Pro: Newly appreciated pathophysiology of ischemic heart disease in women mandates changes in perioperative management.

Amanda A. Fox, MD Cardiovascular disease is the leading killer of women in the developed world. In the United States alone, approximately 220,000 women die annually from causes related to ischemic heart disease (IHD), whereas another 7.3 million women live chronically with this condition. Many of these women are likely to undergo cardiac or noncardiac surgeries that may alter systemic inflammatory and coagulation cascades, algesic pathways, and cardiovascular responses in ways that increase cardiovascular risk. Fortunately, as described in this issue’s thorough review by Matyal, there is an exciting and evolving body of research that is identifying gender-related differences in the manifestation and physiology of cardiovascular disease, particularly IHD. It is now the responsibility of anesthesiologists and other perioperative physicians to become increasingly aware of the research that is defining the pathophysiology of IHD in women and to use this awareness both to implement changes in current perioperative management practices and to motivate researchers along investigative tracks that can capitalize upon gender differences to identify new medical interventions that may benefit future perioperative management. Based on presently available data, one way by which anesthesiologists are likely to have a significant impact on perioperative cardiovascular risk reduction is through better preoperative identification of women with probable IHD. Despite the fact that IHD is a leading health problem in women, many women perceive cancer and not IHD as their major health concern. Furthermore, women’s symptoms during myocardial ischemia or infarction (MI) often differ substantially from those observed in men. These factors may account at least in part for the fact that, despite having a IHD prevalence similar to men, women are generally less likely than men to undergo diagnostic and therapeutic procedures related to IHD. The combination of these variables suggests that a significant number of women presenting for preoperative assessments may have undiagnosed IHD that warrants further work-up, medical management, and possible coronary revascularization before they undergo their scheduled surgeries. The fact that women often describe different symptoms with myocardial ischemia or MI when compared with men also has important implications for early identification of women who experience postoperative MI. In a retrospective survey of more than 500 ambulatory women who experienced an acute MI, 43% of women described no chest pain at all, whereas their most commonly reported symptom was shortness of breath. Therefore, it seems reasonable that myocardial ischemia or MI should be high on the differential when perioperative physicians evaluate women having increased shortness of breath preor postoperatively. The American Heart Association (AHA)/American College of Cardiology’s (ACC) 2004 Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women provide anesthesiologists with a valuable resource for From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Accepted for publication February 13, 2008. Address correspondence and reprint requests to Amanda A. Fox, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. Address e-mail to afox@partners.org. Copyright © 2008 International Anesthesia Research Society DOI: 10.1213/ane.0b013e3181706c3d