​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 of Heart Disease 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

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- to 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.

How to Manage CAD in Women 

Women have worse outcomes with higher in-hospital mortality in acute coronary syndrome (ACS). This is attributed to longer patient delay before presentation, older age, less aggressive treatment, and higher bleeding complications. Transradial access for coronary interventions reduces the incidence of bleeding complications and improves clinical outcomes. Recent trials examining drug-eluting stent placement in men and women have found similar outcomes. However, being female 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. Chest pain is treated effectively with beta-blockers, and ranolazine shows promise.

CAD is the leading cause of mortality in women. Atypical presentation patterns should not detract the doctor 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 gender-specific treatment will help guide future management.