Cardiovascular disease is the leading cause of death
among women in Singapore. In particular, Ischaemic heart disease
(IHD) is a form of cardiovascular ailment that develops 10 years
later in female patients — a process that is not avoided, but merely
delayed.
Symptoms among women
Female patients more often report
atypical symptoms such as epigastric
discomfort, nausea, dyspnoea and
fatigue. This non-specific clinical
presentation renders evaluation of
symptoms and the precision of
ascertaining the likelihood of
obstructive Coronary Artery Disease
(CAD) difficult.
Investigation of cardiac
disease in women
Did You Know?
World Heart Day
falls on 29 September!
Cardiology services are available at Tan Tock Seng Hospital. For appointments, GPs should call 6359 6500.
Women at low risk of IHD generally do
not require further diagnostic testing.
Female patients at intermediate-risk
levels should undergo an exercise
electrocardiogram. Women at
intermediate — high risk levels,
however, should undergo stress imaging or cardiac computerised
tomography. Coronary computed
tomography angiography can identify
women with non-obstructive CAD at
increased risk of events, who benefit
from risk factor modification and
medical therapy. Among women, the spectrum of CAD includes coronary
microvasculature and endothelial
dysfunction, vasospasm and dissection.
These should be considered when
investigating chest pains.
Management of
CAD in women
Women have worse outcomes with higher
in-hospital mortality in acute coronary
syndrome. This is attributed to longer
patient delay before presentation, older
age, less aggressive treatment, and
higher bleeding complications. Transradial
access for coronary interventions
reduces incidence of bleeding
complications, and improves clinical
outcomes. Recent trials examining
drug-eluting stent placement in men and
women have found similar outcomes.
However, the female sex presents a risk
factor for morbidity and mortality among
patients undergoing coronary artery
bypass grafting.
The prognosis of symptomatic women
who have non-obstructive CAD was
initially thought to be benign. The risk of
cardiovascular events is higher than
asymptomatic women. Statins and
angiotensin-converting enzyme inhibitors
have shown improvement in endothelial
function and symptoms. Chest pain is
treated effectively with beta-blockers,
and ranolazine shows promise.
Conclusion
CAD is the leading cause of mortality in
women. Atypical presentation patterns
should not detract the physician from
managing risk factors appropriately and
arranging further investigation. Women
with ACS benefit as much from coronary
intervention and drug-eluting stents,
and should be treated as intensively as
men. More research into genderspecific
treatment will help guide
future management.
By Dr Deanna Khoo, Consultant, Department of Cardiology, Tan Tock Seng Hospital
