Ischemic heart disease in women can lead to a heart attack, but this risk may go unnoticed. This is because a patient’s diagnostic coronary angiogram shows “clear” arteries.

“When diagnosing women for ischemic heart disease, it is important to consider risk factors specific to women — and those that pose a greater risk to women,” said Li Zhou, M.D., Ph.D., medical director of the Norton Heart & Vascular Institute Women’s Heart Program.

As many as 3 million American women may have cholesterol plaque that spreads evenly throughout their artery walls, instead of blocking them. This is according to the Women’s Ischemia Syndrome Evaluation (WISE) study, conducted by the National Institutes of Health (NIH). This condition, non-obstructive coronary arteries, can cause pain similar to blocked arteries, but does not show up on standard tests.

Some researchers have gone so far as to suggest a “female pattern” for ischemic heart disease. This condition is characterized by persistent chest pain, which is usually atypical. Tests to evaluate ischemia usually yield positive results. Coronary angiography typically does not show significant changes.

“Unfortunately, ischemic heart disease in women is underdiagnosed and undertreated,” Dr. Zhou said. “There are things we can do as clinicians to make sure we don’t miss an opportunity to diagnose and treat these women.”

Women face other unique risks for ischemic heart disease, or risk factors that affect them disproportionately.

Adverse pregnancy outcomes are risk factors for ischemic heart disease. Gestational diabetes, preeclampsia, eclampsia, and preterm delivery are all associated with future heart disease. As a result, American Heart Association and American College of Obstetrician and Gynecologists call for appropriate postpartum screening for hypertension and control risk factors of ischemic heart disease for women with a history of preeclampsia.

Systemic autoimmune disorders such as lupus and rheumatoid arthritis are highly prevalent in women and are associated with an increased risk of cardiovascular disease, possibly as the result of underlying chronic inflammation. Anemia is also more common in women and is an independent risk factor for cardiovascular events.

Radiation for breast cancer and Hodgkin lymphoma are also associated with ischemic heart disease. The increased risk for heart disease starts within five years of chest wall or mediastinal radiation and continues for at least 20 years post radiation.

Diabetes is a risk factor for ischemic heart disease for both men and women, but a woman with diabetes is at twofold increased risk of developing ischemic heart disease, compared to a man. This may be the result of a greater insulin resistance and adiposity in women. Studies also have found diabetes is a stronger predictor of mortality in women than men.

Psychosocial variables such as depression and marital stress also appear to have a significant effect on women and their cardiovascular health.

Depression in women 55 or younger was associated with a higher risk of death from heart disease, compared with men 55 or younger. The Women’s Health Initiative found depression was associated with a greater risk for both heart disease and death from heart disease. The Stockholm Women’s Intervention Trial for Coronary Heart Disease, in a randomized trial, found psychosocial intervention prolonged life for women with depression hospitalized for coronary heart disease.

Among women with ischemic heart disease, marital stress — but not work stress —was a strong predictor of poor prognosis at follow-up. Women with severe marital stress had a three times greater risk of coronary events even after controlling for standard risk factors.

Dr. Zhou’s published research

Read more at PubMed.gov