Women and Heart Disease; A Focus Issue

While coronary heart disease (CHD) as a major cause of death among men has been known for almost half a century, it is only in the last 2 decades that CHD is widely recognized as the most common cause of death among women. Clinical studies funded in a large part by the United States National Institutes of Health have revealed major differences in the pathogenesis and presentation of CHD in men and women. It has also become clear that there are real differences in the outcome of CHD in men and women. Some of the differences may relate to hormonal differences in men and women, primarily estrogen levels, which decline rapidly during the menopause. Although estrogen was thought to be the basis of lower prevalence of CHD among women almost since its discovery, it was in mid-1960s when Dr. Robert Watson published the book Feminine Forever and started to promote premarin as an elixir of life that would maintain women’s youthfulness and prevent many of the diseases affecting men like CHD and cancers. Premarin and other estrogen preparations were prescribed in large quantities to keep away the hot flashes and other unpleasant symptoms of menopause. In the 1980s, there were reports of increased risk of cancer of the uterus with estrogen intake. In 2001, the Women’s Health Initiative study showed that estrogens not only did not prevent CHD but actually increased it. Work done by a number of prominent investigators defined not only the role of sex hormones in CHD, but also the role of metabolic syndrome (dyslipidemia, hypertension, altered insulin sensitivity and increase in body weight) in the development of atherosclerosis. At an editorial board meeting of Cardiovascular Drugs and Therapy, Prof. Remme, the Editor-in-Chief, and I thought of putting together a focus issue of the Journal relating to CHD in women and to highlight the differences in men and women with regard to the pathogenesis of atherosclerosis and hypertension, regulation of myocardial blood flow, presentation of this malady, and differences in the treatment, especially the use of pharmacotherapy. Although not a complete encyclopedia on the vast topic of CHD, this issue presents select aspects of CHD in women. Mathur et al. [1] very succinctly but completely discuss the data on various aspects of gender-related differences in atherogenesis with emphasis on the effects of sex hormones, differences in plaque morphology, and vascular endothelial function. Rochlani et al. [2] discuss various aspects of metabolic syndrome-epidemiology of this syndrome in many parts of the world, significant sex disparities in metabolic syndrome components, and genetic and hormonal influences that could impact the development of CHD in women. Cenko and Bugiardini [3], based on their vast experience, write that a large proportion of women have normal coronary arteries on angiography without any significant evidence of flow-limiting disease but have biochemical and/or imaging evidence of myocardial ischemia. In these women, they suggest that it may well be a dysfunction of coronary microcirculation and/or macrocirculation, or vasotonic angina that leads to abnormal vasoconstriction, and potentially to myocardial infarction, ventricular arrhythmias, and sudden death. Epidemiologic studies show differences in left ventricular mass in hypertensive men and women, and left ventricular mass is an independent index of mortality. Wittnich et al. [4] * Jawahar L. Mehta mehtajl@uams.edu