Assessing coronary artery disease in women: how useful is coronary angiography?

The data are conflicting, but the suspicion is that there may be a gender bias against referring women for angiography in coronary disease evaluation. These cardiologists, however, review the studies and conclude that, even with the available noninvasive tests, coronary angiography continues to be the gold standard for assessing and monitoring heart disease -- even in women. The burden of coronary artery disease (CAD) in women is significant. In spite of increasing uses of noninvasive testing, coronary angiography remains the gold standard in the diagnosis and assessment of CAD. Since gender differences exist in the clinical presentation of CAD and in the sensitivity and specificity of noninvasive testing, coronary angiography remains an invaluable tool in providing diagnostic and prognostic information in women. Angiography is also appropriate when vasospastic disease is suspected. Although gender differences in the indication for coronary angiography are recognized, evidence as to whether there is a bias against women in the referral for cardiac catheterization after noninvasive testing or myocardial infarction is conflicting. The possibility that physicians underestimate the risk of disease in women cannot be ruled out. Therefore, proper training of physicians in the clinical assessment and prediction of the pretest risk for coronary disease in women cannot be overemphasized. In addition, physicians should be aware that normal coronary angiograms in women cannot always rule out the existence of myocardial ischemia, especially in conditions such as variant angina and syndrome X. Coronary angiography has also been invaluable in elucidating the benefits of lipid-lowering therapy and estrogen use in women in the prevention of heart disease. Coronary angiography, therefore, remains an invaluable tool in the management of CAD in women.