Gender differences in coronary artery disease: review of diagnostic challenges and current treatment

Coronary artery disease (CAD) in women is an important public health concern. However, the delayed onset of CAD in women and the apparent protective effect of estrogen are partly responsible for the misconception that CAD primarily affects men. Though women share the same traditional risk factors as men, they have some unique risk factors and differences in pathophysiology. Women are more likely to have atypical symptoms, contributing to the under-diagnosis of CAD. Fewer women than men receive pharmacological treatment for CAD on admission but more women receive anxiolytics, antidepressants, and narcotics. Disparities have been found in the administration and performance of both noninvasive testing and cardiac catheterization. The frequent absence of angiographic disease in symptomatic women often leads to searching for a noncardiac etiology for chest pain rather than the recognition of a higher incidence of nonocclusive CAD in women, a concept supported by imaging studies. Observational studies have pointed toward a beneficial effect of hormone replacement therapy (HRT) on CAD, but more recent randomized trials have disputed this and advocate against the use of HRT for CAD prevention. The role of HRT in CAD is still debated. Physicians have to be acutely aware of gender bias and gender-based differences in clinical presentation, accuracy of diagnostic tests, and clinical outcomes.