Stable Ischemic Heart Disease in Women

  • Kelly M. T. Schmidt
  • John Nan
  • Dawn C. Scantlebury
  • Niti R. AggarwalEmail author
Women’s Health (M Wood, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Women’s Health


Purpose of the review

Paradoxically, although women have a lower burden of coronary atherosclerosis, they experience more symptoms, more frequent hospitalizations, and a worse prognosis compared to men. This is in part due to biological variations in pathophysiology between the two sexes, and in part related to inadequate understanding of these differences, subconscious referral bias, and suboptimal application of existing women-specific guidelines. We sought to review the contemporary literature and provide an update on risk assessment, diagnosis, and management of IHD in women.

Recent findings

IHD in women is often secondary to diffuse non-obstructive atherosclerosis, coronary spasm, inflammation, and endothelial and microvascular dysfunction, and less commonly due to the male pattern of flow-limiting epicardial stenosis. Both IHD patterns likely represent sex-specific manifestations of the same disease process. Additionally, there is a differential expression of risk factors and symptoms between men and women. Application of male-pattern IHD risk factors and presentation to women contributes to under-recognition, under-testing, and under-treatment of IHD in women compared to men. Traditional diagnostic evaluation has focused on detection of epicardial disease, amenable to revascularization. Our improved understanding of sex-specific pathophysiology of IHD has enabled us to also develop tools for detection of microvascular disease. Advances in stress MRI, flow quantification on stress PET, and provocative invasive angiography have filled this void and offer important diagnostic and prognostic information.


Despite our improved understanding of sex-specific differences in presentation, risk factors, pathophysiology, diagnostic testing, and management strategies of IHD, women with IHD continue to experience worse outcomes than men. This disparity underscores the need for improved research and understanding of biological sex differences, elimination of subconscious gender bias in referral patterns, and improved application of existing research into clinical practice.


Ischemic heart disease Women Sex differences Microvascular disease Coronary artery disease Diagnostic imaging 



The authors wish to thank Mr. Guy Bolling for his editorial assistance.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137:e67–e492.CrossRefPubMedGoogle Scholar
  2. 2.
    Shaw LJ, Pepine CJ, Xie J, Mehta PK, Morris AA, Dickert NW, et al. Quality and equitable health care gaps for women: attributions to sex differences in cardiovascular medicine. J Am Coll Cardiol. 2017;70:373–88.CrossRefPubMedGoogle Scholar
  3. 3.
    Garcia M, Mulvagh SL, Bairey Merz CN, Buring JE, Manson JE. Cardiovascular disease in women. Circ Res. 2016;118:1273–93.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol. 2017;70:1–25.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Shaw LJ, Bairey Merz CN, Pepine CJ, Reis SE, Bittner V, Kelsey SF, et al. Insights from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study. J Am Coll Cardiol. 2006;47:S4–S20.CrossRefPubMedGoogle Scholar
  6. 6.
    Gijsberts CM, Agostoni P, Hoefer IE, Asselbergs FW, Pasterkamp G, Nathoe H, et al. Gender differences in health-related quality of life in patients undergoing coronary angiography. Open Heart. 2015;2:e000231.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Humphries KH, Izadnegahdar M, Sedlak T, Saw J, Johnston N, Schenck-Gustafsson K, et al. Sex differences in cardiovascular disease—impact on care and outcomes. Front Neuroendocrinol. 2017;46:46–70.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Yusuf S, Hawken S, Ôunpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937–52.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mehta PK, Wei J, Wenger NK. Ischemic heart disease in women: a focus on risk factors. Trends Cardiovasc Med. 2015;25:140–51.CrossRefPubMedGoogle Scholar
  10. 10.
    Vaccarino V, Badimon L, Corti R, et al. Ischaemic heart disease in women: are there sex differences in pathophysiology and risk factors?: position paper from the Working Group on Coronary Pathophysiology and Microcirculation of the European Society of Cardiology. Cardiovasc Res. 2010;90:9–17.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Aggarwal NR, Patel HN, Mehta LS, Sanghani RM, Lundberg GP, Lewis SJ, et al. Sex differences in ischemic heart disease: advances, obstacles, and next steps. Circ Cardiovasc Qual Outcomes. 2018;11:e004437.CrossRefPubMedGoogle Scholar
  12. 12.
    Hokanson JE, Austin MA. Plasma triglyceride level is a risk factor for cardiovascular disease independent of high-density lipoprotein cholesterol level: a meta-analysis of population-based prospective studies. J Cardiovasc Risk. 1996;3:213–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549–55.CrossRefPubMedGoogle Scholar
  14. 14.
    McSweeney JC, Rosenfeld AG, Abel WM, Braun LT, Burke LE, Daugherty SL, et al. Preventing and experiencing ischemic heart disease as a woman: state of the science. Circulation. 2016;133:1302–31.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Aviña-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. 2008;59:1690–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, et al. Association of History of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US women. JAMA Intern Med. 2017;177:1735–42.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Rademaker J, Schöder H, Ariaratnam NS, Strauss HW, Yahalom J, Steingart R, et al. Coronary artery disease after radiation therapy for Hodgkin’s lymphoma: coronary CT angiography findings and calcium scores in nine asymptomatic patients. Am J Roentgenol. 2008;191:32–7.CrossRefGoogle Scholar
  18. 18.
    Andersen R, Wethal T, Günther A, Fosså A, Edvardsen T, Fosså SD, et al. Relation of coronary artery calcium score to premature coronary artery disease in survivors >15 years of Hodgkin’s lymphoma. Am J Cardiol. 2010;105:149–52.CrossRefPubMedGoogle Scholar
  19. 19.
    Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Brønnum D, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368:987–98.CrossRefPubMedGoogle Scholar
  20. 20.
    Lubiszewska B, Kruk M, Broda G, et al. The impact of early menopause on risk of coronary artery disease (PREmature Coronary Artery Disease In Women – PRECADIW case-control study). Eur J Prev Cardiol. 2011;19:95–101.CrossRefPubMedGoogle Scholar
  21. 21.
    Mason JC, Libby P. Cardiovascular disease in patients with chronic inflammation: mechanisms underlying premature cardiovascular events in rheumatologic conditions. Eur Heart J. 2014;36:482–9.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Tooher J, Thornton C, Makris A, Ogle R, Korda A, Hennessy A. All hypertensive disorders of pregnancy increase the risk of future cardiovascular disease novelty and significance. Hypertension. 2017;70:798–803.CrossRefPubMedGoogle Scholar
  23. 23.
    •• Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315–81. European guideline on primary and secondary prevention of IHD. Sex specific differences in conventional risk factors and novel female-predominant risk factors are highlighted.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. J Am Coll Cardiol. 2011;57:1404–23.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    •• Bairey Merz CN, Andersen H, Sprague E, et al. Knowledge, attitudes, and beliefs regarding cardiovascular disease in women: the Women’s Heart Alliance. J Am Coll Cardiol. 2017;70:123–32. Although IHD is the leading cause of mortality in women, awareness in public and medical community is still sub-optimal. Campaigns, physician education and additional investment in women’s IHD research is warranted.CrossRefPubMedGoogle Scholar
  26. 26.
    Wilson PWF, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–47.CrossRefPubMedGoogle Scholar
  27. 27.
    Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women. JAMA. 2007;297:611–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;63:2935–59.CrossRefPubMedGoogle Scholar
  29. 29.
    Hemal K, Pagidipati NJ, Coles A, Dolor RJ, Mark DB, Pellikka PA, et al. Sex differences in demographics, risk factors, presentation, and noninvasive testing in stable outpatients with suspected coronary artery disease. J Am Coll Cardiol Img. 2016;9:337–46.CrossRefGoogle Scholar
  30. 30.
    Finks S. Cardiovascular disease in women. In: Richardson M, Chessman KH, Chant C, editors. Pharmacotherapy self-assessment program. 7th ed. Kansas City: American College of Clinical Pharmacy; 2010. p. 179–99.Google Scholar
  31. 31.
    Canto JG, Goldberg RJ, Hand MM, Bonow RO, Sopko G, Pepine CJ, et al. Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch Intern Med. 2007;167:2405–13.CrossRefPubMedGoogle Scholar
  32. 32.
    Khan NA, Daskalopoulou SS, Karp I, Eisenberg MJ, Pelletier R, Tsadok MA, et al. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med. 2013;173:1863–71.PubMedGoogle Scholar
  33. 33.
    Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300:1350–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Lichtman JH, Leifheit EC, Safdar B, Bao H, Krumholz HM, Lorenze NP, et al. Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (variation in recovery: role of gender on outcomes of young AMI patients). Circulation. 2018;137:781–90.CrossRefPubMedGoogle Scholar
  35. 35.
    Bucholz EM, Strait KM, Dreyer RP, Lindau ST, D’Onofrio G, Geda M, et al. Editor’s choice-Sex differences in young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care. 2017;6:610–22.CrossRefPubMedGoogle Scholar
  36. 36.
    Anderson RD, Pepine CJ. Gender differences in the treatment for acute myocardial infarction: bias or biology? Circulation. 2007;115:823–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Jespersen L, Hvelplund A, Abildstrom SZ, Pedersen F, Galatius S, Madsen JK, et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J. 2012;33:734–44.CrossRefPubMedGoogle Scholar
  38. 38.
    Pepine CJ, Anderson RD, Sharaf BL, Reis SE, Smith KM, Handberg EM, et al. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women’s Ischemia Syndrome Evaluation) study. J Am Coll Cardiol. 2010;55:2825–32.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Reis SE, Holubkov R, Smith AJC, et al. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J. 2001;141:735–41.CrossRefPubMedGoogle Scholar
  40. 40.
    von Mering GO. Abnormal coronary vasomotion as a prognostic indicator of cardiovascular events in women: results from the National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE). Circulation. 2004;109:722–5.CrossRefGoogle Scholar
  41. 41.
    Pepine CJ, Ferdinand KC, Shaw LJ, Light-McGroary K, Shah RU, Gulati M, et al. Emergence of nonobstructive coronary artery disease: a Woman’s problem and need for change in definition on angiography. J Am Coll Cardiol. 2015;66:1918–33.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Sharaf BL, Pepine CJ, Kerensky RA, Reis SE, Reichek N, Rogers WJ, et al. Detailed angiographic analysis of women with suspected ischemic chest pain (pilot phase data from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation [WISE] study angiographic core laboratory). Am J Cardiol. 2001;87:937–41.CrossRefPubMedGoogle Scholar
  43. 43.
    • Kenkre TS, Malhotra P, Johnson BD, et al. Ten-year mortality in the WISE study (Women’s Ischemia Syndrome Evaluation). Circ Cardiovasc Qual Outcomes. 2017;10:e003863. 10-year outcome in a landmark study evaluating symptomatic women with nonobstructive coronary artery disease. This angiographic finding is not benign and associated with increased risk compared to asymptomatic women.Google Scholar
  44. 44.
    Taqueti VR, Ridker PM. Inflammation, coronary flow reserve, and microvascular dysfunction: moving beyond cardiac syndrome X. JACC Cardiovasc Imaging. 2013;6:668–71.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Paul TK, Sivanesan K, Schulman-Marcus J. Sex differences in nonobstructive coronary artery disease: recent insights and substantial knowledge gaps. Trends Cardiovasc Med. 2017;27:173–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Mendelsohn ME. Molecular and cellular basis of cardiovascular gender differences. Science. 2005;308:1583–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Boardman HM, Hartley L, Eisinga A, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal woman. Cochrane Database Syst Rev. 2015;3:CD002229.Google Scholar
  48. 48.
    •• Mieres JH, Gulati M, Bairey Merz N, et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation. 2014;130:350–79. A consensus statement highlighting the algorithm for non-invasive stress testing in women at risk for IHD.CrossRefPubMedGoogle Scholar
  49. 49.
    Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130:1749–67.CrossRefPubMedGoogle Scholar
  50. 50.
    Taqueti VR, Everett BM, Murthy VL, Gaber M, Foster CR, Hainer J, et al. Interaction of impaired coronary flow reserve and cardiomyocyte injury on adverse cardiovascular outcomes in patients without overt coronary artery disease. Circulation. 2015;131:528–35.CrossRefPubMedGoogle Scholar
  51. 51.
    Radico F, Cicchitti V, Zimarino M, De Caterina R. Angina pectoris and myocardial ischemia in the absence of obstructive coronary artery disease: practical considerations for diagnostic tests. J Am Coll Cardiol Intv. 2014;7:453–63.CrossRefGoogle Scholar
  52. 52.
    Caspersen CJ, Pereira MA, Curran KM. Changes in physical activity patterns in the United States, by sex and cross-sectional age. Med Sci Sports Exerc. 2000;32:1601–9.CrossRefPubMedGoogle Scholar
  53. 53.
    Sanders GD, Patel MR, Chatterjee R, et al. AHRQ future research needs papers. Noninvasive technologies for the diagnosis of coronary artery disease in women: future research needs: identification of future research needs from comparative effectiveness review no 58. Rockville: Agency for Healthcare Research and Quality (US); 2013.Google Scholar
  54. 54.
    Bateman T, Heller G, McGhie A, et al. Diagnostic accuracy of rest/stress ECG-gated Rb-82 myocardial perfusion PET: comparison with ECG-gated Tc-99m sestamibi SPECT. J Nucl Cardiol. 2006;13:24–33.CrossRefPubMedGoogle Scholar
  55. 55.
    Marwick TH, Anderson T, Williams MJ, Haluska B, Melin JA, Pashkow F, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol. 1995;26:335–41.CrossRefPubMedGoogle Scholar
  56. 56.
    From AM, Kane G, Bruce C, Pellikka PA, Scott C, McCully RB. Characteristics and outcomes of patients with abnormal stress echocardiograms and angiographically mild coronary artery disease (<50% stenoses) or normal coronary arteries. J Am Soc Echocardiogr. 2010;23:207–14.CrossRefPubMedGoogle Scholar
  57. 57.
    Chuah SC, Pellikka PA, Roger VL, McCully RB, Seward JB. Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease. Circulation. 1998;97:1474–80.CrossRefPubMedGoogle Scholar
  58. 58.
    Gargiulo P, Petretta M, Bruzzese D, Cuocolo A, Prastaro M, D’Amore C, et al. Myocardial perfusion scintigraphy and echocardiography for detecting coronary artery disease in hypertensive patients: a meta-analysis. Eur J Nucl Med Mol Imaging. 2011;38:2040–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Einstein AJ, Blankstein R, Andrews H, Fish M, Padgett R, Hayes SW, et al. Comparison of image quality, myocardial perfusion, and left ventricular function between standard imaging and single-injection ultra-low-dose imaging using a high-efficiency SPECT camera: the MILLISIEVERT study. J Nucl Med. 2014;55:1430–7.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Taqueti VR, Dorbala S, Wolinsky D, Abbott B, Heller GV, Bateman TM, et al. Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease—state-of-the-evidence and clinical recommendations. J Nucl Cardiol. 2017;24:1402–26.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Cerci MSJ, Cerci JJ, Cerci RJ, Pereira Neto CC, Trindade E, Delbeke D, et al. Myocardial perfusion imaging is a strong predictor of death in women. J Am Coll Cardiol Img. 2011;4:880–8.CrossRefGoogle Scholar
  62. 62.
    Yoshinaga K, Chow BJW, Williams K, Chen L, deKemp RA, Garrard L, et al. What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography? J Am Coll Cardiol. 2006;48:1029–39.CrossRefPubMedGoogle Scholar
  63. 63.
    Shaw LJ, Hage FG, Berman DS, Hachamovitch R, Iskandrian A. Prognosis in the era of comparative effectiveness research: where is nuclear cardiology now and where should it be? J Nucl Cardiol. 2012;19:1026–43.CrossRefPubMedGoogle Scholar
  64. 64.
    Greenwood JP, Motwani M, Maredia N, et al. Comparison of cardiovascular magnetic resonance and single-photon emission computed tomography in women with suspected coronary artery disease from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) trial. Circulation. 2013;129:1129–38.CrossRefPubMedGoogle Scholar
  65. 65.
    Coelho-Filho OR, Seabra LF, Mongeon F-P, Abdullah SM, Francis SA, Blankstein R, et al. Stress myocardial perfusion imaging by CMR provides strong prognostic value to cardiac events regardless of patient’s sex. J Am Coll Cardiol Img. 2011;4:850–61.CrossRefGoogle Scholar
  66. 66.
    Wallace EL, Morgan TM, Walsh TF, Dall'Armellina E, Ntim W, Hamilton CA, et al. Dobutamine cardiac magnetic resonance results predict cardiac prognosis in women with known or suspected ischemic heart disease. J Am Coll Cardiol Img. 2009;2:299–307.CrossRefGoogle Scholar
  67. 67.
    • Aggarwal NR, Bond RM, Mieres JH. The role of imaging in women with ischemic heart disease. Clin Cardiol. 2018;41:194–202. A concise review on the contemporary role of imaging for detection of epicardial and microvascular disease in womenCrossRefPubMedGoogle Scholar
  68. 68.
    Jalnapurkar S, Zarrini P, Mehta PK, Thomson LEJ, Agarwal M, Samuels BA, et al. Role of stress cardiac magnetic resonance imaging in women with suspected ischemia but no obstructive coronary artery disease. J Radiol Nurs. 2017;36:180–3.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Yiu KH, de Graaf FR, Schuijf JD, et al. Age- and gender-specific differences in the prognostic value of CT coronary angiography. Heart. 2011;98:232–7.CrossRefPubMedGoogle Scholar
  70. 70.
    Stone GW, Hochman JS, Williams DO, Boden WE, Ferguson TB Jr, Harrington RA, et al. Medical therapy with versus without revascularization in stable patients with moderate and severe ischemia: The Case for Community Equipoise. J Am Coll Cardiol. 2016;67:81–99.CrossRefPubMedGoogle Scholar
  71. 71.
    Humphries KH, Pu A, Gao M, Carere RG, Pilote L. Angina with “normal” coronary arteries: sex differences in outcomes. Am Heart J. 2008;155:375–81.CrossRefPubMedGoogle Scholar
  72. 72.
    Lee BK, Lim HS, Fearon WF, Yong AS, Yamada R, Tanaka S, et al. Invasive evaluation of patients with angina in the absence of obstructive coronary artery disease. Circulation. 2015;131:1054–60.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.CrossRefPubMedGoogle Scholar
  74. 74.
    Kim HS, Tonino PA, De Bruyne B, et al. The impact of sex differences on fractional flow reserve-guided percutaneous coronary intervention: a FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) substudy. JACC Cardiovasc Interv. 2012;5:1037–42.CrossRefPubMedGoogle Scholar
  75. 75.
    Fineschi M, Guerrieri G, Orphal D, Palmerini E, Münzel T, Warnholtz A, et al. The impact of gender on fractional flow reserve measurements. EuroIntervention. 2013;9:360–6.CrossRefPubMedGoogle Scholar
  76. 76.
    Iqbal MB, Shah N, Khan M, Wallis W. Reduction in myocardial perfusion territory and its effect on the physiological severity of a coronary stenosis. Circ Cardiovasc Interv. 2010;3:89–90.CrossRefPubMedGoogle Scholar
  77. 77.
    Olson M. Symptoms, myocardial ischaemia and quality of life in women: results from the NHLBI-sponsored WISE study. Eur Heart J. 2003;24:1506–14.CrossRefPubMedGoogle Scholar
  78. 78.
    Gulati M, Cooper-DeHoff RM, McClure C, et al. Adverse cardiovascular outcomes in women with nonobstructive coronary artery disease: a report from the Women’s Ischemia Syndrome Evaluation Study and the St James Women Take Heart Project. Arch Intern Med. 2009;169:843–50.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: a systematic review and meta-analysis. Int J Cardiol. 2018;254:1–9.CrossRefPubMedGoogle Scholar
  80. 80.
    Sedlak TL, Lee M, Izadnegahdar M, Merz CN, Gao M, Humphries KH. Sex differences in clinical outcomes in patients with stable angina and no obstructive coronary artery disease. Am Heart J. 2013;166:38–44.CrossRefPubMedGoogle Scholar
  81. 81.
    Shaw LJ, Merz CNB, Pepine CJ, et al. The economic burden of angina in women with suspected ischemic heart disease. Results from the National Institutes of Health–National Heart, Lung, and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation. Circulation. 2006;114:894–904.CrossRefPubMedGoogle Scholar
  82. 82.
    Roswell RO, Kunkes J, Chen AY, Chiswell K, Iqbal S, Roe MT, et al. Impact of sex and contact-to-device time on clinical outcomes in acute ST-segment elevation myocardial infarction—findings from the National Cardiovascular Data Registry. J Am Heart Assoc. 2017;6:e004521.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA, on behalf of the American Heart Association Cardiovascular Disease and Stroke in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular Nursing, Council on High Bloo. Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey. Circulation. 2013;127:1254–63. e1–29Google Scholar
  84. 84.
    Leifheit-Limson EC, D'Onofrio G, Daneshvar M, et al. Sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction. The VIRGO Study J Am Coll Cardiol. 2015;66:1949–57.CrossRefPubMedGoogle Scholar
  85. 85.
    Shah AS, Griffiths M, Lee KK, et al. High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. Bmj. 2015;g7873:350.Google Scholar
  86. 86.
    Melloni C, Berger JS, Wang TY, Gunes F, Stebbins A, Pieper KS, et al. Representation of women in randomized clinical trials of cardiovascular disease prevention. Circ Cardiovasc Qual Outcomes. 2010;3:135–42.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Kelly M. T. Schmidt
    • 1
  • John Nan
    • 1
  • Dawn C. Scantlebury
    • 2
  • Niti R. Aggarwal
    • 3
    Email author
  1. 1.Department of MedicineUniversity of WisconsinMadisonUSA
  2. 2.Faculty of Medical SciencesUniversity of the West IndiesSt. MichaelBarbados
  3. 3.Division of Cardiovascular Medicine, Departments of Medicine and RadiologyUniversity of Wisconsin School of Medicine & Public HealthMadisonUSA

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