32 HOW TO TREAT: ISCHAEMIC HEART DISEASE IN WOMEN
32 HOW TO TREAT: ISCHAEMIC HEART DISEASE IN WOMEN
20 JUNE 2025 ausdoc. com. au and a high index of suspicion, with three types of SCAD identified based
167, 179 on the angiographic pattern. Consider intracoronary imaging in selected cases when the definitive diagnosis cannot be established, but take care to avoid propagation of further dissection. 180 CT coronary angiogram( CTCA) is limited when diagnosing SCAD because of poor spatial resolution and is not suited to identify distal or mild lesions but may be useful for subsequent imaging of SCAD in large proximal vessels, to confirm angiographic resolution. 181
Medical management with careful monitoring is preferred, as angiographic healing occurs in 70-97 % of cases in weeks to months after the acute event. In addition, there are higher rates of PCI complications and bypass graft failure in SCAD compared with MI from CAD. 159, 182 Coronary revascularisation( PCI if feasible, or CABG) is indicated if there is ongoing ischaemia despite medical therapy or in the presence of haemodynamic compromise. 159 In clinically stable patients with SCAD in the left main or severe two vessel proximal dissection, consider CABG or conservative medical therapy. 159
Beta blockers, if tolerated, reduce the risk of recurrence, based on observational study data. 160 Lipid-lowering therapy is not indicated unless there is underlying hyperlipidaemia or a risk factor profile that warrants treatment. 183 Aspirin is recommended lifelong. There is a lack of consensus on the use of aspirin alone or dual antiplatelet therapy( DAPT) in patients conservatively managed. While some treat per ACS, others limit or avoid early
1. Which THREE statements regarding IHD are correct? a Chest pain is the most common symptom. b IHD mortality rates in young women are increasing. c Mounting evidence indicates that flow-limiting stenoses are more common than non-epicardial coronary artery causes of angina. d Factors contributing to sex disparities in treatment include limited awareness of heart disease among women and inaccurate assessment of risk by healthcare professionals.
2. Which THREE are mechanisms of INOCA? a Atherosclerotic CVD. b Coronary microvascular dysfunction. c Vasospasm. d Myocardial bridge.
3. Which THREE are sex-specific risk factors for IHD? a Early menopause. b Socioeconomic deprivation. c Adverse pregnancy outcomes. d Breast cancer treatment.
Box 6. Diagnosis of MINOCA
• Rise and / or fall of cardiac troponin( cTn) with one level above the 99th percentile. Plus
• Ischaemic symptoms / signs. Plus
• Non-obstructive CAD( less than 50 % lesion on angiography).
1. Consider the clinical context and exclude different clinical diagnoses, pulmonary embolism and sepsis.
2. Exclude missed obstruction by re-evaluating the coronary angiogram( significant stenosis / side branch occlusion); exclude other non-ischaemic mechanisms for myocardial injury such as takotsubo syndrome, myocarditis and other cardiomyopathies with ECHO / LV angiogram, and early cardiac MRI. If alternative causes for the clinical presentation and myocardial injury are excluded in steps 1 and 2, a diagnosis of‘ true’ MINOCA can be made. 3. Determine the underlying cause of MINOCA, if possible.
or prolonged DAPT. 159 ACE-I and ARB are indicated in heart failure and hypertension. 160
Assess patients for concurrent arteriopathies. 184 The most commonly involved are renal( 79.7 %) and extracranial carotid arteries( 74.3 %).
Cardiac rehabilitation has demonstrated overall benefit and safety. 185 Encourage a gradual return to pre- SCAD exercise levels as the benefits of regular moderate intensity exercise
How to Treat Quiz. likely outweighs the risks of recurrent SCAD. 186 Avoid clear precipitants, if present( eg, Valsalva). It may be reasonable to recommend avoiding
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4. Which TWO, in addition to symptoms similar to angina with obstructive CAD, may be presenting symptoms in INOCA? a Breathlessness. b Weight loss. c Sleep disturbances. d Syncope.
5. Which THREE are associated with INOCA and ANOCA? a Impaired quality of life. b Higher hospital readmissions. c Reduced mortality d Repeated coronary angiograms.
6. Which THREE are common non-cardiac causes of chest pain? a Appendicitis. b Costochondritis. c Gasto-oesophageal reflux. d Panic attack.
7. Which THREE options may be appropriate in the management of INOCA? a Management of lifestyle and traditional risk factors. b Antianginal therapy. c Anticoagulation. d Reducing or avoiding mental stress.
8. Which THREE are appropriate in the GP management of IHD? a Withold angina treatment pending specialist review. b Lifestyle interventions and optimisation of CV risk factor control. c Pharmacologic secondary prevention with guidelinedirected medical therapy to achieve and maintain treatment targets for BP, lipids and blood glucose. d Full evaluation of ischaemic symptoms, with history, examination and ECG.
9. Which THREE statements regarding MI are correct? a Spontaneous coronary
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Table 2. Antianginal treatment directed to the mechanism responsible for angina
ASCVD
Treatment
Obstructive CAD Effort induced angina:
• HR greater than 80bpm:
• Beta blockers
• Non-dihydropyridine CCBs
• Ivabradine
• Ranolazine
INOCA
Microvascular angina( MVA)
Vasospastic angina( VSA)
Both MVA + VSA
• HR less than 50bpm:
• Dihydropyridine CCBs
• Long-acting nitrate
• Ranolazine
• Nicorandil
• Low BP:
• Ivabradine
• Ranolazine
• Low-dose beta blockers
• Low-dose non-dihydropyridine CCBs
Treatment
Beta blockers: nebivolol 2.5-10mg CCBs: amlodipine 10mg daily ACE-I: ramipril 2.5-10mg daily ARBs Ranolazine: 375mg-750mg bd or 500mg-1g bd
CCBs: amlodipine 10mg, verapamil 240mg SR, diltiazem 90mg bd or 120-360mg od / divided doses Nitrates: isosorbide mononitrate XL 30mg daily Nicorandil: 10mg-20mg bd
CCBs: amlodipine 10mg, verapamil 240mg SR, diltiazem 90mg bd or 120-360mg od / divided doses Nicorandil 10-20mg bd ACE-I: ramipril 2.5-10mg daily ARBs Statins: rosuvastatin 10-20mg
Adapted from Boden WE et al 2023 18, Kunadian V et al 2020 24
ISCHAEMIC HEART DISEASE IN WOMEN
extreme endurance exercise, exercising to exhaustion, elite competitive sports, vigorous exertion in temperature extremes, or lifting / carrying
artery dissection is the most common aetiology of MI in women. b Elevated troponin in women can also be caused by non-MI aetiologies such as takotsubo syndrome, myocarditis and non-ischaemic cardiomyopathy. c Women have a greater risk of major vascular access site complications after PCI for ACS. d The preferred treatment of MINOCA is medical.
10. Which TWO statements are correct? a Spontaneous coronary artery dissection may be mistaken for MI from atherosclerosis and thrombosis. b Aspirin and statins are indicated for all patients with SCAD. c Early surgical intervention is indicated in all cases of spontaneous coronary artery dissection. d Women are generally advised to avoid pregnancy after spontaneous coronary artery dissection because of the risk of recurrence. heavy objects that require straining or prolonged Valsalva. There is a high burden of psychological distress among SCAD patients, which should be addressed.
Rates of recurrent SCAD range from 10 % to 30 % depending on the definition, study design and time to follow-up— 5-20 % at five years, up to 30 % by 10 years. 159 FMD, hypertension and migraine headaches have variably been associated with recurrence. Women are generally advised to avoid pregnancy after SCAD because of the risk of recurrence. 159
CASE STUDY
HARSHITA, a thin 56-year-old South Asian woman presents to her GP complaining of left-sided exertional chest pain( on walking uphill, and which resolves on stopping) for the past year. She has a normal stress test. Her chest pain was felt to be“ due to other causes” and Harshita was treated for H. pylori, which made no difference to her pain.
Her father, a smoker, had an MI at 60. Harshita has no other traditional cardiovascular risk factors: she has a low blood pressure, an LDL of 2mmol / L, is not diabetic and does not smoke. There is no significant past medical history, and menopause occurred at 48.
Harshita undergoes CTCA because of ongoing symptoms. This reveals a coronary calcium score of 17( 10-100 = mild atheroma), a proximal LAD stenosis of less than 25 %, and other coronary arteries normal. A resting echo is normal. INOCA is suspected.
She is started on aspirin and diltiazem. Harshita continues to have exertional chest pain that does not respond to GTN spray. She is referred for invasive functional coronary angiogram. This shows proximal LAD stenosis of less than 25 %, non-significant FFR( greater than 0.8), and evidence of CMD( CFR 2 and IMR 37). Acetylcholine test shows no epicardial spasm.
Harshita is diagnosed with microvascular angina due to CMD. The diltiazem is stopped and a beta blocker started, with an improvement in symptoms.
CONCLUSION
IHD is the second leading cause of death in Australian women. It is under-recognised, under-treated and has a poorer prognosis in women. IHD can be due to obstructive atherosclerotic coronary artery disease and non-obstructive coronary artery disease.
Consider possible cardiac causes in all women presenting with chest pain, and do not label their chest pain as‘ atypical’. In women with recurrent angina but without obstructive CAD, consider ANOCA or INOCA as possible diagnoses, as these are more common in women. In addition, there are diverse causes of MI in women, including atherosclerotic CVD, MINOCA and SCAD. Diagnosing these conditions correctly helps with management as all are associated with major adverse cardiovascular events.
RESOURCES
• Foo, F.‘ How to Treat Cardiovascular risk in women’ bit. ly / 3So6Xvo
References Available on request from howtotreat @ adg. com. au