Coronary microvascular dysfunction causing cardiac ischemia in women

See Microvascular angina


Patients with persistent symptoms of ischemia have no evidence of obstructive coronary artery disease on angiography.

Nearly half of women with myocardial ischemia suffer from coronary microvascular disease, a condition often called microvascular angina.

Women have a greater ability to widen and narrow their arteries.

Women in addition experience relatively more pain sensations than men leading to more perceived chest pain.

Patients are typically women age 40-65 years with multiple comorbidities of hypertension, obesity, hypercholesterolemia, diabetes, inactivity, and chronic kidney disease.

Cardiac ischemia is manifested by chest pain, chest discomfort, shortness of breath, decreased exercise tolerance, and ST-segment abnormalities.

Patients often exhibit diastolic left ventricular dysfunction and cardiac imaging and central aortic stiffening.

Patients with coronary microvascular dysfunction phenotypically are similar to patients with HFpEFMicrovascular coronary disease (heart failure with preserved ejection fraction.

One of 13 women who have a clinical presentation suggesting ischemic heart disease but have a normal angiogram die from cardiac cause within 10 years of the angiographic evaluation, and most frequent cardiac adverse event is hospitalization for heart failure with preserved ejection fraction at 10 fold higher rate compared with asymptomatic women.

CMD clinical features include subjective symptoms of chest pain with ischemia, objective evidence of myocardial ischemia based on low functional capacity, dynamic abnormalities including exercised induced ST-segment EKG changes, reversible abnormalities on non-invasive stress testing, or any acute coronary syndrome, yet, no obstructive coronary artery disease found on invasive or non-invasive coronary angiography.

Most women with coronary microvascular dysfunction have additional risk factors: hypertension, hyperlipidemia, family history of premature coronary artery disease, and evidence of nonobstructive coronary atherosclerosis.

Contributing factors to CMD include the presence of autoimmune disorders, the history of malignancy, and a history of an adverse pregnancy outcome.

Noninvasive diagnostic testing can include: exercise EKG, stress electrocardiography and single-photon emission computed tomography.

The above tests have low sensitivity and moderate specificity for diagnosis.

Further testing possibilities include: pharmacologic stress cardiac positron emission tomography, cardiac magnetic resonance imaging, and transthoracic Doppler echocardiography.

Invasive diagnostic tests should be pursued with a lack of diagnosis for persistent chest pain after multiple medical encounters and noninvasive evaluations.

Invasive functional angiography testing has the potential to identify abnormal coronary pathways.

Management of CMD may include: statin therapy, low-dose aspirin therapy, antihypertensive agents-ACEI or angiotensin receptor blockers, anti–anginal/anti-ischemic agents such as vasodilating beta blockers and calcium channel blockers and ranolazine.

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