Ischaemic heart disease is the second leading cause of death among Australian woman, with around 20 women dying from it each day here. Yet women are less likely to be investigated or diagnosed with heart disease and receive timely treatment compared to their male counterparts – and their outcomes are poorer.

In fact, in 2023 the European Society of Cardiology presented findings that showed women were twice as likely to die after a heart attack than men.

“Multiple studies have shown women are under-diagnosed, under-treated and have worse outcomes,” says clinical and interventional cardiologist Dr Fiona Foo, of Sydney Cardiology Group.

Women experience delays in receiving invasive angiography, reperfusion for STEMIs, and appropriate pharmacotherapy. They also face greater morbidity, including repeat hospitalisations, more angina, and decreased health status, Dr Foo says.

What’s behind the disparity?

It’s multifactorial. Both women and health professionals still think of heart disease, as a male disease, and there’s a lack awareness around what symptoms women present with, Dr Foo says.

Women also tend to have more co-morbidities, socioeconomic risk-factors, and sex-specific risk factors including adverse pregnancy outcomes such as gestational diabetes, gestational hypertension, hypertensive disorders of pregnancy, small for gestational age and premature babies, as well as premature menopause, PCOS, endometriosis; and breast cancer treatment.

Some non-traditional risk factors e.g. autoimmune diseases such as SLE and rheumatoid arthritis, and mental health issues including depression, tend to affect women more and are associated with greater risk of ischaemic heart disease, Dr Foo adds. Additionally, some misperceptions persist.

Chest pain is not ‘atypical’ in women

Dr Foo says it’s time to let go of the ‘atypical’ heart attack terminology. Why? Because chest pain is still the main symptom of ischemic heart disease and the word ‘atypical’ could imply it’s non cardiac, which in turn could lead to delayed diagnosis and treatment.

“There are now guidelines or indications to say that we shouldn’t be calling women’s chest pain atypical. It is not helpful in the diagnosis and can be misinterpreted as being benign in nature,” she says. “The most important thing is that chest pain is the most common symptom for ischemic heart disease.”

Women most commonly present with chest pain, she emphasises, but they are more likely than men to have other accompanying symptoms including shortness of breath, fatigue, sweats, weakness, vomiting or sleep disturbances and nausea.

“Those other symptoms are quite common in women, but the most important thing is that if a woman has chest pain, we should still be thinking whether could this be cardiac,” Dr Foo says

Underlying causes of ischaemia may be different

“Traditionally everyone thinks that angina is due to atherosclerotic obstructive coronary artery disease (defined as an obstructive of 50% or more), but studies have shown that a lot of women who present with angina, who have a coronary angiogram, don’t have obstructive coronary artery disease even though they have ischemia.”

Ischaemic heart disease may be due to obstructive atherosclerotic coronary artery disease or non-obstructive coronary artery disease. Patients with IHD but non-obstructive coronary artery disease may be diagnosed with:

• ischaemia with non-obstructive coronary arteries (INOCA)
• angina with non-obstructive coronary arteries (ANOCA)
• or myocardial infarction with non-obstructive coronary arteries (MINOCA).

INOCA: Ischaemia with Non-Obstructive Coronary Arteries

INOCA occurs when patients present with symptoms like chest pain (either during exertion or at rest) and evidence of ischemia on stress tests (such as MIBI scan or stress echo), yet have non-obstructive coronary arteries on CT coronary angiogram or invasive angiogram.

There are two main mechanisms behind INOCA:

coronary microvascular dysfunction, which is “problems with microvasculature of the coronary arteries – not the ones you can see on an angiogram.”

coronary artery spasm, which “can affect the epicardial arteries and the microvasculature. You get a spasm of the artery that obstructs it as if you’ve got a stenosis in there.”

INOCA/ANOCA is more frequent in women. About 50%-70% of women, compared with 30-50% of men, who undergo coronary angiograms lack angiographic evidence of obstructive CAD.

“It definitely affects females a lot more, and it’s associated with other things like inflammatory diseases, diabetes, hypertension and dyslipidaemia. These are some of the risk factors.”

ANOCA: Angina with Non-Obstructive Coronary Arteries

ANOCA is similar to INOCA, but without evidence of ischemia. “There’s no abnormal stress test, but very similar presentation,” Dr Foo explains.

Both ANOCA and INOCA are associated with a bad prognosis, despite non obstructive coronary arteries.

“Studies have shown increased mortality, morbidity, higher hospital readmissions, and repeated coronary angiograms. And it’s actually also been associated with increased risk of death and further heart attacks, as well as heart failure with preserved ejection fraction, HFpEF, as well as stroke,” Dr Foo explains.

Many also have recurrent chest pain and worse mental health outcomes and quality of life.

MINOCA: Myocardial Infarction with Non-Obstructive Coronary Arteries

MINOCA is another distinct condition where patients experience elevated troponin, ischemic symptoms such as chest pain, and even ECG changes, yet no obstructive coronary artery disease is found on angiogram.

“This can be due to things like plaque rupture or plaque erosion,” Dr Foo says.

Again, it’s more common in women and is associated with significant major adverse cardiac events including death.

Diagnosing non-obstructive coronary conditions

If you can’t see it on a coronary angiogram, how do you make the diagnosis?

If you suspect these conditions, particularly in female patients with recurring chest pain despite normal angiograms, a functional coronary angiogram (also known as coronary physiology studies) can be diagnostic. You can test the microvasculature and assess for microvascular dysfunction using an FFR wire and adenosine. Then you can test for spasm by injecting acetylcholine.

It’s also important to rule out other non-cardiac and non-ischemic causes such as gastritis, she adds.

Management

It’s managed similarly to atherosclerotic cardiovascular disease, Dr Foo says.

Lifestyle modifications and risk factor management are crucial – including exercise, weight management and stress reduction, as well as controlling hypertension, diabetes and dyslipidaemia.

“There’s evidence that ACE inhibitors and statins may improve microvascular function,” Dr Foo says.

Antianginal therapy will depend on the condition.

For microvascular dysfunction, beta blockers are considered first-line therapy, followed by calcium channel blockers and nicorandil if needed.

For vasospastic angina, calcium channel blockers are first-line, due to their ability to prevent coronary spasm. Long-acting nitrates can be added as needed for symptom control.

For patients with MINOCA, “aspirin, statins, and ACE inhibitors or Angiotensin 2 receptor blockers may have some benefit,” Dr Foo says. “And again, with angina, it’s either beta blockers or calcium channel blockers or long-acting nitrates.”

Other cardiac conditions that disproportionately affect women

Two other conditions that are far more common in women than men are SCAD (spontaneous coronary artery dissection) and Takotsubo cardiomyopathy, which is sometimes called broken heart syndrome. Dr Foo says 87-95% of SCAD cases and 90% of Takotsubo cardiomyopathy cases are in women.

SCAD: Spontaneous Coronary Artery Dissection

SCAD is an acute coronary event where an intramural hematoma develops (with or without intimal tear), compressing the true vessel lumen and leading to ischemia and myocardial infarction.

“This dissection plane can occur between any three layers of the artery wall, such as the intima, media, or adventitia. So, they present with a myocardial infarct, they have a troponin leak, they have ECG changes and they have chest pain,” Dr Foo says.

Who is at risk?

SCAD tends to affect younger women with an average age of 45-53, who don’t usually have traditional CVD risk factors.

“Sometimes there’s a bit of an increased prevalence of hypertension and hyperlipidaemia, but in general, they’re young females who have an acute coronary event in the absence of any traditional risk factors.”

That said, a predisposing factor is being pregnant or in the post-partum period.

“SCAD is the main cause of myocardial infarct during pregnancy as well as postpartum,” Dr Foo says.

“Up to two thirds of SCAD cases have precipitating triggers, most commonly extreme emotional or physical stress, recreational drugs or exogenous hormone.”

SCAD is associated with other vascular disorders, fibromuscular dysplasia and auto immune conditions such as SLE, and migraines.

“Women with SCAD should be screened for fibromuscular dysplasia – look at renal arteries and extra cranial carotid arteries,” she adds.

Diagnosis and management

Diagnosis requires careful attention to the coronary angiogram and a high index of suspicion, with three types of SCAD identified based on the angiographic pattern.

“You don’t see an obstruction like a stenosis in the coronary arteries. But you have to look at the angiogram really carefully because you just essentially see a line, where you can see a dissection plane in the coronary arteries,” Dr Foo explains.

In terms of treatment, medical management is preferred. Dr Foo says the dissection generally heals within weeks to months after the event and you would only consider a stent if the patient had ongoing ischemia or hemodynamic compromise.

“These patients should be on aspirin, and beta blockers have been shown to reduce the risk of recurrence,” she says.

“Statins are not indicated unless they have atherosclerotic cardiovascular disease. If they have heart failure, consider ACE inhibitors and angiotensin II receptor blockers.”

“We need to also treat the psychological distress and look for the extracardiac arteriopathies. There is a general advice as well to avoid pregnancy because there is a risk of recurrence in the next pregnancy,” Dr Foo adds.

Takotsubo Cardiomyopathy: “broken heart syndrome”

Takotsubo cardiomyopathy is another condition that affect women predominantly, especially in post menopause.

It is an acute reversible left ventricle dysfunction. Those presenting with it have normal coronary arteries. It is relatively common, making up 1% to 2% of all acute coronary syndromes, and up to 7.5% of female presentations.

Commonly referred to a broken heart syndrome, it’s often triggered by acute emotional or physical stress.

The symptoms are similar to acute coronary syndromes. There can be chest pain, but people often also present as if they have heart failure and a reduced ejection fraction, often with shortness of breath.

Diagnosis and management

Takotsubo cardiomyopathy is diagnosed with a LV angiogram. They have apical akinesis (ballooning) but preserved basal wall motion, which looks like a Japanese crab pot, hence the name.

Most patients recover their LV function within a few months, but there can be complications such as ventricular tachycardia, cardiac arrest, and further major adverse cardiac events, Dr Foo says. There is also around a 2- 5% risk of recurrence.

Treatment is similar heart failure management – ACE inhibitors and ARBs have been shown to improve survival, as well as some of the newer heart failure medications, Dr Foo says.

The moral of the story: women may not necessarily present differently, but a woman’s heart is indeed a different thing.

Key points:

While chest pain is the most common symptom of IHD, women may experience additional symptoms like shortness of breath, fatigue, sweating, weakness, and nausea.

When a woman presents with chest pain, cardiac causes should always be considered rather than dismissing symptoms as “atypical” or non-cardiac in nature.

Non-obstructive coronary artery conditions (INOCA, ANOCA, MINOCA) are significantly more common in women, requiring different diagnostic approaches and treatments than traditional obstructive coronary artery disease.

Female-predominant cardiac conditions like Spontaneous Coronary Artery Dissection (SCAD) and Takotsubo cardiomyopathy (“broken heart syndrome”) require specific identification and management strategies that differ from standard cardiac care.

Women have both traditional risk factors (diabetes, smoking) that affect them more severely than men, and sex-specific risk factors (pregnancy complications, early menopause, autoimmune conditions) that often go unrecognised in cardiac risk assessments.

This article was based on a podcast Dr Fiona Foo recorded with Dr Terri Foran. It has been reviewed by Dr Foo. Listen to the full podcast here.