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6/14/2016 Clinicalfeaturesanddiagnosisofcoronaryheartdiseaseinwomen

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Clinicalfeaturesanddiagnosisofcoronaryheartdiseaseinwomen

Author SectionEditors DeputyEditor


PamelaSDouglas,MD JuanCarlosKaski,DSc,MD,DM GordonMSaperia,MD,FACC
(Hons),FRCP,FESC,FACC,FAHA
PatriciaAPellikka,MD,FACC,FAHA,
FASE

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2016.|Thistopiclastupdated:Aug19,2014.
INTRODUCTIONCardiovasculardiseasesarethemostcommoncauseofdeathanddisabilityinwomenintheUnited
States[1,2].Althoughtherehasbeenareductioninthedeathratefromcoronaryheartdisease(CHD)since1980[3],
CHDaccountedfor35percentofallcausemortalityinwomenin1995[2]and23percentin2004[4].Betweentheagesof
45to64,oneinninewomendevelopssymptomsofsomeformofcardiovasculardisease.Afterage65,theratioclimbsto
oneinthreewomen,accordingtotheNationalCenterforHealthStatistics[5].

Therearesignificantdifferencesbetweenmenandwomenintheepidemiology,diagnosis,treatment,andprognosisof
CHDthatshouldbetakenintoaccountinthecareofwomenwithknownorsuspecteddisease.Furthermore,most
availabledatasuggestthatwomenarenotreferredasoftenasmenforappropriatediagnosticand/ortherapeutic
procedures,despitesimilarclinicalconditions[612].(See'DiagnostictestingforsuspectedCHD'below.)

TheclinicalfeaturesanddiagnosisofCHDinwomenwillbereviewedhere.TheepidemiologyandprognosisofCHD,
managementofCHDinwomen,andtheproblemofCHDinyoungwomenarediscussedseparately.(See"Epidemiology
ofcoronaryheartdisease"and"Managementofcoronaryheartdiseaseinwomen"and"Coronaryheartdiseaseand
myocardialinfarctioninyoungmenandwomen".)

CLINICALPRESENTATIONWomenwithcoronaryheartdisease(CHD)aregenerallyabout10yearsolderthanmen
atthetimeofpresentationandcarryagreaterburdenofriskfactors[1315].Womenmaynotidentifytheirinitial
symptomsasanexpressionofheartdiseaseandthereforemaynotseekmedicaladvicepromptlyandpractitionersmay
notevaluatesymptomsthatrepresentmyocardialischemiaasearlyinwomen[4,16].(See"Overviewofcardiovascular
riskfactorsinwomen".)

Althoughwomenaregenerallyolderthanmenatpresentation,womenyoungerthanage45yearsalsodevelopCHD[17]
andhaveaworseprognosisthanmen[18].ThefirstpresentationofCHDmaybechestpain,myocardialinfarction(MI),
heartfailure(HF),orsuddencardiacdeath(SCD).(See"Coronaryheartdiseaseandmyocardialinfarctioninyoungmen
andwomen".)

Ofimportance,theFraminghamRiskEstimationunderestimatesriskinwomenwithafamilyhistoryofearlyheartdisease
andforthisreasonalternativescores,suchastheReynoldsRiskScore,havebeendevelopedspecificallyforusein
women[19].(See"Estimationofcardiovascularriskinanindividualpatientwithoutknowncardiovasculardisease",
sectionon'ReynoldsCVDriskscoreforwomen(2007)'.)

ChestpainWhiledifferencesbetweenwomenandmeninthedescriptionofischemicsymptomshavebeenidentified
[20],webelievethattherearemoresimilaritiesthandifferences.Chestpainisthemostcommonanginalsymptominboth
sexesandisdescribedsimilarlywithregardtoqualityofpain(heaviness,pressure),patternofradiation,andmany
associatedsymptoms(fatigue,nausea,etc).Further,asinmen,thequalityofchestpain(typicalversusatypical)isan
importantpredictorofangiographicdiseaseinwomen(table1AB)[21,22].

Inastudyof109womenand128menwithsuspectedcoronaryarterydisease(CAD)withorwithoutanginaandatleast
onepriorabnormalcardiactestresultwhounderwentcoronaryarteriography,theratesoftheuseofthefollowing
descriptorsofchestpainweresimilarbetweenwomenandmenwhowerefoundtohaveobstructiveCAD:chestpain(84
versus82percent),pressure(58versus54percent),andtightness(58versus43percent)[20].Similarfindingshave
beennotedinotherstudies[23,24],whileolderstudiesbasedonpatientsundergoingtestingsuggestthatwomenmay
havemoreatypicalpain[25].

Onepotentialfactorimportantintheinterpretationofsymptomsinwomenisthegreaterlikelihoodoftheirbeinginducedby
rest,sleep,andmentalstress,inadditiontoorinsteadofphysicalexertion[26].Asanexample,aprevioushistoryofan
anxietydisorderisassociatedwithalowerriskofsignificantangiographicCHDinwomen(oddsratio2.74)[27].
Psychosocialfactorsarealsoimportant,aswomendrasticallyunderestimatetheirownriskofCHD,andphysicians'
estimatesarecoloredbypatientaffect[28].

MIMIinwomenmaygounrecognized,particularlyatyoungeragesandwhencomparedtomen:

ThefrequencyofunrecognizedMIwasillustratedinareportfromIcelandinwhich13,000womenwerefollowedfor
29years[29,30].TheincidenceofMIontheelectrocardiogram(ECG)increasedfrom1.3per1000atage35to60
per1000atage75theproportionthatwereunrecognizedwashigherintheyoungerwomen(41versus24percent).

AhigherproportionofsilentQwaveinfarctionsinolderwomenwasnotedinareportfromtheHERStrial,which
evaluatedtheefficacyofhormonereplacementtherapyin2763postmenopausalwomenwithknownCHD[30].
Duringafouryearfollowup,9.3percenthadECGevidenceofanMIthatwasunrecognizedclinicallyin46percent.
(See"Epidemiologyofcoronaryheartdisease",sectionon'Silentmyocardialischemiaandinfarction'.)

Similartothebroadpopulationofpatientswithchestpain(see'Chestpain'above),webelievethattherearemore

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similaritiesthandifferencesbetweenwomenandmeninthepresentationofMI.Most[3133],butnotall[34],studies
supportthispoint.However,womenwhopresentwithMImaymorefrequentlypresentwithoutchestpain.Thefollowing
studiesillustratethesetwopoints:

Aprospectivecohortstudyevaluated796womenand1679menwhopresentedtoanemergencydepartmentwithin
12hoursoftheonsetofacutechestpain(adiagnosisofMIwasgiveninabout20percent)[33].Thewomenwere
older(medianage70versus59years)andfewerhadaprioracuteMI(15versus28percent).Thirtyfourpredefined
chestpaincharacteristicswererecordedforeachpatient,includinglocationandsizeoftheareaofpain,painquality,
radiation,onset,duration,dynamics,severity,andtheaggravatingandrelievingfactorsincludingresponseto
nitrates.Mostofthesecharacteristicswerereportedwithsimilarfrequencyinwomenandmen,includingthe
subpopulationofindividualswhowerediagnosedwithMI.Ofnote,theaccuracyofmostofthesecharacteristicsfor
thediagnosisofMIwaslowinbothsexes.

Inasecondprospectivecohortstudyof1015patients(30percentwomen)55yearsofageoryoungerwhowere
evaluatedforanacutecoronarysyndrome(ACS),thepercentofpatientswhopresentedwithoutchestpainwas
significantlygreaterinwomen(19.0versus13.7)[35].Patientswithoutchestpainreportedfewersymptomsoverall.

Inareportof515womenwithanacuteMI,acutechestpainwasabsentin43percentandonly30percent
experiencedprodromalchestpain[31].

Inastudyofover1,000,000womenandmenintheNationalRegistryofMyocardialInfarction(UnitedStates),the
proportionofMIpatientswhopresentedwithoutchestpainwassignificantlyhigherforwomenthanmen(42.0versus
30.7percent)[32].

SeveralstudieshavespecificallyevaluatedtheoutcomesinwomenwithanonSTelevationACS(unstableanginaornon
STelevationMI).IntheGUSTOIIbtrial,whichevaluated12,142patientspresentingwithanACS,womenwereless
likelytohaveSTsegmentelevation(27versus37percentformen)and,amongthosewithoutSTsegmentelevation,
womenwerelesslikelytohaveanMI(37versus48percent).

TheoptimalapproachtoaccurateassessmentofriskinwomenwithanonSTelevationACSmaydifferfromthatinmen.
ThiswassuggestedbyananalysisfromTACTICSTIMI18,whichfoundthatwomenweremorelikelytohaveelevations
ofhighsensitivityCreactiveprotein(hsCRP)andbrainnatriureticpeptide(BNP),andlesslikelytohaveelevationsof
troponinsandcreatinekinaseMBfraction,thanmen,despitesimilarlevelsofrisk[36].Further,whenamultimarker
approachincorporatinghsCRP,BNP,andtroponinswasused,womenwithanypositivemarkerbenefitedfroman
invasivestrategy,whilethosewithnopositivemarkersbenefitedfromaconservativestrategy.Incontrast,menbenefited
fromaninvasivestrategywhentherewasbiomarkerpositivity,buttherewasnodifferenceinbenefitaccordingtostrategy
ifbiomarkerswerenegative.Thus,womenwithunstableanginawithoutpositivebiomarkersshouldbetreated
conservatively,withoutearlycatheterizationoruseofglycoproteinIIb/IIIainhibitors.

HeartfailureWomenwithCHDmorefrequentlyhaveordevelopsymptomaticHFthanmen[37,38].Thisappearsto
bedueatleastinparttoagreaterfrequencyofdiastolicdysfunction[38].Whythismightoccurisnotknown,butis
postulatedtoberelatedtoagreaterprevalenceofhypertensiveheartdiseaseandhypertrophyinwomen.

RiskfactorsforHFinwomenwithCHDwereexaminedinananalysisfromtheHERStrialof2391womenwith
establishedcoronarydiseasewhohadnoHFatbaseline[39].Atameanofsixyears,237women(10percent)developed
HF.Significantriskfactorsincludedthefollowing:

Diabetesmellitus
Atrialfibrillation
MI
Renaldysfunction(creatinineclearance<40mL/min)
Hypertension(systolicbloodpressure>120mmHg)
Currentsmoking
Obesity(bodymassindex>35kg/m2)
Leftbundlebranchblockonelectrocardiogram
Leftventricularhypertrophyonelectrocardiogram

DiabeteswasthevariableassociatedwiththegreatestincreaseinHFrisk(adjustedhazardratio3.1).Womenwith
diabetesandatleastthreeotherriskfactorshadanannualHFincidenceof8.2percent.

SuddencardiacdeathA38yearfollowupfromtheFraminghamHeartstudyevaluatedtheincidenceofSCDin
womencomparedtomen[40].Thefollowingfindingswerenoted:

WomenhadalowerSCDratethanmenatallagesandatanylevelofmultivariaterisk(figure1)theriskofsudden
deathamongwomenwithCHDwasonehalfthatofmenwithCHDandaccountedforasmallerproportionof
coronarydeaths(37versus56percent).

AhigherfractionofsuddendeathsinwomenoccurredintheabsenceofpriorovertCHD(63versus44percentin
men).(See"Pathophysiologyandetiologyofsuddencardiacarrest".)

ThepresenceofHFincreasedoverallmortalityandtheincidenceofSCDhowever,amongpatientswithHF,the
absoluteriskinwomenwasonlyonethirdthatofmen(figure2).

PhobicanxietyisassociatedwithanincreasedriskofSCDinwomen[41].Some,butnotall,ofthisriskcanbeascribed
toCHDriskfactorsassociatedwithphobicanxietysuchasdiabetes,hypertension,andelevatedserumcholesterol.

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DIAGNOSTICTESTINGFORSUSPECTEDCHDTheinitialevaluationofawomanpresentingwithsymptomsof
chestpainandsuspectedcoronaryheartdisease(CHD)issimilartothatformenandoftenincludessomeformof
noninvasivetesting.(See"Stresstestingforthediagnosisofobstructivecoronaryheartdisease".)

NoninvasivetestingThefollowingtestsareavailable:

Treadmillexercisetesting.(See"Stresstestingforthediagnosisofobstructivecoronaryheartdisease".)

Radionuclidemyocardialperfusionimagingwitheitherexerciseorpharmacologicstress.

Stressechocardiographywitheitherexerciseorpharmacologicstress.

Coronaryangiographywithcardiaccomputedtomography.(See"Noninvasivecoronaryimagingwithcardiac
computedtomographyandcardiovascularmagneticresonance".)

Coronaryarterycalciumscoring(CCTA).(See"Diagnosticandprognosticimplicationsofcoronaryarterycalcification
detectedbycomputedtomography".)

Cardiacmagneticresonanceimagingforeitherwallmotionorperfusion.(See"Noninvasivecoronaryimagingwith
cardiaccomputedtomographyandcardiovascularmagneticresonance",sectionon'Cardiovascularmagnetic
resonance'and"Teststoevaluateleftventricularsystolicfunction"and"Clinicalutilityofcardiovascularmagnetic
resonanceimaging".)

EachofthesetestsisimperfectinitsabilitytoaccuratelydiagnoseCHD(seeindividualtopicreviews).Thefollowing
pointsneedtobekeptinmindwhenconsideringanoninvasivetestinwomen:

Treadmillexercisetestinghasahigherfalsepositiverateinwomen[42].Thisisinpartduetoalowerprevalenceof
CHDinwomeninthepopulationsstudied(Bayesianfactors).Thediagnosticaccuracyinwomenisalsolowerdueto
olderageatpresentationwiththeattendanthigherfrequencyofcomorbiditiesandlowerexercisecapacity[4].Other
explanationsforthesexrelateddifferenceshaveincludedhormonalmedicationandautonomicinfluences[4].
Nevertheless,exercisestressprovidesvaluableinformationregardingreproducibilityofsymptoms,exercisecapacity
andlongevity,andisthepreferredmodeofstressinwomen,withorwithoutimaging.Ofnote,womenhavealower
functionalcapacitythanmen,usuallyachievingamaximalworkloadthatis2METslessthanformen.

Thesensitivityandspecificityofthesetestsaresuboptimal.Inametaanalysisthatevaluated19studiesofwomen
whounderwentexerciseelectrocardiogram(ECG)testing(fiveexercisethalliumandthreeofexercise
echocardiography)andcoronaryangiography,thesensitivityandspecificityforCHDofexerciseECGstresstesting,
exercisethallium,andexerciseechocardiographywere61and70percent,78and64percent,and86and79percent,
respectively[43].Thesevaluesaresimilartothoseinmenforstressechoandnuclear,butlowerforstressECG.

Noneofthestresstestsiswithoutsourcesofartifact.Allrequireadequatestressforoptimalaccuracy,whether
pharmacologicorexercise.Thus,anegativeexercisetestinapatientwithpoorexercisetolerancemaybe
inconclusive.

RadiationexposurefromCCTAandradionuclidetestshavenotbeenconvincinglyshowntobeharmful,butarebest
avoidedinyoungwomen,asbreasttissueisincludedintheradiationfield.(See"Radiationdoseandriskof
malignancyfromcardiovascularimaging".)

ForepisodicchestpainWomenwhopresentwithepisodicchestpainneedtobeevaluatedforCHD.The
likelihoodofCHDisbasedinpartuponthecharacterofthepresentingsymptoms(eg,typicalversusatypicalangina)and
thepresenceorabsenceofcoronaryriskfactors.Theriskassessmentmustbesexspecificbecausetheriskfactors
themselves,aswellastheirrelativeimportance,maydifferbetweenwomenandmen.Inparticular,hormonalstatus,
diabetes,smoking,andafamilyhistoryofprematureCHDappeartobemoreimportantinwomen.Ofnote,theAmerican
HeartAssociationguidelinesforprimarypreventioninwomensuggestthatusingalifetimelikelihoodofcoronaryartery
diseaseispreferredinwomen,ratherthanamoreconventional10yearFraminghamriskcalculation,asthelatteroften
underestimatesrisk[44].(See"Overviewofcardiovascularriskfactorsinwomen".)

Atpresent,localexpertiseandtestavailabilityshoulddictatenoninvasivetestselection,giventhelackofclearly
identifiabledifferencesinaccuracy.Onesequentialapproachisasfollowsanditisgenerallyinaccordwiththatinthe
2012AmericanCollegeofCardiology/AmericanHeartAssociationguidelineforthediagnosisandmanagementofpatients
withstableischemicheartdiseasethisapproachwasnotchangedinthe2014focusedupdate[4547].This2012
guidelinedoesnotspecifyseparatediagnosticapproachesforwomenandmen.

TheevaluationofawomanwithsuspectedCHDbeginswithacarefulhistoryandphysicalexamination,laboratory
work,andassessmentofrisk.Ifthepatientisdeterminedtobeatintermediaterisk,astresstestmaybeordered.
Theexactchoiceoftestwilldependonavarietyofclinicalfactorssuchaspatientrisk,abilitytoexercise,body
habitus,priortestinformationforcomparison,andnonclinicalfactorssuchaslocaltestavailabilityandexpertise.If
anexercisetreadmillischosen,thestressisadequate(maximal),theECGinterpretable,andthetestnegative,no
furtherevaluationisnecessary.

Womenwithapositivetestoranegativesubmaximaltestshouldundergoadditionaltesting,whichmayinclude
stressechocardiographyorstressnuclearimaging(ideallywithatechnetiumperfusionradiotracer),cardiac
computedtomographyangiography,ordiagnosticcath.Inparticular,patientswithahighprobabilitypositivetest
shouldgoontocoronaryangiographyiftheyarecandidatesforrevascularization.Suchwomenhaveaworse
outcomeiftheyarenotfurtherevaluated[48].

Theoptimalroleofcoronarycalciumscoringormeasurementofcarotidintimalmedialthicknessintheevaluationofstable

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symptomsisunclearatthistime[49].(See"Diagnosticandprognosticimplicationsofcoronaryarterycalcification
detectedbycomputedtomography"and"Noninvasivecoronaryimagingwithcardiaccomputedtomographyand
cardiovascularmagneticresonance"and"Overviewofthepossibleriskfactorsforcardiovasculardisease",sectionon
'Arterialintimamediathickness'.)

AfternonSTelevationACSEarlyexercisetestinginwomenafteranonSTelevationacutecoronarysyndrome
(ACS)canbeusefulinthosewhohavenothadacoronaryangiogramforestablishingthepresenceofcoronarydisease
andforriskstratificationandprognosis.Themajorityofpatientswhohaveundergonecoronaryangiographydonotneed
furtherriskassessment,althoughtestingmaybeindicatedoncetheacutephaseofACSisresolvedtoevaluatethe
possiblesignificanceoflesionsinvesselsotherthantheinfarctrelatedartery.

Iftestingisindicated,findingsontheexercisetestthatindependentlypredictfuturecardiaceventsarelowmaximal
workload,thenumberofleadswith0.1mVSTsegmentdepression,andmaximalratepressureproduct[5052].(See
"RiskfactorsforadverseoutcomesafternonSTelevationacutecoronarysyndromes".)

Highriskpatientshaveatleasttwoofthesethreecriteria,intermediateriskpatientshaveonecriterion,andlowrisk
patientslackallthreecriteria[52].However,asnotedabove,womenhaveahighpercentageoffalsepositiveexercise
tests,whichmightmakethetestlessreliable[42].Thisissuewasaddressedinastudyof395womenwithunstable
anginaenteredintotheFRISCtrialwhowerefollowedforsixmonths[52].Basedupontheexercisetestresults,low,
intermediate,andhighriskgroupswereidentifiedwitheventratesofcardiacdeathormyocardialinfarction(MI)of1,9,
and19percent,respectively.Theresultswerethesameasthoseobservedfor778meninthetrial.

AfterSTelevationMIWerecommendthattheuseofnoninvasivetestingbesimilarformenandwomen.

CoronaryangiographyTheindicationsfordiagnosticcardiaccatheterizationandcoronaryangiographyaresimilarfor
womenandmen.Recommendationsforinvasivetestingarefoundelsewhere.(See"Coronaryangiographyand
revascularizationforunstableanginaornonSTelevationacutemyocardialinfarction"and"Overviewoftheacute
managementofSTelevationmyocardialinfarction"and"Stableischemicheartdisease:Overviewofcare",sectionon
'Coronaryangiographyandrevascularization'.)

Theprevalenceofsignificantcoronarydiseasefoundatthetimeofangiographyislowerinwomenthanmenpresenting
withchestpain[37,53,54].Themagnitudeofthisdifferencewasillustratedinareportof886patientsreferredfor
angiographicevaluationofpresumedangina,23percentofwhomwerewomen[53].Normalcoronaryarteriesweremuch
morecommoninwomen(41versus8percentinmen).

AhigherrateofabsenceofsignificantcoronarystenoseshasalsobeennotedinwomenwithanonSTelevationACS
(unstableanginaornonSTelevationMI).Indifferentclinicaltrials,12to14percentofsuchpatientshave,oncoronary
angiography,eithernormalvesselsornovesselwith50to60percentstenosis.Thisappearstobemorecommonin
women(17versus9percentinmeninonetrial)[55,56].Possiblemechanismsfortheabsenceofsignificantcoronary
diseaseinthesepatientsincluderapidclotlysis,vasospasm,andcoronarymicrovasculardisease.(See"Classificationof
unstableanginaandnonSTelevationmyocardialinfarction",sectionon'Absenceofsignificantcoronarydisease'.)

GenderbiasAnumberofstudieshavedocumentedgenderbaseddifferencesinutilizationratesofcoronary
angiographyandrevascularization,evenamongthosewithanacuteMI[7,48,5763].Thesedifferencesreflectphysicians'
failuretoreferwomenwithpositiveexercisetestsforsubsequenttesting[62],leadingtoapooreroutcome[48].Inone
report,forexample,womenwithapositiveexercisetestweremorelikelytohavenofurthercardiacevaluationthanmen
(62versus38percent),adifferencethat,atthreeyearfollowup,wasassociatedwithahigherincidenceofMIordeathin
women(14.3versus6percentperyearinmen)[48].Alleventsoccurredinnonrevascularizedindividuals.

Otherstudieshavenotfoundadifferenceincatheterizationratesbetweenmenandwomen[6467].However,closer
examinationofthesereportsrevealsanoverreferraloflowriskmen(baseduponclinicalriskstratification)[64],anda
nearequalrateofcatheterizationfollowingMIwhentheprocedurewasperformedforthetreatment,notdiagnosis,ofCHD
[65].Inareviewofover3000patients(33percentwomen)whounderwentexerciseradionuclideimaging,referralratesfor
menandwomenwerecomparablewhenstratifiedbytheamountofabnormallyperfusedmyocardiumdetected[67].
However,amongpatientswithanabnormalscan,thesubsequentcardiaceventratewashigherforwomenthanmen(17.5
versus6.3percent),indicatingthatwomenwereunderreferredforcomparabledegreesofrisk.

Aseparateissueiswhethergenderbiasaffectsthelikelihoodofrevascularizationaftercardiaccatheterization.Inareview
ofover21,000patients,womenhadequalaccesstorevascularizationafteradjustmentforclinicalvariables(eg,age,
diabetes,heartfailure,renalinsufficiency)andcoronaryvariables(eg,extentofdisease,leftventricularejectionfraction)
[68].(See"Managementofcoronaryheartdiseaseinwomen".)

NonCHDcausesofchestpainThreenonCHDcausesofchestpainmaybefoundatthetimeofcatheterization:
cardiacsyndromeX,stressinducedcardiomyopathy,andspontaneouscoronaryarterydissection.

CardiacsyndromeXorcoronarymicrovasculardiseaseMyocardialischemiaand/orcoronarymicrovascular
dysfunctionispresentin20to50percentofwomenwithchestpainandnormalcoronaryarteries[6973].(See"Cardiac
syndromeX:Anginapectoriswithnormalcoronaryarteries".)

StressinducedcardiomyopathyAnuncommonbutincreasinglyreportedcauseofanacute,usuallySTelevation
coronarysyndromeoccurringintheabsenceofcriticalcoronaryarterydiseaseisstressinducedcardiomyopathy,also
calledtransientleftventricularapicalballooning,takotsubocardiomyopathy,andbrokenheartsyndrome.Thisdisorderis
typicallyprecipitatedbyintensepsychologicstressandprimarilyoccursinpostmenopausalwomen.Thistopicis
discussedindetailelsewhere.(See"Clinicalmanifestationsanddiagnosisofstress(takotsubo)cardiomyopathy".)

SpontaneouscoronaryarterydissectionSpontaneouscoronaryarterydissectionisararecauseofacuteMIthat

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ismorecommoninyoungerpatientsandinwomen[74].Theunderlyingmechanismisunknown,butanintimaltearor
bleedingofvasavasorumwithintramedialhemorrhagehavebeenproposed[75].Inpregnantwomen,dissectionmaybea
consequenceofincreasedhemodynamicstressorofhormonaleffectsonthearterialwall[76].(See"Acquiredheart
diseaseandpregnancy",sectionon'Myocardialinfarction'.)

MostpatientspresentingwiththisentitytypicallydonothaveriskfactorsforCHD.Histologically,aninflammatory
reactionintheadventitiahasbeendescribed,suggestiveofperiarteritis.However,thisinflammatoryresponsemaybe
reactiveratherthancausative[76].

A2012singlecenterreport(MayoClinic)containsthelargestseriesofpatients(87individualsfromoverthreedecades)
withspontaneouscoronaryarterydissectionandnoassociatedcoronaryarteryatherosclerosis[77].Thediagnosiswas
madebythefindingofadissectionplaneonangiography.Thisregistryreportnotedthefollowing:

Themeanagewas43yearsand82percentwerewomen.

Extremeexertionprecededtheeventin7of16menand2of71womenpostpartumstatuswaspresentin13of71
women(meanpostpartumperiod38days).

STelevationMI(STEMI)waspresentin49percentandnonSTelevationin44percentofpatientsonpresentation.
Chestpainwaspresentin91percentandlifethreateningventriculararrhythmiasin14percent.

Theleftanteriordescendingcoronaryarterywasthemostfrequentlyaffectedvesselandmultivesseldissectionwas
foundin23percent.

Theinhospitalprognosiswasgenerallygoodforthosemanagedeitherconservativelyorwithcoronaryarterybypass
grafting(CABG),whiletheshorttermoutcomewaslessfavorableinthosemanagedwithpercutaneouscoronary
intervention(PCI).TheauthorsspeculatedthatthispooreroutcomewithPCImighthavebeenattributabletotheuse
ofballoonangioplastywithoutstentinginpatientspresentingbeforetheuseofstentswascommon.

The10yearrecurrenceratewas29.4percent.Theestimated10yearrateofdeath,heartfailure,MI,ordissection
recurrencewas47percent(medianfollowupof47months).

Fibromusculardysplasiaoftherenalarterieswasfoundin8of16femoralangiograms.Twopatientswerenotedto
havecarotidarterydissection.

Thesefindingsaregenerallyconsistentwithearlierreports[76,7880].However,manyoftheseincludedpatientswith
associatedsignificantatheroscleroticcoronaryarterydisease,whichcouldpotentiallyinfluenceepidemiology,clinical
presentation,orprognosis.

Spontaneouscoronarydissectionshouldbeconsideredinanyyoungpatient,especiallyanyyoungwomanwithouta
previouscardiachistoryorCHDriskfactors,whopresentswithcardiacarrestoranacutecoronarysyndrome.The
optimalmanagementofspontaneouscoronaryarterydissectionisuncertain,inpartbecauseofthelimitedclinical
experience.

EmergentcoronaryangiographyfollowedbyPCIorCABGislikelytoofferthebestprospectofsurvival.Fibrinolytic
therapymayalsobesuccessfulforpatientswithSTEMI[74],butextensionofthedissectionispossible[81,82].

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsandBeyond
theBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,and
theyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestfor
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Basicstopics(see"Patientinformation:Coronaryheartdiseaseinwomen(TheBasics)")

SUMMARYCardiovasculardiseasesarethemostcommoncauseofdeathanddisabilityinwomenintheUnited
States.Importantdifferencesbetweenwomenandmeninthepresentationofcoronaryheartdisease(CHD)maymakeit
moredifficulttoestablishthediagnosisinwomen(see'Clinicalpresentation'above):

Womengenerallypresentabout10yearslaterthanmenandwithagreaterriskfactorburden.

Womenarelesslikelythanmentohavetypicalangina.

Womenwhopresenttotheemergencydepartmentwithnewonsetchestpainareapproachedanddiagnosedless
aggressivelythanmen.

Womenaremorelikelytoinitiallypresentwithchestpainthanamoreclearlydefinedeventsuchasamyocardial
infarction(MI).

ThesymptomsofMIinwomenmaydifferslightlyfromthoseinmen.ManycasesofMIinwomengounrecognized,
particularlyatyoungeragesorinpatientswithdiabetes.(See'MI'above.)

TheprocessofestablishingthediagnosisofCHDinwomenissimilartothatinmen,butseveralpointsneedtobekeptin
mind:

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Treadmillexercisetestinghasahigherfalsepositiverateinwomen,whilestressimagingappearstohavesimilar
accuracy.(See'Noninvasivetesting'above.)

Theprevalenceofsignificantcoronarydiseasefoundatthetimeofangiographyislowerinwomenthanmen
presentingwithchestpain.

Womenwithchestpainandnoevidenceofatheroscleroticcoronaryarterydiseaseoncoronaryangiographymay
havecardiacsyndromeXormicrovasculardisease,orfarmorerarely,takotsubocardiomyopathyorcoronary
dissection.(See'NonCHDcausesofchestpain'above.)

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

REFERENCES

1.EakerED,ChesebroJH,SacksFM,etal.Cardiovasculardiseaseinwomen.Circulation199388:1999.
2.MoscaL,MansonJE,SutherlandSE,etal.Cardiovasculardiseaseinwomen:astatementforhealthcare
professionalsfromtheAmericanHeartAssociation.WritingGroup.Circulation199796:2468.
3.CooperR,CutlerJ,DesvigneNickensP,etal.Trendsanddisparitiesincoronaryheartdisease,stroke,andother
cardiovasculardiseasesintheUnitedStates:findingsofthenationalconferenceoncardiovasculardisease
prevention.Circulation2000102:3137.
4.StanglV,WitzelV,BaumannG,StanglK.Currentdiagnosticconceptstodetectcoronaryarterydiseaseinwomen.
EurHeartJ200829:707.
5.http://www.americanheart.org/downloadable/heart/123783441267009Heart%20and%20Stroke%20Update.pdf.
6.LehmannJB,WehnerPS,LehmannCU,SavoryLM.Genderbiasintheevaluationofchestpainintheemergency
department.AmJCardiol199677:641.
7.SciricaBM,MoliternoDJ,EveryNR,etal.Differencesbetweenmenandwomeninthemanagementofunstable
anginapectoris(TheGUARANTEERegistry).TheGUARANTEEInvestigators.AmJCardiol199984:1145.
8.ArnoldAL,MilnerKA,VaccarinoV.Sexandracedifferencesinelectrocardiogramuse(theNationalHospital
AmbulatoryMedicalCareSurvey).AmJCardiol200188:1037.
9.SeilsDM,FriedmanJY,SchulmanKA.Sexdifferencesinthereferralprocessforinvasivecardiacprocedures.JAm
MedWomensAssoc200156:151.
10.PolkDM,NaqviTZ.Cardiovasculardiseaseinwomen:sexdifferencesinpresentation,riskfactors,andevaluation.
CurrCardiolRep20057:166.
11.BaireyMerzCN,ShawLJ,ReisSE,etal.InsightsfromtheNHLBISponsoredWomen'sIschemiaSyndrome
Evaluation(WISE)Study:PartII:genderdifferencesinpresentation,diagnosis,andoutcomewithregardtogender
basedpathophysiologyofatherosclerosisandmacrovascularandmicrovascularcoronarydisease.JAmColl
Cardiol200647:S21.
12.MieresJH,GulatiM,BaireyMerzN,etal.Roleofnoninvasivetestingintheclinicalevaluationofwomenwith
suspectedischemicheartdisease:aconsensusstatementfromtheAmericanHeartAssociation.Circulation2014
130:350.
13.OrenciaA,BaileyK,YawnBP,KottkeTE.Effectofgenderonlongtermoutcomeofanginapectorisandmyocardial
infarction/suddenunexpecteddeath.JAMA1993269:2392.
14.KannelWB,VokonasPS.Demographicsoftheprevalence,incidence,andmanagementofcoronaryheartdisease
intheelderlyandinwomen.AnnEpidemiol19922:5.
15.LernerDJ,KannelWB.Patternsofcoronaryheartdiseasemorbidityandmortalityinthesexes:a26yearfollowup
oftheFraminghampopulation.AmHeartJ1986111:383.
16.MoscaL,LinfanteAH,BenjaminEJ,etal.Nationalstudyofphysicianawarenessandadherencetocardiovascular
diseasepreventionguidelines.Circulation2005111:499.
17.WengerNK.You'vecomealongway,baby:cardiovascularhealthanddiseaseinwomen:problemsandprospects.
Circulation2004109:558.
18.AlterDA,NaylorCD,AustinPC,TuJV.Biologyorbias:practicepatternsandlongtermoutcomesformenand
womenwithacutemyocardialinfarction.JAmCollCardiol200239:1909.
19.MichosED,VasamreddyCR,BeckerDM,etal.WomenwithalowFraminghamriskscoreandafamilyhistoryof
prematurecoronaryheartdiseasehaveahighprevalenceofsubclinicalcoronaryatherosclerosis.AmHeartJ2005
150:1276.
20.KreatsoulasC,ShannonHS,GiacominiM,etal.Reconstructingangina:cardiacsymptomsarethesameinwomen
andmen.JAMAInternMed2013173:829.
21.DiamondGA,ForresterJS.Analysisofprobabilityasanaidintheclinicaldiagnosisofcoronaryarterydisease.N
EnglJMed1979300:1350.
22.WeinerDA,RyanTJ,McCabeCH,etal.Exercisestresstesting.Correlationsamonghistoryofangina,STsegment
responseandprevalenceofcoronaryarterydiseaseintheCoronaryArterySurgeryStudy(CASS).NEnglJMed
1979301:230.
23.TamuraA,NaonoS,TorigoeK,etal.Genderdifferencesinsymptomsduring60secondballoonocclusionofthe
coronaryartery.AmJCardiol2013111:1751.
24.MackayMH,RatnerPA,JohnsonJL,etal.Genderdifferencesinsymptomsofmyocardialischaemia.EurHeartJ
201132:3107.
25.AlexanderKP,ShawLJ,ShawLK,etal.Valueofexercisetreadmilltestinginwomen.JAmCollCardiol1998
32:1657.
26.PepineCJ,AbramsJ,MarksRG,etal.Characteristicsofacontemporarypopulationwithanginapectoris.TIDES
Investigators.AmJCardiol199474:226.
27.RutledgeT,ReisSE,OlsonM,etal.Historyofanxietydisordersisassociatedwithadecreasedlikelihoodof

https://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofcoronaryheartdiseaseinwomen?topicKey=CARD%2F1467&elapsedTimeMs=6&sour 6/13
6/14/2016 Clinicalfeaturesanddiagnosisofcoronaryheartdiseaseinwomen
angiographiccoronaryarterydiseaseinwomenwithchestpain:theWISEstudy.JAmCollCardiol200137:780.
28.BirdwellBG,HerbersJE,KroenkeK.Evaluatingchestpain.Thepatient'spresentationstylealtersthephysician's
diagnosticapproach.ArchInternMed1993153:1991.
29.JnsdttirLS,SigfussonN,SigvaldasonH,ThorgeirssonG.Incidenceandprevalenceofrecognisedand
unrecognisedmyocardialinfarctioninwomen.TheReykjavikStudy.EurHeartJ199819:1011.
30.ShlipakMG,ElmouchiDA,HerringtonDM,etal.Theincidenceofunrecognizedmyocardialinfarctioninwomenwith
coronaryheartdisease.AnnInternMed2001134:1043.
31.McSweeneyJC,CodyM,O'SullivanP,etal.Women'searlywarningsymptomsofacutemyocardialinfarction.
Circulation2003108:2619.
32.CantoJG,RogersWJ,GoldbergRJ,etal.Associationofageandsexwithmyocardialinfarctionsymptom
presentationandinhospitalmortality.JAMA2012307:813.
33.RubiniGimenezM,ReiterM,TwerenboldR,etal.Sexspecificchestpaincharacteristicsintheearlydiagnosisof
acutemyocardialinfarction.JAMAInternMed2014174:241.
34.GoldbergRJ,O'DonnellC,YarzebskiJ,etal.Sexdifferencesinsymptompresentationassociatedwithacute
myocardialinfarction:apopulationbasedperspective.AmHeartJ1998136:189.
35.KhanNA,DaskalopoulouSS,KarpI,etal.Sexdifferencesinacutecoronarysyndromesymptompresentationin
youngpatients.JAMAInternMed2013173:1863.
36.WiviottSD,CannonCP,MorrowDA,etal.Differentialexpressionofcardiacbiomarkersbygenderinpatientswith
unstableangina/nonSTelevationmyocardialinfarction:aTACTICSTIMI18(TreatAnginawithAggrastatand
determineCostofTherapywithanInvasiveorConservativeStrategyThrombolysisInMyocardialInfarction18)
substudy.Circulation2004109:580.
37.GurevitzO,JonasM,BoykoV,etal.Clinicalprofileandlongtermprognosisofwomen<or=50yearsofage
referredforcoronaryangiographyforevaluationofchestpain.AmJCardiol200085:806.
38.MendesLA,DavidoffR,CupplesLA,etal.Congestiveheartfailureinpatientswithcoronaryarterydisease:the
genderparadox.AmHeartJ1997134:207.
39.BibbinsDomingoK,LinF,VittinghoffE,etal.Predictorsofheartfailureamongwomenwithcoronarydisease.
Circulation2004110:1424.
40.KannelWB,WilsonPW,D'AgostinoRB,CobbJ.Suddencoronarydeathinwomen.AmHeartJ1998136:205.
41.AlbertCM,ChaeCU,RexrodeKM,etal.Phobicanxietyandriskofcoronaryheartdiseaseandsuddencardiac
deathamongwomen.Circulation2005111:480.
42.Gibbons,RF.ExerciseECGtestingwithandwithoutradionuclidestudies.In:CardiovascularHealthandDiseasein
Women,Wenger,NK,Speroff,L,Packard,B(Eds),LeJacqCommunications,Inc,Connecticut1993.p.73.
43.KwokY,KimC,GradyD,etal.Metaanalysisofexercisetestingtodetectcoronaryarterydiseaseinwomen.AmJ
Cardiol199983:660.
44.MoscaL,AppelLJ,BenjaminEJ,etal.Evidencebasedguidelinesforcardiovasculardiseasepreventioninwomen.
JAmCollCardiol200443:900.
45.FihnSD,GardinJM,AbramsJ,etal.2012ACCF/AHA/ACP/AATS/PCNA/SCAI/STSguidelineforthediagnosis
andmanagementofpatientswithstableischemicheartdisease:executivesummary:areportoftheAmerican
CollegeofCardiologyFoundation/AmericanHeartAssociationtaskforceonpracticeguidelines,andtheAmerican
CollegeofPhysicians,AmericanAssociationforThoracicSurgery,PreventiveCardiovascularNursesAssociation,
SocietyforCardiovascularAngiographyandInterventions,andSocietyofThoracicSurgeons.Circulation2012
126:3097.
46.FihnSD,GardinJM,AbramsJ,etal.2012ACCF/AHA/ACP/AATS/PCNA/SCAI/STSguidelineforthediagnosis
andmanagementofpatientswithstableischemicheartdisease:areportoftheAmericanCollegeofCardiology
Foundation/AmericanHeartAssociationtaskforceonpracticeguidelines,andtheAmericanCollegeofPhysicians,
AmericanAssociationforThoracicSurgery,PreventiveCardiovascularNursesAssociation,Societyfor
CardiovascularAngiographyandInterventions,andSocietyofThoracicSurgeons.Circulation2012126:e354.
47.FihnSD,BlankenshipJC,AlexanderKP,etal.2014ACC/AHA/AATS/PCNA/SCAI/STSfocusedupdateofthe
guidelineforthediagnosisandmanagementofpatientswithstableischemicheartdisease:areportoftheAmerican
CollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines,andtheAmerican
AssociationforThoracicSurgery,PreventiveCardiovascularNursesAssociation,SocietyforCardiovascular
AngiographyandInterventions,andSocietyofThoracicSurgeons.JAmCollCardiol201464:1929.
48.ShawLJ,MillerDD,RomeisJC,etal.Genderdifferencesinthenoninvasiveevaluationandmanagementof
patientswithsuspectedcoronaryarterydisease.AnnInternMed1994120:559.
49.HendelRC,PatelMR,KramerCM,etal.ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR2006
appropriatenesscriteriaforcardiaccomputedtomographyandcardiacmagneticresonanceimaging:areportofthe
AmericanCollegeofCardiologyFoundationQualityStrategicDirectionsCommitteeAppropriatenessCriteria
WorkingGroup,AmericanCollegeofRadiology,SocietyofCardiovascularComputedTomography,Societyfor
CardiovascularMagneticResonance,AmericanSocietyofNuclearCardiology,NorthAmericanSocietyforCardiac
Imaging,SocietyforCardiovascularAngiographyandInterventions,andSocietyofInterventionalRadiology.JAm
CollCardiol200648:1475.
50.AlKhaliliF,SvaneB,WamalaSP,etal.Clinicalimportanceofriskfactorsandexercisetestingforpredictionof
significantcoronaryarterystenosisinwomenrecoveringfromunstablecoronaryarterydisease:theStockholm
FemaleCoronaryRiskStudy.AmHeartJ2000139:971.
51.AlKhaliliF,WamalaSP,OrthGomrK,SchenckGustafssonK.Prognosticvalueofexercisetestinginwomenafter
acutecoronarysyndromes(TheStockholmFemaleCoronaryRiskStudy).AmJCardiol200086:211.
52.SfstrmK,LindahlB,SwahnE.RiskstratificationinunstablecoronaryarterydiseaseexercisetestandtroponinT
fromagenderperspective.FRISCStudyGroup.FragminduringInStabilityinCoronaryarterydisease.JAmColl
Cardiol200035:1791.
53.SullivanAK,HoldrightDR,WrightCA,etal.Chestpaininwomen:clinical,investigative,andprognosticfeatures.
BMJ1994308:883.
54.MerzCN,KelseySF,PepineCJ,etal.TheWomen'sIschemiaSyndromeEvaluation(WISE)study:protocol
design,methodologyandfeasibilityreport.JAmCollCardiol199933:1453.

https://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofcoronaryheartdiseaseinwomen?topicKey=CARD%2F1467&elapsedTimeMs=6&sour 7/13
6/14/2016 Clinicalfeaturesanddiagnosisofcoronaryheartdiseaseinwomen

55.GlaserR,HerrmannHC,MurphySA,etal.Benefitofanearlyinvasivemanagementstrategyinwomenwithacute
coronarysyndromes.JAMA2002288:3124.
56.RoeMT,HarringtonRA,ProsperDM,etal.Clinicalandtherapeuticprofileofpatientspresentingwithacute
coronarysyndromeswhodonothavesignificantcoronaryarterydisease.ThePlateletGlycoproteinIIb/IIIain
UnstableAngina:ReceptorSuppressionUsingIntegrilinTherapy(PURSUIT)TrialInvestigators.Circulation2000
102:1101.
57.RogerVL,FarkouhME,WestonSA,etal.Sexdifferencesinevaluationandoutcomeofunstableangina.JAMA
2000283:646.
58.GanSC,BeaverSK,HouckPM,etal.Treatmentofacutemyocardialinfarctionand30daymortalityamongwomen
andmen.NEnglJMed2000343:8.
59.AyanianJZ,EpsteinAM.Differencesintheuseofproceduresbetweenwomenandmenhospitalizedforcoronary
heartdisease.NEnglJMed1991325:221.
60.SteingartRM,PackerM,HammP,etal.Sexdifferencesinthemanagementofcoronaryarterydisease.Survival
andVentricularEnlargementInvestigators.NEnglJMed1991325:226.
61.BeardenD,AllmanR,McDonaldR,etal.Age,race,andgendervariationintheutilizationofcoronaryarterybypass
surgeryandangioplastyinSHEP.SHEPCooperativeResearchGroup.SystolicHypertensionintheElderly
Program.JAmGeriatrSoc199442:1143.
62.TobinJN,WassertheilSmollerS,WexlerJP,etal.Sexbiasinconsideringcoronarybypasssurgery.AnnInternMed
1987107:19.
63.RathoreSS,ChenJ,WangY,etal.Sexdifferencesincardiaccatheterization:theroleofphysiciangender.JAMA
2001286:2849.
64.BickellNA,PieperKS,LeeKL,etal.Referralpatternsforcoronaryarterydiseasetreatment:genderbiasorgood
clinicaljudgment?AnnInternMed1992116:791.
65.KrumholzHM,DouglasPS,LauerMS,PasternakRC.Selectionofpatientsforcoronaryangiographyandcoronary
revascularizationearlyaftermyocardialinfarction:isthereevidenceforagenderbias?AnnInternMed1992
116:785.
66.MarkDB,ShawLK,DeLongER,etal.Absenceofsexbiasinthereferralofpatientsforcardiaccatheterization.N
EnglJMed1994330:1101.
67.HachamovitchR,BermanDS,KiatH,etal.Genderrelateddifferencesinclinicalmanagementafterexercise
nucleartesting.JAmCollCardiol199526:1457.
68.GhaliWA,FarisPD,GalbraithPD,etal.Sexdifferencesinaccesstocoronaryrevascularizationaftercardiac
catheterization:importanceofdetailedclinicaldata.AnnInternMed2002136:723.
69.BuchthalSD,denHollanderJA,MerzCN,etal.Abnormalmyocardialphosphorus31nuclearmagneticresonance
spectroscopyinwomenwithchestpainbutnormalcoronaryangiograms.NEnglJMed2000342:829.
70.JohnsonBD,ShawLJ,BuchthalSD,etal.Prognosisinwomenwithmyocardialischemiaintheabsenceof
obstructivecoronarydisease:resultsfromtheNationalInstitutesofHealthNationalHeart,Lung,andBlood
InstituteSponsoredWomen'sIschemiaSyndromeEvaluation(WISE).Circulation2004109:2993.
71.ReisSE,HolubkovR,ConradSmithAJ,etal.Coronarymicrovasculardysfunctionishighlyprevalentinwomen
withchestpainintheabsenceofcoronaryarterydisease:resultsfromtheNHLBIWISEstudy.AmHeartJ2001
141:735.
72.MasciPG,LaclaustraM,LaraJG,KaskiJC.Brachialarteryflowmediateddilationandmyocardialperfusionin
patientswithcardiacsyndromeX.AmJCardiol200595:1478.
73.AtmacaY,OzdemirAO,OzdolC,etal.Angiographicevaluationofmyocardialperfusioninpatientswithsyndrome
X.AmJCardiol200596:803.
74.LeoneF,MacchiusiA,RicciR,etal.Acutemyocardialinfarctionfromspontaneouscoronaryarterydissectiona
casereportandreviewoftheliterature.CardiolRev200412:3.
75.AlfonsoF.Spontaneouscoronaryarterydissection:newinsightsfromthetipoftheiceberg?Circulation2012
126:667.
76.BassoC,MorgagniGL,ThieneG.Spontaneouscoronaryarterydissection:aneglectedcauseofacutemyocardial
ischaemiaandsuddendeath.Heart199675:451.
77.TweetMS,HayesSN,PittaSR,etal.Clinicalfeatures,management,andprognosisofspontaneouscoronary
arterydissection.Circulation2012126:579.
78.DeMaioSJJr,KinsellaSH,SilvermanME.Clinicalcourseandlongtermprognosisofspontaneouscoronaryartery
dissection.AmJCardiol198964:471.
79.JorgensenMB,AharonianV,MansukhaniP,MahrerPR.Spontaneouscoronarydissection:aclusterofcaseswith
thisrarefinding.AmHeartJ1994127:1382.
80.RothA,ElkayamU.Acutemyocardialinfarctionassociatedwithpregnancy.AnnInternMed1996125:751.
81.BuysEM,SuttorpMJ,MorshuisWJ,PlokkerHW.Extensionofaspontaneouscoronaryarterydissectiondueto
thrombolytictherapy.CathetCardiovascDiagn199433:157.
82.ZupanI,NocM,TrinkausD,PopovicM.Doublevesselextensionofspontaneousleftmaincoronaryartery
dissectioninyoungwomentreatedwiththrombolytics.CatheterCardiovascInterv200152:226.

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GRAPHICS

Pretestprobabilityofcoronaryheartdisease(CHD)inpatientswithchest
painaccordingtoage,gender,andsymptoms

Nonanginalpain Atypicalangina Typicalangina


Age
Men Women Men Women Men Women

30to39 4 2 34 12 76 26

40to49 13 3 51 22 87 55

50to59 20 7 65 31 93 73

60to69 27 14 72 51 94 86

Theprobabilityvaluesareexpressedasthepercentofpatientswithsignificantcoronaryarterydiseaseon
angiography.

CombineddatafromDiamondGA,ForresterJS.NEnglJMed1979300:1350andfromWeinerDA,RyanTJ,
McCabeCH,etal.NEnglJMed1979301:230.

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Pretestprobabilityofcoronaryheartdisease(CHD)andaccuracyof
exercisetestintheCASSpopulation

Clinical Prevalenceof Falsepositive, Falsenegative,


Gender
history CHD,percent percent percent
Definiteangina Male 89 4 65

Definiteangina Female 63 27 23

Probableangina Male 70 13 44

Probableangina Female 40 46 22

Nonischemic Male 22 91 14
chestpain

Nonischemic Female 5 94 5
chestpain

TheCoronaryArterySurgeryStudy(CASS)examinedinpartthepretestprobabilityofcoronaryheart
disease(CHD)andtheaccuracyofexercisetestingamongpatientspresentingwithcomplaintsof
chestpain.Theexercisetestwasconsideredpositivewhentherewas1mmSTsegmentdepression
orelevationforatleast0.08seccomparedtothebaselineECG.Whenpatientsweredividedinto
subgroupsbasedupongenderandthequalityoftheirchestpaincomplaints,thepretestprobability
ofCHD(asdeterminedbycoronaryangiography)variedbetween5and89percentandthefalse
positiveandnegativeratesofexercisetestingvariedbetween4and94and5and65percent,
respectively.Thehigherfalsepositiverateinwomencomparedtomencouldbeexplainedbythe
lowerprevalenceofCHDinwomen.

DatafromWeinerDA,RyanTJ,McCabeCH,etal.NEnglJMed1979301:230.

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Incidenceofsuddendeathinmenandwomen
increaseswithage

Duringa38yearfollowupofsubjectsintheFraminghamHeart
Study,theannualincidenceofsuddendeathincreasedwithagein
bothmenandwomen.However,ateachage,theincidenceofsudden
deathishigherinmenthanwomen.

DatafromKannelWB,WilsonPWF,D'AgostinoRB,etal.AmHeartJ1998
136:205.

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Heartfailurepredictsincreasedsuddencardiac
deathandoverallmortality

Duringa38yearoldfollowupofsubjectsintheFraminghamHeart
Study,thepresenceofheartfailure(HF)significantlyincreased
suddendeathandoverallmortalityinbothmenandwomen.

*p<0.01.
p<0.001.

Datafrom:KannelWB,WilsonPWF,D'AgostinoRB,etal.AmHeartJ1998
136:205.

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ContributorDisclosures
PamelaSDouglas,MDGrant/Research/ClinicalTrialSupport:NationalInstitutesofHealth(NIH)NHLBI,NCI,NIAID
UniversityofSouthFlorida[Cancer]ColumbiaUniversity[Diagnostictesting]MassachusettsGeneralHospital
[Diagnostictesting(FFRCT)]BristolMeyersSquibb[HepatitisC]EdwardsLifesciences[Valvularheartdisease(Sapien
valves)]GEHealthCare[Diagnostictesting(Optison)]Gilead[HepatitisC(Sofosbuvir)]HeartFlow[CADdiagnosis
(FFRCT)]Ikaria/Bellerophon[Heartfailure(IK5001)]ResMed[HeartFailure(ASVventilation)]Roche[Heartfailure]
Stealthpeptides[Heartfailure(Bendavia)].Consultant/AdvisoryBoards:PatientAdvocateFoundationGeneralElectric
HealthcareDSMB[Heartfailure(AdreScan)]Alere,IncGenomeMagazineOmiciaTGENHealthVenturesThirdPoint
LLCUSDiagnosticStandardsCardioDxInterleukinGeneticsPappasVenturesQCROC/PMPC/PreThera
TheHeart.orgMedscape/WebMDMedscape,LLC,GenomicMedicineInstituteUSDefenseAdvancedResearch
ProjectsAgencyNationalInstitutesofHealthNHGRI,NIAID,NHLBI,NIGMSGatesFoundationUnitedStatesAir
ForceHenryJacksonFoundationNovartisMerck.EquityOwnership/StockOptions:CardioDXOmicia.JuanCarlos
Kaski,DSc,MD,DM(Hons),FRCP,FESC,FACC,FAHASpeakersBureau:Menarini[Anginapectoris(Ranolazine)]
ServierUKSanofi[Anginapectoris(Ivabradine)].PatriciaAPellikka,MD,FACC,FAHA,FASENothingtodisclose.
GordonMSaperia,MD,FACCNothingtodisclose.

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