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Exercise-induced myocardial ischaemia in women: factors affecting prevalence
1Faculty of Physical Education and Health, University of Toronto, Ontario, Canada.
Insights
Coronary artery disease (CAD) diagnosis in women is challenging due to atypical symptoms and less frequent detection of stenotic lesions. This leads to underdiagnosis and gender bias in treatment for women with this leading cause of death.
Area of Science:
- Cardiology
- Women's Health
- Diagnostic Imaging
Background:
- Coronary artery disease (CAD) is a leading cause of death in women, often presenting with delayed or atypical symptoms.
- Women experience higher rates of all-cause angina but less frequently demonstrate stenotic lesions on traditional diagnostic tests.
Purpose of the Study:
- To explore the complexities in diagnosing and identifying CAD in women.
- To address the underdiagnosis and gender bias in CAD management for women.
Main Methods:
- Review of diagnostic challenges including ECG and imaging technologies.
- Consideration of non-epicardial coronary disease and microcirculatory dysfunction.
- Analysis of factors complicating diagnosis, such as co-morbidities and atypical presentations.
Main Results:
- Diagnostic techniques like ECG and imaging show lower sensitivity and specificity in women.
- Angiography may fail to detect microcirculatory disease, common in post-menopausal women.
- Factors contribute to a falsely lower post-test likelihood of CAD in women, exacerbating gender bias.
Conclusions:
- Underdiagnosis of CAD in women is linked to diagnostic limitations and atypical presentations.
- Gender bias in diagnosis and treatment referral persists due to lower detection precision.
- Further research is needed to improve CAD detection and management in women.
Abstract:
Coronary artery disease (CAD) is a major health care challenge, and is the leading cause of death amongst women. Both the delay in the clinical manifestations of CAD and 'atypical' symptomatology in women complicates both diagnosis and treatment strategies in this population. It appears that the age-adjusted prevalence of all-cause angina (effort, unstable, etc.) appears to be greater in women than men, although stenotic lesions are demonstrated less frequently. There are a number of factors that complicates the diagnosis and identification of CAD in women, including more diffuse anginal symptoms, a lower initial detection rate of myocardial ischemia by traditional methods, lower rates of interventional procedures, and lastly, potential differences in the pathophysiology of myocardial ischemia. The lower sensitivity and specificity of many diagnostic techniques including ECG and various imaging technologies contributes significantly to these findings. The increased presence of syndrome X in post-menopausal women may reflect an increased likelihood of microcirculatory disease, where the 'gold standard' angiography fails to detect the presence of disease. Thus nonepicardial coronary stenotic disease may be largely undetected by most studies, rendering many positive ECG stress results unverifiable. The increased co-morbidity seen with CAD in women further complicates diagnosis and interventional results. Combined, these factors act to falsely lower the post-test likelihood of disease in women, adding to the existing gender bias in the diagnosis and referral rates for treatment of CAD in women. The lower precision of disease detection in women contributes to the perception that women have less exertional angina than men, despite evidence to the contrary.