Up to 50% of the patients undergoing coronary angiography present no epicardial disease. Most of these patients are women. Takotsubo cardiomyopathy, coronary microvascular dysfunction, and spontaneous coronary artery dissection are the most common syndromes that affect these patients. Their mechanisms are complex, with a interplay between neurohormonal factors and a number of other systems. The present review describes how changes in the estrogen state may lead to changes in vasomotor tone and endothelial dysfunction which result in coronary epicardial and microvascular spasm and coronary arterial wall instability in these three conditions. The sex-dependent differences in prevalence, pathogenesis, and prognosis are described.
JespersenL, HvelplundA, AbildstrømSZ, PedersenF, GalatiusS, MadsenJK, et al.Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J. 2012;33(6):734–44.
2.
SharafB, WoodT, ShawL, JohnsonBD, KelseyS, AndersonRD, et al.Adverse outcomes among women presenting with signs and symptoms of ischemia and no obstructive coronary artery disease: Findings from the National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE) angiographic core lab. Am Heart J. 2013;166(1):134–41.
3.
PalmeriniT, Biondi-ZoccaiG, Della Riva D, MarianiA, Sabate M, SmitsPC, et al.Clinical outcomes with bioabsorbable polymer- Versus durable polymer-based drug-eluting and bare-metal stents: Evidence from a comprehensive network meta-analysis. J Am Coll Cardiol. 2014;63(4):299–307.
4.
NegliaD, RovaiD, CaselliC, PietilaM, TeresinskaA, Aguade-BruixS, et al.Detection of Significant Coronary Artery Disease by Noninvasive Anatomical and Functional Imaging. Circ Cardiovasc Imaging. 2015;8(3).
5.
SafdarB, D’OnofrioG. Women and chest pain: Recognizing the different faces of angina in the emergency department.
Yale J Biol Med. 2016;89(2):227–38.
6.
ParkYM, HanSH, KoK-P, KohKK, KangWC, LeeK, et al.Diffuse multi-vessel coronary artery spasm: Incidence and clinical prognosis. Int J Cardiol. 2012;167(2):398–402.
7.
PaulTK, SivanesanK, Schulman-MarcusJ.
Sex differences in nonobstructive coronary artery disease: Recent insights and substantial knowledge gaps. Trends Cardiovasc Med. 2017;27(3):173–9.
8.
OrphalD, GoriT.
The influence of sex on microvascular function. Clin Hemorheol Microcirc. 2017;64(3):267–72.
9.
AzizA, HansenHS, SechtemU, PrescottE, OngP. Sex-Related Differences in Vasomotor Function in Patients With Angina and Unobstructed Coronary Arteries. J Am Coll Cardiol. 2017;70(19):2349–58.
10.
DuarteC, NapoleãoP, FreitasT, SaldanhaC.
An ex vivo study of nitric oxide efflux from human erythrocytes in both genders. Clin Hemorheol Microcirc. 2016;64(4):951–5.
11.
LanzaG a, PedrottiP, PasceriV, LucenteM, CreaF, Maseria. Autonomic changes associated with spontaneous coronary spasm in patients with variant angina. J Am Coll Cardiol. 1996;28(5):1249–56.
12.
FineschiM, GuerrieriG, OrphalD, PalmeriniE, MunzelT, WarnholtzA, et al.The impact of gender on fractional flow reserve measurements. Eurointervention. 2013;9(3):360–6.
13.
GhadriJ-R, WittsteinIS, PrasadA, SharkeyS, DoteK, AkashiYJ, et al.International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018;(June):1–15.
14.
ScantleburyDC, PrasadA, RabinsteinAA, BestPJM.
Prevalence of migraine and raynaud phenomenon in women with apical ballooning syndrome (Takotsubo or Stress Cardiomyopathy). Am J Cardiol. 2013;111(9):1284–8.
15.
SchnabelRB, WildPS, SchulzA, ZellerT, SinningCR, WildeS, et al.Multiple endothelial biomarkers and noninvasive vascular function in the general population: The gutenberg health study. Hypertension. 2012;60(2):288–95.
16.
MuxelS, RadmacherMC, SchäferS, DamaskeA, MünzelT, GoriT. Changes in endothelial function in healthy volunteers during soccer World Cup 2010 games. Int J Cardiol. 2011;152(3):395–6.
17.
SudhirK. Estrogen Supplementation Attenuates Glucocorticoid and Catecholamine Responses to Mental Stress in Preimenopausal Women. 1999;84(2):606–10.
DračaS. A possible relationship between Takotsubo cardiomyopathy and female sex steroid-related modulation of functional cerebral asymmetry. Med Hypotheses. 2015;84(3):238–40.
Pérez-CastellanosA, Martínez-SellésM, Mejía-RenteríaH, AndrésM, SionisA, Almendro-DeliaM, et al.Tako-tsubo Syndrome in Men: Rare, but With Poor Prognosis. Rev Esp Cardiol. 2017;71(9):703–8.
HayesSN, KimESH, SawJ, AdlamD, Arslanian-EngorenC, EconomyKE, et al.Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018;137(19):e523–557.
24.
ElkayamU, JalnapurkarS, BarakkatMN, KhatriN, KealeyAJ, MehraA, et al.Pregnancy-associated acute myocardial infarction: A review of contemporary experience in 150 cases between 2006 and 2011. Circulation. 2014;129(16):1695–702.
