CLINICAL CASE PRESENTATION
A 53-year-old woman with a history of hypertension (HTN), diabetes mellitus Type 2 (Type 2 DM), and tobacco abuse presents to urgent care for symptoms of nausea, chest tightness, and bilateral shoulder pain. The discomfort started 4 hours ago and was not relieved with aspirin or antacid. She had recently been going to a chiropractor for pain in her neck and shoulders, which had been persisting over the past week, but felt this pain was more intense. Her blood pressure was elevated to 165/84 mm Hg and pulse to 93 beats per minute (bpm). Physical examination was unremarkable for cardiac findings with a normal S1 and S2, no rubs, murmurs or gallops, no pulmonary abnormalities, and no signs of heart failure. Further evaluation demonstrated no arrhythmias or acute ischemic changes on a normal-appearing electrocardiogram (ECG). Biomarkers for ischemia were negative.
CLINICAL FEATURES OF ISCHEMIC HEART DISEASE
Angina pectoris is a common presentation of ischemic heart disease (IHD). Based on data from the CASS trial in women who had typical angina, 62% had coronary artery disease (CAD), and even those with atypical features, 40% had CAD.1,2,3
During an acute ischemic event, many women do not experience typical angina, but have atypical symptoms. This may cause a delay in presentation, evaluation, and therapy. Lack of symptoms with an acute coronary syndrome (ACS) can occur in both men as well as women. But pooled data from large cohort studies have shown this to be more common in women, 37% versus 27%.4 Myocardial infarction (MI) without chest pain has been more common in younger women, under the age of 55 years. And this group has a higher associated mortality than men within the same age group.5
Other symptoms common in women presenting with ACS include upper abdominal discomfort, dyspnea, and fatigue as well as middle or upper back pain, nausea, indigestion, and loss of appetite.4
EPIDEMIOLOGY OF ISCHEMIC HEART DISEASE
Heart disease accounts for more deaths in women than cancer. Looking at data from the Centers for Disease Control from 2008, IHD accounts for 24.5% of deaths among women of all races6 (see Table 6-1).
Women are 5.5 times more likely to die from heart disease than breast cancer. Lifetime risk of developing IHD after 40 years of age is 32% for women.7
Nearly 250,000 women die annually in the United States from IHD. The mortality rate for women is higher than men at initial presentation of MI (52% vs 42%) and within 1 year following an MI (23% vs 18%).8,9,10
Women, on average, present with IHD 10 years later than men, and occurrence of a clinical event such as MI and sudden death lags behind men by 20 years. However, by the time they reach the eighth decade, both men ...