Ischemic Heart Disease and Women: More Answers Are Needed

To the Editor,

Cardiovascular diseases are the leading cause of death among women.¹ Unfortunately, few physicians or patients are conscious of this risk. Consequently, studies such as that carried out by Vidal-Pérez et al. are especially relevant for routine clinical practice.² Nevertheless, some of the results presented should be analyzed in greater depth.

With respect to the patients’ clinical characteristics by sex, the finding that the men were older than the women is surprising, when several registries have shown that women with ischemic heart disease are of more advanced age, since, in general, the onset of the disease in the female population usually takes place after menopause.³ Consequently, further explanation of this finding by the authors would be interesting. Was patient recruitment in the primary care setting rather than in cardiology units of importance? Did the requirement of a history of ischemic heart disease of at least 1 year in order to qualify for inclusion–which would exclude the most seriously ill patients–influence the findings in any way?

Another surprising finding was that, although the men were older and had a higher incidence of previous myocardial infarction and of multivessel disease, the mortality rate and number of hospital admissions were similar in the two sexes. How can these results be explained?

Previous studies have demonstrated that fewer tests to detect ischemia are performed in women, and the same can be said for coronary angiography,³ data that are confirmed in the study by Vidal-Pérez et al.² Explanations for these findings are that, compared with men, in women, myocardial infarction is less common and stable angina is more common as the clinical presentation of heart disease, and that the clinical features tend to be more atypical in women.⁴ Another point is that, in patients with stable angina, percutaneous intervention has not been shown to be superior over the long term when compared with optimal medical treatment.^{5, 6, 7}

Finally, various studies have demonstrated that to reduce mortality from ischemic heart disease, medical treatment (anti-ischemic drugs, surgical/percutaneous revascularization, etc.) is as important as adequate control of cardiovascular risk factors.^{8, 9} Previous studies have reported poorer risk factor control in women with ischemic heart disease, which, over the long term, could contribute to a worse prognosis.³ It would be interesting if the authors showed the degree of control of the various cardiovascular risk factors by sex.

Despite these considerations, studies like that published by Vidal-Pérez et al.² are highly useful. New studies are needed that specifically analyze both the clinical profile and the management of women with ischemic heart disease in Spain. Currently, the SIRENA study (eStudio observacIonal sobre CaRdiopatía isquémica Estable eN lA mujer [Observational Study on Stable Ischemic Heart Disease in Women], whose promoter was Spanish Society of Cardiology) is underway. This study will no doubt provide truly relevant information in this context.

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