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Sex Differences in Non-Obstructive Coronary Artery Disease

Cardiovasc Res. 2020 Jan 20.

Sex Differences in Non-Obstructive Coronary Artery Disease.

Waheed N1, Elias-Smale S2, Malas W3, Maas AH2, Sedlak TL4, Tremmel J5, Mehta PK3.

1 Internal Medicine Residency Program, University of Florida, Gainesville, Florida.

2 Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands.

3 Emory Women’s Heart Center, Emory University, Atlanta, Georgia.

4 Leslie Diamond Women’s Heart Center, University of British Columbia, Vancouver, British Columbia.

5 Division of Cardiology, Stanford University, California.


Ischemic heart disease is a leading cause of morbidity and mortality in both women and men. Compared to men, symptomatic women who are suspected of having myocardial ischemia are more likely to have no obstructive coronary artery disease (CAD) on coronary angiography. Coronary vasomotor disorders and coronary microvascular dysfunction (CMD) have been increasingly recognized as important contributors to angina and adverse outcomes in patients with no obstructive CAD. CMD from functional and structural abnormalities in the microvasculature is associated with adverse cardiac events and mortality in both sexes. Women may be particularly susceptible to vasomotor disorders and CMD due to unique factors such as inflammation, mental stress, autonomic and neuro-endocrine dysfunction, which predispose to endothelial dysfunction and CMD. CMD can be detected with coronary reactivity testing and non-invasive imaging modalities; however, it remains underdiagnosed. This review focuses on sex differences in presentation, pathophysiologic risk factors, diagnostic testing, and prognosis of CMD.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email:


angina; coronary microvascular dysfunction; women


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