Clinical Profile of Young Women with CAD
abstract & commentary
Synopsis: Hyperlipidemia and the postmenopausal state were most commonly associated with young women who have CAD.
Source: Gurevitz O, et al. Am J Cardiol 2000;85:806-809.
Since young women have been identified as a group in whom the misdiagnosis of acute ischemic heart disease syndromes can often occur, Gurevitz and associates examined clinical data on 135 women younger than age 50 who were referred for coronary angiography because of chest pain. Catheterization revealed coronary artery disease (CAD) in 79, whereas 56 had no significant CAD. After a two- to seven-year follow-up, the patients’ charts were examined. The mean age of 45 years was the same for both groups. Previous myocardial infarction (MI), hyperlipidemia, and postmenopausal state without hormone replacement were significantly more common in the women with CAD. Among the 61 women who had a stress test before the catheterization, positive or negative studies did not identify those with CAD. Of the 56 women with no significant CAD, 88% had completely normal coronary arteries. Most of the women with significant CAD had single-vessel disease (61%). Revascularization was performed in 82% of the women with CAD. During the mean follow-up of 45 months, three women had acute MI and five died. All of these women had CAD. Congestive heart failure and subsequent revascularization were also more common during follow-up in the women with CAD, but there was no difference in admissions for chest pain. Gurevitz et al conclude that hyperlipidemia and the postmenopausal state were most commonly associated with young women who have CAD. Unfortunately, noninvasive testing does not accurately identify those with CAD, suggesting that a more invasive approach is preferable in women with risk factors for CAD.
Comment by Michael H. Crawford, MD
Although this study represents the women who made it through the triage process and underwent cardiac catheterization, it sheds some light on which young women are more likely to have CAD and thus should be more aggressively diagnosed. Not surprisingly, hyperlipidemia and the postmenopausal state were most predictive of the presence of CAD among these women with chest pain. Somewhat surprisingly, other risk factors such as smoking, diabetes, and hypertension were not predictive. Undoubtedly, this had something to do with the selection process. In our hospital, we pay more attention to young women with chest pain and any risk factors.
The incidence of CAD was high in this cohort (58%), which again must be due to the selection process. Epidemiological studies have suggested that CAD in women younger than age 50 is still unusual. The fact that most of the CAD was single-vessel disease is not surprising, but I was surprised that the left anterior descending was the most commonly involved vessel, since LAD disease is usually the most readily detected by noninvasive tests. With the high incidence of CAD in this group of women, it is remarkable that stress testing did not do a better job of detecting CAD. Of course, this has been reported before, but usually in less selected groups where you would expect more false negatives. It is a tribute to the clinical acumen of these physicians that they persevered and did catheterization on these women with negative stress tests. This would be hard to do in the United States (the study was done in Israel).
The message here is that young women who present with chest pain and have risk factors for CAD, especially hyperlipidemia and the postmenopausal state, should be managed aggressively, with cardiac catheterization being seriously considered. (Dr. Crawford is Robert S. Flinn Professor, Chief of Cardiology, University of New Mexico, Albuquerque, NM.)
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