Nejm 1996;334:1311

Despite its limited prognostic value, chest pain is the most common initial manifestation of ASHD in women. The risk of death due to ASHD in women is similar to that of men 10 yr younger. Death rates are 34% higher for black women than for white women. Smoking remains the leading preventable cause of ASHD in women; > 50% of MIs among middle-aged women are attributable to tobacco. Diabetes is associated with a 3- to 7-fold elevation in ASHD risk among women (Circ 1997;96:2468).

Elevated total cholesterol and LDL are only weakly associated with CAD in women (Nejm 1995;332:1758). HDL and triglycerides have greater predictive value (Atherosclerosis 1994;108:S73).

An increase in cholesterol precedes natural menopause by 3 yr and occurs at the time of surgical menopause (Circ 1996;94:61). During average follow-up of 4.1 yr, rx with oral conjugated estrogen plus medroxyprogesterone did not reduce the overall rate of coronary events in postmenopausal women with established CAD. Because more events occurred in the hormone group in yr 1 and fewer in yr 4 and 5, it could be appropriate for women already receiving this rx to continue it (HERS trial) (Jama 1998;280:605). A population-based case-control study concluded that low-dose oral contraceptives did not increase the risk of MI in women (Circ 1998;98:1058).

Estrogen and estrogen/medroxyprogesterone acetate produced reductions in LDL and increases in HDL cholesterol levels but did not
alter the progression of coronary atherosclerosis in postmenopausal women with established disease (Nejm 2003;349:535; 2000;343:522). Estrogen plus progesterone did not protect against CAD in healthy postmenopausal women (Nejm 2003;349:523).

Amongpts presenting to the ER with acute cardiac ischemia, gender is not an independent predictor of hospital mortality. Women tend to have higher mortality from AMI but are older and have greater frequency of diabetes and higher Killip class on presentation (J Am Coll Cardiol 1997;29:1490). Women with ACS are older than men and have more comorbidity. The outcome with unstable angina and non—Q-wave MI is related to severity of illness and not gender, and mortality associated with revascularization for unstable angina and non—Q-wave MI is similar for women and men (TIMI IIIb) (J Am Coll Cardiol 1997;30:141). After MI, younger women—but not older women—have higher rates of death during hospitalization than men of the same age; the younger the age of thepts, the higher the risk of death among women relative to men (NRMI 2 registry) (Nejm 1999;341:217).

Female survivors of cardiac arrest are less likely to have underlying CAD, but ASHD status is the most important predictor of survival in women, while impaired LV function is the most important predictor in men (Circ 1996;93:1170).

Although the unadjusted mortality rate suggests that women and men undergoing CABG and PTCA have a similar 5-yr mortality, women have higher risk profiles. Consequently, female sex is an independent predictor of improved 5-yr survival (Circ 1998;98:1279).

Treadmill testing without imaging is reported to have higher false-positive rates in women than in men (38-67% vs 7-44%); the false-negative rate in women is 12-22% (Am J Cardiol 1995;75:865). Radionuclide treadmill imaging has sensitivity of 71-93% and specificity of 85-91%. Dobutamine stress echocardiography reliably detects multivessel stenosis in women but is usually negative in single-vessel stenosis (WISE Study) (J Am Coll Cardiol 1999;33:1462).

ASA 100 mg po qd lowered the risk of CVA in women > 45 yr old but did not reduce the risk of MI or of death from CV causes (Nejm 2005;352:1293).

Cardiac Syndrome X: Chest pain with normal coronary angiograms; usually not associated with increased mortality or risk of CV events; may represent 20% ofpts with chest pain and abnormal exercise EKGs; associated with reduced coronary microvascular dilatory response and increased coronary resistance along with subendocardial hypoperfusion on cardiac MRI in response to iv adenosine administration (Nejm 2002;346:1948; Am J Cardiol 1988;61:1338). Pts with microvascular angina secondary to systemic disease (DM, HT, amyloidosis, myeloma) and/or LBBB have a poor prognosis (Circ 2004;109:452). Rx includes imipramine for analgesia, aminophylline (adenosine receptor antagonist), TENS or spinal cord stimulation, and physical training.

Aortic regurgitation: Indications for surgical correction of aortic regurgitation were established mostly in men. Unadjusted LV diameter surgical criteria result in criteria irrelevant to women, who often undergo surgery after developing severe sx and exhibit excess late mortality. Surgery should be performed even in asymptomaticpts if EF < 55% or if end-systolic dimension ≥ 55 mm. Whether smaller end-systolic dimension should be recommended in women is still in question (Circ 1996;94:2472).