Risk factors and noninvasive diagnostic assessment of NOCAD in women

In the current issue of Cardiovascular Innovations and Applications (Special Issue on Women's Cardiovascular Health, Volume 3, Number 4, 2019, Guest Editor Gladys P. Velarde) pp. 349-361(13); DOI: https://doi.org/10.15212/CVIA.2017.0077 Keith C. Ferdinand, MD and Rohan Samson, MD from the Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA consider nonobstructive coronary artery disease in women: risk factors and noninvasive diagnostic assessment.

The authors review differences in coronary anatomy, microcirculation, vascular tone and differences in the atherosclerosis process while stressing the importance of key risk factors in women such as hypertension, obesity and inflammation and its association not only with sex but ethnicity. Sex-specific differences in the epidemiology and pathophysiology of coronary artery disease and ischemic heart disease are now well recognized. Women with angina more often have nonobstructive coronary artery disease ( NOCAD) compared with men. This patient population carries a significant risk of future cardiovascular events that is not commonly appreciated, often leading to delayed diagnosis and treatment. While coronary microvascular dysfunction plays a central role in the athophysiology of NOCAD in women, other mechanisms of myocardial ischemia are now recognized. Risk factors such as hypertension and obesity disparately affect women and are likely to account for a significant proportion of NOCAD in the coming years. Vascular inflammation is an important pathophysiologic pathway in NOCAD and is a potential therapeutic target. Coronary CT angiography provides a comprehensive assessment of coronary anatomy and plaque morphology and is a reasonable screening test of choice for NOCAD.

This article forms part of a special issue on Women's Cardiovascular Health, guest edited by Gladys P. Velarde. Recent decades have witnessed great progress in the treatment of cardiovascular disease (CVD). Due to improved therapies, preventive strategies and increased public awareness, CVD (stroke, heart failure, ischemic heart disease, peripheral arterial disease and congenital heart disease) mortality has been on the decline over this span of time for both genders. Unfortunately, the decline has been less prominent for women, especially women of color. Once viewed as a man's disease, CVD remains the leading cause of mortality for women in the United States and is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. In the United States, CVD far outpaces all other causes of death, including all forms of cancer combined. The statistics are sobering with about one female death in the United States every 80 seconds from CVD. That represents close to 400,000 deaths per year according to the more recent statistics. Of these, more than one quarter of a million women will die this year from ischemic heart disease (IHD) which includes obstructive and non-obstructive coronary disease, and about 64% of women who die suddenly of IHD have no prior symptoms. Despite a significant number of females with known CVD and increased awareness among women of heart disease as their major health threat, a substantial proportion of women (46% as per the most recent American Heart Association survey) remain unaware of their cardiovascular risk and continue to fail to recognize its significance.

This lack of awareness is more profound (over 60% unaware) among women in higher-risk groups, racial and ethnic minorities, and has changed little in decades.

Poorly understood sex/gender differences in pathobiologic mechanisms, clinical presentation, management and application of diagnostic and therapeutic and preventive strategies have contributed to this gap. A critically important factor has been the underrepresentation of women in CVD research to date. In fact, only one-third of CVD clinical trials report sex-specific results despite The Food and Drug Administration regulations requiring sex stratification data, as well as the National Institute of Health recommendations of increased inclusion of women in clinical trials. This makes it difficult for researchers and clinicians to draw accurate conclusions about sex differences in mechanisms of disease, accuracy of specific diagnostic modalities and risks or benefits of a particular drug or device for the treatment of women with CVD. Furthermore, physicians and other healthcare providers continue to underestimate women's cardiovascular risk, in part because of utilization of traditional approaches which can lead to over-testing or inappropriate risk assessment without accurate differentiating who is truly at risk and inadequate use of preventive therapies for women.

The goal of this special edition Cardiovascular Innovations and Applications is to shed some light on specific topics that dominate the spectrum of CVD in women.