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This chapter discusses ischemic heart disease (IHD) in women. IHD is the leading cause of morbidity, mortality, and disability in US women. Among all ages, women have a lower prevalence of coronary artery disease (CAD) than do men; however, once clinical manifestations of IHD develop, women have less favourable outcomes than do their male peers in the settings of stable IHD, acute coronary syndromes (ACS), and coronary revascularization. Prevention strategies in women should take into account risk factors that are unique or predominant in women, such as pregnancy complications and systemic autoimmune disorders, as well as the differential risks of traditional risk factors in men and women (see accompanying Hurst’s Central Illustration). The clinical diagnosis of angina can be challenging in women; a careful history is required to assess the likelihood of CAD and to aid decision making regarding additional testing. Noninvasive diagnostic testing can refine the management of symptomatic women. Invasive coronary angiography may be used as a frontline procedure in high-risk women or those whose symptom burden is considered unstable, or in the setting of demonstrable ischemia by stress testing. Compared with men, women with acute or stable IHD more often have nonobstructive CAD. Women with IHD are less likely than men to receive guideline-based therapy, and have worse outcomes.

eFig 108-01

Ischemic heart disease (IHD) in women.


Throughout the 20th century, coronary heart disease (CHD) was viewed as predominantly a problem of middle-aged men, and little information was available regarding its impact on women. Recent decades have witnessed an emerging interest in CHD in women, with consequent performance of research studies and the acquisition of data specific to women. There now exists a burgeoning evidence base on sex differences in the presentation, diagnostic evaluation, management, and clinical outcomes for women as compared with men with suspected and known ischemic heart disease (IHD).1,2,3,4,5,6,7,8 This evidence base has evolved rapidly over the past several decades, but remains incomplete with regard to understanding the biologic basis for sex differences, distinct pathophysiologic alterations, and variability in treatment effectiveness, which contribute to the largely elevated risk for morbid and fatal outcomes related to cardiovascular disease (CVD) among women as compared to men.

Historic evidence is replete with documentation of under-referral, -testing, and -treatment of women.9,10 For women, outcomes are further impacted by delays in seeking care.11 The ensuing impact of reduced financial means and other socioeconomic factors contribute to higher risk status for women. Although recent improvements have been reported, the lack of public awareness has resulted in an insufficient knowledge regarding CVD in women.12 The gamut of cultural, social, and financial differences among women profoundly impact prompt diagnosis, clinical management, and outcomes of at-risk women. These factors result in women presenting ...

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