Microvascular Dysfunction

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Recently, there has been renewed interest in micro-vascular dysfunction in women. Of note, women have smaller epicardial arteries than men, independent of body size.15 Women taking androgens have much larger arteries than control women, and andro-gen-deprived men have smaller arteries than control men.16,17 Moreover, male patients who have received transplanted female donor hearts show progressive epicardial vessel enlargement independent of body size.18 However, there is no change in vessel size for male hearts transplanted into women. These findings suggest that sex hormones have a unique effect on arterial remodeling. Much is still unknown regarding this effect.

Most women undergoing cardiac catheterization for chest pain have minimal coronary artery disease (CAD).19 However, many of these women have abnormal stress test findings and continue to have

Table 8-2.

Long-Term (1-Year) Outcome of PCI by Gender

Study (Year)

No. Women/No. Men

Women (%)

Men (%)

Adjusted OR (95% CI)

Jacobs (2002)

895/1,629

Death

6.5

4.3

1.26 (0.85-1.87)

Death/MI

11.1

9.0

1.14 (0.86-1.50)

Lansky (2002)

2,077/5,295

Death

4.4

3.3

MACE

29.2

32.7

Mehili (2000)

1,001/3,263

Death

4.0

4.1

0.99 (0.54-1.13)

MACE

6.0

5.8

Chiu (2004)

5,301/12,738

Death

7

5

1.14 (0.93-1.41)

MACE

1.05 (0.97-1.13)

*No difference between genders noted; however, OR was not reported.

CI, confidence interval; MACE, major adverse cardiac events; MI, myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention.

*No difference between genders noted; however, OR was not reported.

CI, confidence interval; MACE, major adverse cardiac events; MI, myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention.

□ Female □ Male —Linear (Male) —Linear (Female)

□ Female □ Male —Linear (Male) —Linear (Female)

Figure 8-1. One-year unadjusted mortality rates after percutaneous coronary intervention in women and men between 1992 and 2002 at The Cleveland Clinic Foundation. (From Chiu JH, Bhatt DL, Ziada KM, et al: Impact of female sex on outcome after percutaneous coronary intervention. Am Heart J 2004; 148:998-1002.)

Figure 8-1. One-year unadjusted mortality rates after percutaneous coronary intervention in women and men between 1992 and 2002 at The Cleveland Clinic Foundation. (From Chiu JH, Bhatt DL, Ziada KM, et al: Impact of female sex on outcome after percutaneous coronary intervention. Am Heart J 2004; 148:998-1002.)

symptoms. Innovations in the technique of phos-phorus-31 nuclear magnetic resonance (NMR) spectroscopy have shed light on this issue. Phosphorus-31 NMR can monitor myocardial high-energy phosphates, phosphocreatine, and adenosine triphosphate (ATP) after stress. A transient decrease in the ratio of myocardial phosphocreatine to ATP during exercise indicates myocardial ischemia. In the National Institute of Health-National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study, 20% of women with chest pain and minimal CAD had evidence of myocardial ischemia with a decreased phos-phocreatine/ATP ratio with exercise.20 The magnitude of ischemia in these women was equal to or greater than that in patients with 70% stenosis of the left anterior descending coronary artery.20 Myocardial ischemia in these women is most likely caused by microvascular smooth muscle cell dysfunction and endothelial dysfunction. Vascular testing with aden-osine or nitroprusside infusion has shown smooth muscle cell dysfunction, and testing with endothe-lium-dependent vasodilators such as acetylcholine has shown endothelial dysfunction in these women.21 Patients with microvessel dysfunction have higher risk for death or MI.21

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