Kapka Miteva: Why Sex and Gender Matter in Ischemic Heart Disease
Kapka Miteva, Associate Editor at the European Heart Journal, shared a post on LinkedIn:
”Why Sex and Gender Matter – ESC Scientific Statement revealing critical disparities in ischemic heart disease between men and women
Key Findings at a Glance
- Women are underdiagnosed and undertreated due to male-centric diagnostic criteria and guideline biases.
- Symptoms differ: Women more often present with atypical symptoms (fatigue, nausea, back pain) rather than classic chest pain.
- Pathophysiology varies: Women have higher rates of microvascular dysfunction, coronary spasm, and non-obstructive CAD.
- Risk profiles are sex-specific: Pregnancy complications, autoimmune diseases, and hormonal changes uniquely affect women’s cardiovascular risk.
- Outcomes are worse for young women with STEMI, despite less obstructive disease.
- Pharmacological responses differ: Women experience more side effects and different efficacy profiles for common CV drugs.
- Transgender individuals on hormone therapy face distinct cardiovascular risks that are poorly understood.
Critical Data Points
Women with ACS are less likely to receive guideline-recommended therapies (aspirin, statins, beta-blockers).
- Young women (<55) with STEMI have significantly higher mortality than men, even after adjusting for risk factors.
- Microvascular angina and coronary spasm are 2–3 times more common in women.
- 20–30% of participants in CV clinical trials are women, limiting evidence-based care for half the population.
Diagnostic bias: Using male-derived troponin cutoffs leads to underdiagnosis of MI in women.
Treatment gaps: Women are less often referred for invasive procedures (angiography, PCI, CABG)
Research inequity due to dangerous knowledge gap: Most pathophysiology and treatment studies are conducted in men.
Actionable Recommendations
- Adopt sex-specific diagnostic thresholds (e.g., high-sensitivity troponin).
- Increase awareness of non-traditional female-specific risk factors (e.g., preeclampsia, menopause, PCOS).
- Promote inclusion of women in RCTs—aim for equal enrollment and sex-stratified analysis.
- Develop female-focused guidelines for prevention, diagnosis, and management.
- Use advanced imaging (CMR, CT perfusion) to detect microvascular dysfunction in women with angina and non-obstructive CAD.
- Train healthcare providers to recognize sex- and gender-specific presentations and risks.
The Big Picture: Equity in Cardiovascular Care – need for horizontal equity (equal access to care) and vertical equity (tailored care for biological and social differences). Achieving this requires:
- Sex-disaggregated data collection
- Education campaigns
- Policy changes
Collaboration across cardiology, primary care, endocrinology, and obstetrics
How sex and gender shape heart disease could not be ignored!
‘women’s heart health’— focus on precision medicine and equity!”
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