Author + information
- Received August 14, 2015
- Accepted August 28, 2015
- Published online October 27, 2015.
- Carl J. Pepine, MD∗∗ (, )
- Keith C. Ferdinand, MD†,
- Leslee J. Shaw, PhD‡,
- Kelly Ann Light-McGroary, MD§,
- Rashmee U. Shah, MD, MS‖,
- Martha Gulati, MD, MS¶,
- Claire Duvernoy, MD#,
- Mary Norine Walsh, MD∗∗,
- C. Noel Bairey Merz, MD††,
- ACC CVD in Women Committee
- ∗Division of Cardiology, University of Florida, Gainesville, Florida
- †Tulane University School of Medicine, New Orleans, Louisiana
- ‡Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
- §Division of Cardiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- ‖Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- ¶The College of Medicine and The College of Clinical Public Health, The Ohio State University, Columbus, Ohio
- #Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
- ∗∗St. Vincent Heart Center of Indiana, Indianapolis, Indiana
- ††Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
- ↵∗Reprint requests and correspondence:
Dr. Carl J. Pepine, Division of Cardiovascular Medicine, University of Florida, 1600 SW Archer Road, P.O. Box 100277, Gainesville, Florida 32610-0277.
Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.
This work was supported by contracts N01-HV-68161, N01-HV-68162, N01-HV-68163, N01-HV-68164 from the National Heart, Lung, and Blood Institutes; grants U0164829, U01 HL649141, U01 HL649241, K23HL105787, T32HL69751, R01 HL090957, 1R03AG032631 from the National Institute on Aging; GCRC grant MO1-RR00425 from the National Center for Research Resources; the National Center for Advancing Translational Sciences Grants UL1TR000124 and UL1TR000064; and grants from the Gustavus and Louis Pfeiffer Research Foundation, Danville, NJ; The Women’s Guild of Cedars-Sinai Medical Center, Los Angeles; The Ladies Hospital Aid Society of Western Pennsylvania, Pittsburgh, PA; QMED, Inc., Laurence Harbor, NJ; the Edythe L. Broad and the Constance Austin Women’s Heart Research Fellowships; Cedars-Sinai Medical Center, Los Angeles; the Barbra Streisand Women’s Cardiovascular Research and Education Program, Cedars-Sinai Medical Center, Los Angeles; The Society for Women’s Health Research (SWHR), Washington, D.C.; The Linda Joy Pollin Women’s Heart Health Program; and the Erika Glazer Women’s Heart Health Project, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Light-McGroary is the principal investigator for several multicenter, pharmaceutical clinical trials in heart failure and pulmonary hypertension. Dr. Shah holds equity in Gilead Sciences. Dr. Bairey Merz has received lecture fees from consulting fees from Amgen, Medscape, Pfizer, and has served on the grand review committee for Gilead. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 14, 2015.
- Accepted August 28, 2015.
- American College of Cardiology Foundation
- The Problem of Nonobstructive CAD: Definition, Prevalence, and Pathophysiological Implications for Management
- Is Coronary Atherosclerosis Present?
- Is Myocardial Ischemia Really Present?
- Is Coronary Microvascular Dysfunction Present?
- Syndromes Associated With Nonobstructive CAD and Adverse Outcomes
- Predictors of Adverse Outcomes With Nonobstructive CAD: Role of Hypertension, Diabetes, and Related Insulin-Resistant States
- Proposed Mechanistic Classification of IHD Syndromes With Nonobstructive CAD
- Knowledge Gaps
- Clinical Trials to Provide Evidence-Based Guideline Development
- Summary and Conclusions