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Canadian Journal of Cardiology

Optimizing Risk Stratification and Noninvasive Diagnosis of Ischemic Heart Disease in Women

Published:February 04, 2018DOI:https://doi.org/10.1016/j.cjca.2018.01.026

      Abstract

      Ischemic heart disease (IHD) is an important and previously underappreciated cause of significant morbidity and mortality in women. Key differences exist in the pathophysiology, sex-specific risk factors, and clinical presentation in women compared with men, which influence diagnostic accuracy and utility of pretest risk assessments and noninvasive testing. Women are disproportionately affected by ischemia from microvascular dysfunction as evidenced by having less obstructive coronary artery disease on angiography, contributing to the challenge in diagnosis and prognosis of IHD in women via conventional methods, which tend to emphasize detection of epicardial stenoses. In this article, we review the utility, evidence for, and challenges of currently available risk assessments and noninvasive cardiac diagnostic tests in women. We propose an approach to investigation of the symptomatic woman with suspected IHD and selection of the appropriate testing modality. Finally, we explore opportunities for future research and highlight the urgent need for updated, evidence-based, Canadian guidelines specific to women with IHD.

      Résumé

      La cardiopathie ischémique (CI) est une cause importante, autrefois négligée, de morbidité et de mortalité significatives chez les femmes. Des différences clés existent au chapitre de la physiopathologie, des facteurs de risque selon le sexe et du tableau clinique chez les femmes par rapport aux hommes, ce qui influe sur la précision du diagnostic et l’utilité de l’évaluation préalable du risque et des examens non invasifs. Les femmes sont touchées de manière disproportionnée par l’ischémie résultant d’une dysfonction microvasculaire, comme en témoigne la fréquence moins élevée de la coronaropathie obstructive aux examens angiographiques, ce qui contribue à la difficulté de diagnostiquer et de pronostiquer la CI chez les femmes à l’aide des méthodes classiques, tendant à mettre l’accent sur la détection des sténoses épicardiques. Dans le présent article, nous examinons l’utilité de l’évaluation du risque et des examens cardiodiagnostiques non invasifs tels que pratiqués actuellement chez les femmes, de même que les données probantes et les difficultés qui s’y rattachent. De plus, nous proposons une démarche d’investigation des symptômes laissant soupçonner une CI chez les femmes, ainsi que des techniques d’examen appropriées. Enfin, nous abordons les perspectives de recherche et soulignons l’urgente nécessité de lignes directrices canadiennes factuelles et à jour visant précisément les femmes atteintes de CI.
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