
  32. 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.
  33. 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.
  34. Arnold AL, Milner KA, Vaccarino V. Sex and race differences in electrocardiogram use (the National Hospital Ambulatory Medical Care Survey). Am J Cardiol 2001; 88:1037.
  35. Seils DM, Friedman JY, Schulman KA. Sex differences in the referral process for invasive cardiac procedures. J Am Med Womens Assoc (1972) 2001; 56:151.
  36. Polk DM, Naqvi TZ. Cardiovascular disease in women: sex differences in presentation, risk factors, and evaluation. Curr Cardiol Rep 2005; 7:166.
  37. Bairey Merz CN, Shaw LJ, Reis SE, et al. Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006; 47:S21.
  38. Mieres JH, Gulati M, Bairey Merz N, et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350.
  39. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097.
  40. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354.
  41. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 64:1929.
  42. Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women. J Am Coll Cardiol 2004; 43:900.
  43. Michos ED, Vasamreddy CR, Becker DM, et al. Women with a low Framingham risk score and a family history of premature coronary heart disease have a high prevalence of subclinical coronary atherosclerosis. Am Heart J 2005; 150:1276.
  44. Gibbons, RF. Exercise ECG testing with and without radionuclide studies. In: Cardiovascular Health and Disease in Women, Wenger, NK, Speroff, L, Packard, B (Eds), Le Jacq Communications, Inc, Connecticut 1993. p.73.
  45. Kwok Y, Kim C, Grady D, et al. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol 1999; 83:660.
  46. Pagidipati NJ, Hemal K, Coles A, et al. Sex Differences in Functional and CT Angiography Testing in Patients With Suspected Coronary Artery Disease. J Am Coll Cardiol 2016; 67:2607.
  47. Wiviott SD, Cannon CP, Morrow DA, et al. Differential expression of cardiac biomarkers by gender in patients with unstable angina/non-ST-elevation myocardial infarction: a TACTICS-TIMI 18 (Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction 18) substudy. Circulation 2004; 109:580.
  48. Akhter N, Milford-Beland S, Roe MT, et al. Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). Am Heart J 2009; 157:141.
  49. Shah ASV, Ferry AV, Mills NL. Cardiac Biomarkers and the Diagnosis of Myocardial Infarction in Women. Curr Cardiol Rep 2017; 19:40.
  50. Kaur S. High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. Ann Clin Biochem 2015; 52:622.
  51. Al-Khalili F, Svane B, Wamala SP, et al. Clinical importance of risk factors and exercise testing for prediction of significant coronary artery stenosis in women recovering from unstable coronary artery disease: the Stockholm Female Coronary Risk Study. Am Heart J 2000; 139:971.
  52. Al-Khalili F, Wamala SP, Orth-Gomér K, Schenck-Gustafsson K. Prognostic value of exercise testing in women after acute coronary syndromes (The Stockholm Female Coronary Risk Study). Am J Cardiol 2000; 86:211.
  53. Säfström K, Lindahl B, Swahn E. Risk stratification in unstable coronary artery disease--exercise test and troponin T from a gender perspective. FRISC-Study Group. Fragmin during InStability in Coronary artery disease. J Am Coll Cardiol 2000; 35:1791.
  54. Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome of unstable angina. JAMA 2000; 283:646.
  55. 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.
  56. Bearden D, Allman R, McDonald R, et al. Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEP. SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program. J Am Geriatr Soc 1994; 42:1143.
  57. Rathore SS, Chen J, Wang Y, et al. Sex differences in cardiac catheterization: the role of physician gender. JAMA 2001; 286:2849.
  58. 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.
  59. Hansen KW, Soerensen R, Madsen M, et al. Developments in the invasive diagnostic-therapeutic cascade of women and men with acute coronary syndromes from 2005 to 2011: a nationwide cohort study. BMJ Open 2015; 5:e007785.
  60. Tobin JN, Wassertheil-Smoller S, Wexler JP, et al. Sex bias in considering coronary bypass surgery. Ann Intern Med 1987; 107:19.
  61. 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.
  62. Bickell NA, Pieper KS, Lee KL, et al. Referral patterns for coronary artery disease treatment: gender bias or good clinical judgment? Ann Intern Med 1992; 116:791.
  63. Krumholz HM, Douglas PS, Lauer MS, Pasternak RC. Selection of patients for coronary angiography and coronary revascularization early after myocardial infarction: is there evidence for a gender bias? Ann Intern Med 1992; 116:785.
  64. Mark DB, Shaw LK, DeLong ER, et al. Absence of sex bias in the referral of patients for cardiac catheterization. N Engl J Med 1994; 330:1101.
  65. Hachamovitch R, Berman DS, Kiat H, et al. Gender-related differences in clinical management after exercise nuclear testing. J Am Coll Cardiol 1995; 26:1457.
  66. Sullivan AK, Holdright DR, Wright CA, et al. Chest pain in women: clinical, investigative, and prognostic features. BMJ 1994; 308:883.
  67. Merz CN, Kelsey SF, Pepine CJ, et al. The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report. J Am Coll Cardiol 1999; 33:1453.
  68. 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.
  69. Roe MT, Harrington RA, Prosper DM, et al. Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease.The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 2000; 102:1101.
  70. Buchthal SD, den Hollander JA, Merz CN, et al. Abnormal myocardial phosphorus-31 nuclear magnetic resonance spectroscopy in women with chest pain but normal coronary angiograms. N Engl J Med 2000; 342:829.
  71. Johnson BD, Shaw LJ, Buchthal SD, et al. Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease: results from the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation 2004; 109:2993.
  72. Reis SE, Holubkov R, Conrad Smith AJ, et al. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J 2001; 141:735.
  73. Masci PG, Laclaustra M, Lara JG, Kaski JC. Brachial artery flow-mediated dilation and myocardial perfusion in patients with cardiac syndrome X. Am J Cardiol 2005; 95:1478.
  74. Atmaca Y, Ozdemir AO, Ozdol C, et al. Angiographic evaluation of myocardial perfusion in patients with syndrome X. Am J Cardiol 2005; 96:803.
  75. Saw J, Aymong E, Mancini GB, et al. Nonatherosclerotic coronary artery disease in young women. Can J Cardiol 2014; 30:814.