“Cardiovascular disease is still the leading cause of death for women, and in fact we are no longer making gains in cardiovascular mortality for both men and women. And the fastest growing death rate is for women. middle-aged,” Michos said.

She said cardiac computed tomography (CT) calcium scoring is a good way to do a baseline assessment of heart attack risk over 10 years in women. This can help determine if a patient should be put on statin and aspirin preventive therapy.

“It is important to note in terms of gender differences, although females have a lower prevalence of calcium at any given age compared to males. Whenever calcium is present, it actually carries a higher prognostic risk in women than in men,” she explained.

On coronary artery angiography (CCTA), she said women often have plaque, but it’s usually non-obstructive plaque in the setting of angina. However, non-obstructive disease is still strongly associated with major adverse cardiovascular events in both men and women. In women, all high-risk plaques confer a higher risk than in men. Non-obstructive left main coronary artery disease is also associated with a higher risk of a cardiac event in women.

Michos said doctors need to pay more attention to symptoms in women.

“Women are more likely to have angina than men, but in the setting of angina, women are more likely to have non-obstructive disease,” Michos explained. “We did such a disservice for years when women had signs and symptoms of ischemic heart disease and even positive stress tests. They would have a CTA or an angiogram and it would show no obstruction and they would be told:” Oh, that’s a false positive, you’re fine.'”

She said studies had shown that was not the case and that many women actually suffered from a condition now known as ischemia and not obstructive coronary artery disease (INOCA). Women tend to have smaller arteries than men, so smaller amounts of plaque volume can actually cause INOCA-associated ischemia.

“INOCA is not only associated with the risk of major adverse cardiovascular events, but even when compared to patients with obstructive disease, there may be a similar angina burden, a similar reduced quality of life, as well as a similar number of ischemic segments on stress imaging. , it is important that this be recognized because these women deserve a diagnosis. Their symptoms are often overlooked, and it is important that we take their symptoms seriously so that we can make them take preventive agents such as statins and ARBS, and we can get them to give things to control their symptoms, such as calcium channel blockers, nitrates and beta-blockers.”

Once you’ve ruled out the obstruction on imaging, you can estimate coronary blood flow reserve, she said. “The artery should be able to dilate twice its normal size, but if it’s not, and its coronary flow reserve is less than 2, then that’s a really unfavorable marker for future events. and that is part of the diagnosis of coronary microvascular dysfunction (CMD),” Michos said.

Spontaneous coronary artery dissection (SCAD) is another condition found in women at a much higher rate than men. This condition is where the layers of a coronary vessel can tear and hanging tissue in the vessel can block blood flow. There have been several sessions at SCCT on this condition and what to look for in CT imaging. It often presents as STEMI or non-STEMI on the ECG and there are elevated troponins, so these patients are often taken to the cath lab with the belief that it is a heart attack. Michos said invasive angiograms are still the recommended first-line imaging test for SCAD because it has better image resolution inside the vessel. If a patient presents later, SCAD can be seen on a better quality coronary CT scan.

Up to 60-70% of people who have SCAD may have fibromuscular dysplasia (FMD), so she said it’s important to do a CT scan from the head to the pelvis to look for other areas of foot-and-mouth disease. and aneurysms.

She also said there are other factors that also increase the risk of heart disease in women, including early menopause, adverse pregnancy outcomes including preeclampsia, and autoimmune diseases such as rheumatoid arthritis. lupus.