The dynamic development of cardiology and the growing interest in the relationship between gender and the pathogenesis and management of cardiovascular disease have revealed significant discrepancies regarding, among other things, the clinical manifestation and course of ischaemic heart disease in women and men. In recent publications, there is a tendency to distinguish between the so-called male and female patterns of ischaemic heart disease, including acute coronary syndromes (ACS). In women, the prognosis is more severe than in men. In the female population, ACS have a higher risk of complications and pose numerous diagnostic and therapeutic difficulties. According to the World Health Organisation (WHO), one woman dies every six minutes from cardiovascular disease in Europe.
Acute coronary syndromes
Ischaemic heart disease (CAD) consists of stable coronary syndromes and acute coronary syndromes (ACS). Based on ECG, a distinction is made between non-ST-segment elevation ACS and ST-segment elevation ACS.
ACS without ST-segment elevation
This is a clinical syndrome underlying a fresh or increasing restriction of blood flow through the coronary artery (so-called unstable angina - UA). In some patients, this leads to myocardial necrosis without fresh ST-segment elevation on ECG recording (i.e. non-ST-segment elevation myocardial infarction - NSTEMI).
ST-segment elevation myocardial infarction (STEMI)
A clinical syndrome usually caused by closure of a coronary artery and stoppage of blood flow through it, resulting in myocardial necrosis (with an increase in necrosis markers in the blood and persistent ST-segment elevation on ECG).
Despite the continuous development of diagnostic and therapeutic methods, the annual mortality rate after myocardial infarctions is 26 per cent in women and 19 per cent in men. Within five years after an episode of ACS, 47 per cent of women and 36 per cent of men died.
According to available data, myocardial infarction is the leading cause of disability and death worldwide.
Ischaemic heart disease - male pattern, female pattern
The American Heart Association (HTA) has issued recommendations for the prevention of cardiovascular disease in women. The members of the HTA also produced the first comprehensive study of myocardial infarction in women, taking into account (gender-dependent) differences in, among other things, epidemiology, clinical presentation, course and therapeutic management. Abnormalities that may worsen the prognosis of female patients with fresh myocardial infarction were also identified.
Two types of ischaemic heart disease were distinguished. The male pattern is primarily associated with the presence of critical coronary artery stenosis (which is less commonly found in women). The female CAD pattern consists of atypical symptoms, normal coronary arteries (no significant coronary lesions on coronary angiography) and positive results on non-invasive tests (assessing myocardial ischaemia). Underlying the condition may be coronary microvascular dysfunction, which represents the first phase of atherosclerotic lesions in the coronary vessels.
The knowledge of (gender-related) differences in risk factors, clinical presentation and response to treatment of cardiovascular disease makes it possible to develop new diagnostic and therapeutic regimens - for women and for men. However, a problem is the low representation of women in the most important clinical trials on the basis of which standards of medical management are set (it is estimated that the proportion of women in trials influencing the formulation of recommendations is only 15-40 per cent).
Cardiovascular risk factors in women
Clinical and epidemiological studies show that women with ACS, more often than men, are diagnosed with comorbidities (and other burdens). Risk factors typical of the female population such as menopause or complications of pregnancy (gestational diabetes, eclampsia, pregnancy-induced hypertension) should not be forgotten.
Coronary syndromes and the age of women
Acute coronary syndromes are more likely to occur in older patients - age being one of the most important non-modifiable risk factors in the female population. There is a significant increase in incidence after 60 years of age; the average age of onset in women is 71.8 years (women become ill 13 years later than men). The favourable difference for women is usually explained by the cardioprotective effect of premenopausal oestrogens. Estrogens beneficially modulate vascular endothelial function and show vasodilatory effects. They also decrease angiotensin receptor synthesis, increase nitric oxide and prostaglandin synthesis and inhibit vascular smooth muscle proliferation and endothelial cell apoptosis. In the postmenopausal period, the protective effect of endogenous oestradiol ceases, which may contribute to the development of atherosclerotic lesions in epicardial coronary arteries.
However, it should be emphasised that no type of hormone replacement therapy (HRT) is currently recommended for coronary risk reduction.
Young women using hormonal contraception (reports are not consistent) and patients with premature menopause are also at potentially higher risk of an acute coronary incident.
Cigarette smoking and coronary heart disease
One of the main risk factors for coronary heart disease is smoking, which increases the risk of the disease by 7 times (especially in young female patients). The risk of myocardial infarction increases 3-fold in obese patients.
Cardiovascular diseases
- Diabetes increases the risk of ACS 5-fold and significantly worsens early prognosis.
- Hypertension in the female population is associated with a 3-fold higher risk of death from cardiovascular causes (increases the risk of ACS by 30 per cent).
- Depression and psychosocial factors can increase the risk of myocardial infarction in women by up to 50 per cent.
CAD and ACS in women - clinical picture
Physical examination and physical examination are still crucial in the diagnosis of ischaemic heart disease. In women, this condition is more likely to present with atypical or sparse symptoms, which complicates the diagnostic process, delays the implementation of optimal therapy and worsens prognosis.
Symptoms of ischaemic heart disease
Symptoms considered typical such as retrosternal, resting pain are less common in women. In the female population, atypical chest pain (acute, pleuritic type, burning, pruritus) is more common; the equivalent of coronary pain (e.g. back pain, neck pain, jaw pain, arm and shoulder pain, abdominal pain, fatigue, dyspnoea, weakness, anxiety, dyspeptic symptoms) is also more common. The complaints may be variable, recurrent and persist for a long time before the incident. Consequently, women with symptoms of ischaemic heart disease present for help four times later than men; female patients are also less likely to qualify for coronary angiography or invasive treatment.
Findings show that women with ACS are more likely than men to be diagnosed with unstable angina or non-ST-segment elevation myocardial infarction (ST-segment elevation myocardial infarction is more common in the male population). Women are less likely to have a release of myocardial necrosis markers.
Secondary prevention after myocardial infarction
Secondary prevention after acute coronary syndromes includes prevention of further incidents and improvement of prognosis. Successful programmes should therefore not only include proper peri-infarction management, but also offer follow-up (outside the hospital) medical care, rehabilitation, education and promotion of health-promoting behaviour.
