Cardiovascular disease is the greatest killer of women in the developed world,1 and CHD is the largest single cause of death in the UK in both men and women.2
Assessing chest pain
Stable angina is the most common presentation of CHD in women. A careful history is the foundation of the diagnosis of chest pain, assessing the location, character, duration and exacerbating factors related to the symptoms.
Typically, the chest pain is centrally located around the sternum, but it may present anywhere between the jaw and epigastrium. It can be described as a pressure, tightness and heaviness, and sometimes strangling, constricting and burning. Often, it is associated with shortness of breath.
Less specific associated symptoms include fatigue, faintness, nausea and restlessness. Although the duration is typically short (no longer than 10 minutes), chest pain lasting only seconds is likely to be related to non-cardiac causes.
An important characteristic is a relationship to exercise, exertion or emotional stress, with increased symptoms related to increased intensity of exertion.
Symptoms typically resolve rapidly following the end of the exacerbating factor, or treatment with sublingual nitrate.
Until recently, the presenting symptoms were considered to be different in men and women, with women more often presenting with atypical angina, but evidence now suggests a remarkable similarity between angina symptoms described by both sexes in obstructive coronary artery disease.3
This study found that women tended to use similar language to men in describing their symptoms, but also used additional terms such as discomfort, crushing, pressing or bad ache. Associated symptoms were similar between the sexes, but women related their angina to a dry mouth, whereas men did not.
The definitions and characteristics of typical and atypical chest pain are described in table 1.
Angina that is typical but occurs without exacerbating factors may indicate coronary vasospasm, whereas angina occurring some time after an exacerbating factor, such as exertion, with no response to sublingual nitrate, may indicate microvascular angina.4
|Table 1 Classification of chest pain4|
Meets all three of these characteristics:
Meets two of these characteristics
Non-anginal chest pain
Lacks or meets only one or none of these characteristics
After characterising the chest pain as described above, it is advisable to take a careful medical history, considering not only the presence of typical risk factors for CHD, particularly checking for hypertension because elevated BP is a powerful predictor of CHD in women, but also taking a gynaecological history. There are no specific signs for myocardial ischaemia, but a physical examination is important to assess for anaemia, elevated BP, valvular heart disease, hypertrophic cardiomyopathy, arrhythmia, elevated BMI and non-coronary vascular disease.
Other important comorbidities to look for are diabetes mellitus, or renal and thyroid disease.4
Typically, women are nine to 10 years older than men at first presentation of atherosclerotic CHD,5 relating to the number of years that have passed since the average menopausal age.
Negative changes in cardiovascular disease risk factors are coincident with the menopause, albeit natural or surgical, that are at least in part related to the decline in ovarian hormone concentrations in women at this time of life.
Postmenopausal hormone therapy is not currently recommended for CHD prevention or treatment and should be prescribed on an individual basis, depending on need.
Other female-specific factors that may affect atherosclerotic cardiovascular disease risk may include oral contraceptive use, history of polycystic ovary syndrome (PCOS), hypertensive pregnancy disorder and gestational diabetes.
Oral contraceptive use
It is generally accepted that the risk of venous thromboembolism is elevated in oral contraceptive users, although the increase in absolute risk is low.
However, the evidence for an association between oral contraceptives and risk of cardiovascular disease is inconsistent. Two large studies from the UK and the US found no increase in cardiovascular disease mortality in ever-users of oral contraceptives, compared with never-users.6,7
Conversely, a large study in Denmark showed a positive association between oral contraceptives and MI over a 15-year period, especially with higher doses of estrogen.8 In older women (aged over 35 years) with hypertension, diabetes, smoking, nephropathy or other vascular diseases including migraine, oral contraceptives are not recommended. Oral contraceptives can raise BP in normotensive women, so this should be measured in all women before prescribing and at follow-up.
Polycystic ovary syndrome
PCOS is multifaceted, encompassing abnormalities of the reproductive (oligo-ovulation or anovulation, elevated androgen levels, polycystic ovaries), metabolic (insulin resistance, impaired glucose tolerance, type 2 diabetes, obesity) and cardiovascular (hypertension, vascular dysfunction, CHD) systems.9
In one study, the risk of CHD was more than fivefold higher compared with a reference population without PCOS,10although whether the clustering of CHD risk factors in PCOS translates into an increase in cardiovascular events is unclear.
Disorders in pregnancy
In normal pregnancy, several metabolic factors are temporarily increased, such as insulin resistance and lipid levels, as well as coagulation and inflammatory factors.
In women who develop hypertensive pregnancy disorders or gestational diabetes, this physiological response is disturbed, leading to vascular endothelial dysfunction in both the uterine and the maternal circulation.
The Cardiovascular Health After Maternal Placental Syndromes (CHAMPS) study, a population-based cohort study of 1.03m healthy women, showed the risk of premature cardiovascular disease was doubled in women who had any gestational complication.11 Rather than there being a direct causal relation between maternal placental disorders and future cardiovascular disease, the authors suggest that abnormalities pre-dating pregnancy then continue postpartum.
Several epidemiological studies show a positive association between pre-eclampsia and increased risk of cardiovascular disease.12
Gestational diabetes mellitus confers a four- to sevenfold higher risk of type 2 diabetes and the development of metabolic syndrome in midlife. Women with a history of gestational diabetes have a higher risk of CHD, MI and stroke.
Women are 50% more likely than men to have unobstructed epicardial coronary arteries on coronary angiography.4
This fact may influence the evaluation and management of women presenting with chest pain symptoms, with health professionals taking women presenting with angina less seriously. However, recent studies show that these patients are at increased risk of a coronary event, even though their risk is reduced compared with women who have significant atherosclerotic coronary disease.
An intravascular ultrasound study of the coronary arteries of women with stable chest pain and unobstructed epicardial coronary arteries showed a high prevalence of atheroma with positive remodelling and normal lumen size.13
In these patients, it is important to identify and manage any risk factors for CHD according to the guidelines,1 counselling on a healthy lifestyle, together with treating the chest pain symptoms.
Patients should be made aware that their risk of CHD can be reduced by not smoking, being active, avoiding being overweight, and by having a BP and blood cholesterol check. The main recommendations for the prevention of CHD are the same for men and women:
- BMI <25
- Regular moderate to vigorous physical activity (or being as active as possible in more sedentary patients)
- Healthy diet – moderate alcohol consumption, restricted salt, increased intake of fruit and vegetables, dairy products in moderation, fish twice a week
Dr Webb is a research fellow in vascular biology and Professor Collins is professor of clinical cardiology at the National Heart and Lung Institute, Imperial College London, and Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust
|Key learning points|
- Perk J, De Backer G, Gohlke H et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J 2012; 33(13): 1635-701
- British Heart Foundation. Cardiovascular disease statistics 2014. London, BHF, 2014
- Kreatsoulas C, Shannon HS, Giacomini M et al. Reconstructing angina: cardiac symptoms are the same in women and men. JAMA Intern Med 2013; 173(9): 829-31
- Montalescot G, Sechtem U, Achenbach S et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013; 34: 2949-3003
- Anand SS, Islam S, Rosengren A et al. Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J 2008; 29(7): 932-40
- Charlton BM, Rich-Edwards JW, Colditz GA et al. Oral contraceptive use and mortality after 36 years of follow-up in the Nurses’ Health Study: prospective cohort study. BMJ 2014; 349: g6356
- Hannaford PC, Iversen L, Macfarlane TV et al. Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners’ Oral Contraception Study. BMJ 2010; 340: c927
- Lidegaard O, Lokkegaard E, Jensen A et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med 2012; 366(24): 2257-66
- Ehrmann DA, Liljenquist DR, Kasza K et al. Prevalence and predictors of the metabolic syndrome in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2006; 91(1): 48-53
- Dahlgren E, Janson PO, Johansson S et al. Polycystic ovary syndrome and risk for myocardial infarction. Evaluated from a risk factor model based on a prospective population study of women. Acta Obstet Gynecol Scand 1992; 71(8): 599-604
- Ray JG, Vermeulen MJ, Schull MJ et al. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet 2005; 366: 1797-803
- Ahmed R, Dunford J, Mehran R et al. Pre-eclampsia and future cardiovascular risk among women: a review. J Am Coll Cardiol 2014; 63(18): 1815-22
- Khuddus MA, Pepine CJ, Handberg EM et al. An intravascular ultrasound analysis in women experiencing chest pain in the absence of obstructive coronary artery disease: a substudy from the National Heart, Lung and Blood Institute-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). J Interv Cardiol 2010; 23(6): 511-19