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Cardiovascular disease remains the number one killer of women in the United States, but great strides have been made in terms of our knowledge and treatment of cardiovascular disease in women. In just the past two decades, there has been a heightened awareness of cardiovascular disease in women, in what previously had been thought of as a man's disease. As a result, in the past decade we have seen a continuous decline in mortality from cardiovascular disease in women, and most recently, it has demonstrated a more prominent decline in cardiovascular mortality for women than men. Nonetheless, more women than men die from cardiovascular disease in the United States and there are more deaths from cardiovascular causes in women than from all cancers combined. We are just at the earliest stages of understanding the cardiovascular disease process in women. Nonetheless, recent research has demonstrated important sex differences in the pathophysiology and clinical presentation of cardiovascular disease in women.

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Many risk factors for cardiovascular disease are similar for men and women, but for many risk factors their impact on cardiovascular disease differs by sex. This is discussed in Chapter 2. There are risk assessment tools that do exist and should be incorporated routinely into clinical practice, assessing both short-term and lifetime risk on a regular basis (Chapter 3).

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There remains a difference in how we treat women, even once we have recognized that a woman has cardiovascular disease. This difference ultimately impacts outcome differences between sexes. In addition, the pathophysiology of ischemic heart disease may differ for women, with women often having nonobstructive coronary artery disease even in the setting of a myocardial infarction. In the past, such a pattern of disease was not thought to be clinically significant. However, more recent research has shown that symptomatic women with symptoms and signs of ischemia are at an increased risk of future cardiovascular events, despite this nonobstructive coronary disease pattern. Further work needs to be done to determine optimal treatment for such women, but the definition of patterns of ischemic heart disease is already possible (Chapter 4).

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Noninvasive imaging is a useful tool for an accurate diagnosis of cardiovascular disease in women, allowing earlier and more precise disease detection in women. Consideration of the choice of test in women depends on many variables, including consideration regarding the impact of radiation. Gender-related aspects are covered in Chapter 6.

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Cardiac surgery also has many sex-specific issues, which are visually demonstrated in Chapter 5. Heart failure, cardiac arrhythmias, and arterial vascular disease are common in women, with some highly sex-specific issues in terms of their diagnosis, prognosis, and treatment (Chapters 8, 9, and 11). Pulmonary hypertension is far more common in women than in men, and in light of this finding, this book includes an entire chapter that addresses the unique cardiac issues concerning women with this disease (Chapter 12). An issue that is obviously unique for women is pregnancy. During pregnancy, cardiac issues can arise in women, even in those without congenital heart disease. The clinical issues that can arise in pregnancy, in women with and without congenital heart disease, are discussed using a case-based manner in Chapter 10.

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I would like to thank the authors of each chapter in this book for their excellent work in describing the unique risk factors and cardiovascular issues that are specific to women. In addition, I am grateful to the assistance that I have received from Ms Janice Whitmire, as this project unfolded, and her assistance in the preparation of this book. I would like to thank Sarah Ross Soter and Bill Soter and their family for their unrelenting support and for helping us to make the Ross Heart Hospital and The Ohio State University Wexner Medical Center a leader in women's cardiovascular health. I am very grateful for the opportunity provided by Dr William Abraham for making this series possible and for deciding that no atlas series on cardiovascular disease would be complete without addressing the issues of cardiovascular disease in women. My hope is that this book helps us to better understand the issues relating to women and their ever-precious hearts.

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Martha Gulati, MD, MS, FACC, FAHA

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