Coronary microvascular dysfunction in women: an overview of diagnostic strategies

Kuruvilla, Sujith; Kramer, Christopher M.

doi:10.1586/14779072.2013.833854

Cited by 39 publications

(30 citation statements)

References 71 publications

(81 reference statements)

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“…Another possible explanation could be that stress testing was used less frequently in our older cohort compared with some of the more contemporary angiography studies; thus, the newer cohorts may have a higher proportion of patients with functional ischemia who are sent to catheterization. Because functional ischemia due to nonobstructive disease or microvascular angina is more common in women than men 15 and is associated with better prognosis than those with ischemia due to obstructive disease, 16 this could have contributed to the improved outcomes in women observed in our study, whereas newer angiography studies did not find this difference. Another possible explanation is the fact that we used coronary angiography rather than CTA.…”

Section: Discussionmentioning

confidence: 59%

Sex differences in long-term outcomes of patients across the spectrum of coronary artery disease

Pagidipati

Mudrick

Chiswell

et al. 2018

American Heart Journal

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Background Patients with nonobstructive coronary artery disease (CAD) have worse outcomes compared with those without CAD; however, few studies have compared the intermediate- and long-term impact of CAD severity as a function of patient sex. Methods We evaluated 5-year and long-term all-cause mortality of women and men undergoing elective coronary angiography at a single center by degree of CAD: no CAD (1%−24% stenosis), nonobstructive CAD (25%−69% epicardial stenosis or 25%−49% left main stenosis), or obstructive CAD (epicardial stenosis ≥70% or left main stenosis ≥50%), both overall and after adjusting for baseline clinical risk factors using Cox proportional-hazards models. Results Between January 1986 and July 2010, 8,766 women and 11,638 men underwent angiography and were followed for a median of 9.2 years. The majority (67%) of women had no CAD or nonobstructive CAD, whereas the majority of men had obstructive CAD (56%, P < .001). In both sexes, increasing CAD was associated with increased 5-year risk of mortality. Risk-adjusted hazard ratios (vs no CAD) for women were 1.36 (95% CI, 1.16–1.60) and 1.86 (1.61–2.16) for nonobstructive and obstructive CAD, respectively; corresponding hazard ratios for men were 1.24 (1.06–1.45) and 1.38 (1.20–1.59). After risk adjustment, 5-year mortality risk was higher in men than in women at all levels of CAD severity. The relationships between severity of CAD and mortality risk during long-term follow-up in women and men were similar to the 5-year relationships above. Conclusions Although women undergoing elective catheterization have less severe CAD than men, nonobstructive CAD is prevalent in both sexes and carries a worse prognosis than no CAD. These data suggest a need for further investigation to establish optimal therapies for this at-risk group of patients with nonobstructive CAD. (Am Heart J 2018;206:51–60.)

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Section: Discussionmentioning

confidence: 59%

Sex differences in long-term outcomes of patients across the spectrum of coronary artery disease

Pagidipati

Mudrick

Chiswell

et al. 2018

American Heart Journal

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“…The reported high false positive rate of approximately 28% in nuclear stress testing in women without known CAD (2) is particularly relevant to our study, since the majority of patients in the functional arm received this type of test. Another reason for the higher positivity rate of stress testing in women may be the presence of ischemia in the absence of obstructive CAD, possibly due to microvascular coronary dysfunction (MCD) (16-18). The ability of stress tests to detect both obstructive and microvascular disease may have made them more likely to be positive than CTAs in women, and less likely to be associated with clinical events, since MCD has a lower event rate than obstructive disease (19).…”

Section: Discussionmentioning

confidence: 99%

Sex Differences in Functional and CT Angiography Testing in Patients With Suspected Coronary Artery Disease

Pagidipati

Hemal

Coles

et al. 2016

Journal of the American College of Cardiology

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Background Risk stratification is an important goal of cardiac noninvasive tests (NITs), yet little contemporary data exist on the prognostic value of different NITs by patient sex. Objectives To compare the results and prognostic information derived from anatomic versus stress testing in stable men and women with suspected coronary artery disease. Methods In 8966 PROMISE trial patients tested as randomized (4500 computed tomographic angiography [CTA], 52% female; 4466 stress testing, 53% female), we assessed the relationship between sex and NIT results using logistic regression, and the relationship between sex and a composite of death, myocardial infarction, and unstable angina hospitalization using Cox proportional hazards models. Results In women, a positive CTA (≥70% stenosis) was less likely than a positive stress test (8% vs. 12%, adjusted OR 0.67 [95% CI 0.55-0.82]). Compared with negative tests, a positive CTA was more strongly associated with subsequent clinical events than a positive stress test (CTA adjusted HR 5.86 [95% CI 3.32-10.35]; stress adjusted HR 2.27 [95% CI 1.21-4.25]; adjusted p=0.028). Men were more likely to have a positive CTA than stress test (16% vs. 14%, adjusted OR 1.23 [95% CI 1.04-1.47]). Compared with negative tests, a positive CTA was less strongly associated with subsequent clinical events than a positive stress test in men, although this difference was not statistically significant (CTA adjusted HR 2.80 [95% CI 1.76-4.45]; stress adjusted HR 4.42 [95% CI 2.77-7.07]; adjusted p=0.168). Negative CTA and stress tests were equally likely to predict an event in both sexes (adjusted p-values=NS). A significant interaction between sex, NIT type, and test result (p=0.01) suggests that sex and NIT type jointly influence the relationship between test result and clinical events. Conclusions The prognostic value of an NIT result varies by test type and patient sex. Women appear to derive more prognostic information from a CTA, while men tend to derive similar prognostic value from both test types.

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“…87,89,90 Normal coronary endothelial function is defined as a threefold-to-fourfold increase in coronary blood flow (CBF) in response to vasodilators such as acetylcholine, and a reduction in CBF is suggestive of endothelial dysfunction. 91 CBF is a measure of the amount of flow through a given coronary artery per unit of time. Nonendothelial-dependent microvascular dysfunction is defined as a CFR <2.5 with intracoronary infusion of adenosine, although different studies have defined cut-off points between 2.2 and 3.0.…”

Section: Noninvasive Testingmentioning

confidence: 99%

Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy

et al. 2015

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Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.

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Coronary microvascular dysfunction in women: an overview of diagnostic strategies

Cited by 39 publications

References 71 publications

Sex differences in long-term outcomes of patients across the spectrum of coronary artery disease

Sex differences in long-term outcomes of patients across the spectrum of coronary artery disease

Sex Differences in Functional and CT Angiography Testing in Patients With Suspected Coronary Artery Disease

Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy

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