CHAPTER 108: WOMEN AND ISCHEMIC HEART DISEASE: AN EVOLVING SAGA

INTRODUCTION

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 older, with a greater risk factor burden and more comorbidity, and often with more frequent and untreated symptom burden. Much of the earlier sex bias data¹³ are highly relevant to the practices of care for women today. This early evidence prompted more recent explorations regarding biologic and clinical differences between women and men, revealing insight into varying pathophysiologic mechanisms between the sexes. Explorations as to varying pathophysiology, particularly in atherosclerosis development and the clinical sequelae of IHD, remain a focus of ongoing research activities.

This chapter will highlight recent research findings on IHD diagnosis, management, and clinical outcomes for women with stable and acute IHD. Women have greater CVD mortality and report more disability and decreased quality of life. They present later and with more comorbid conditions, yet receive fewer medical therapies and fewer interventions than men, contributing to sex-specific gaps in outcomes. These differences probably reflect both lingering diagnostic and treatment disparities and underlying biological differences. The underuse of guideline-based preventive and therapeutic strategies for women is a substantial contributor to their less favorable coronary outcomes, but the spectrum of sex differences likely reflects a combination of biology and bias.

The term IHD will be used in this chapter to identify myocardial ischemia as the culprit for symptom burden among women. The term IHD is advantageous for women because of their lower prevalence of anatomic obstructive coronary artery disease (CAD), despite ...