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As many as 3 million American women have coronary artery disease (CAD) thatdoesn't show up on standard diagnostic imaging, according to findings from theWomen's Ischemia Syndrome Evaluation (WISE).
In a series of papers published in February by the Journal of theAmerican College ofCardiology,1–3researchers say many women don't develop cholesterol plaques in large arteriesas men do, but instead show disease in smaller microvessels that is notapparent on diagnostic coronary angiography.
"If you define coronary artery disease by standard cardiologyterms—50% or more obstruction—then only one-third of the womenmeet that. Two-thirds would be termed insignificant or normal," saysGeorge Sopko, MD, WISE project officer at the National Heart, Lung, and BloodInstitute (NHLBI).
More than 7,000 women were examined for the WISE study, which NHLBIlaunched in 1991 to address the underrepresentation of female subjects inmedical research. Women found to have no clinical CAD by angiography werefurther evaluated with perfusion testing. About half the women who would havebeen sent home after angiography were found by perfusion testing to haveischemia.
The issue is likely to be greater among women with type 2 diabetes becauseof the risk of endothelial dysfunction, Sopko says.
"If you go to diabetic [patients], it's a much bigger problem,"he says. "If you consider microvascular dysfunction, I don't know of a[patient with diabetes who] doesn't have it." 
Footnotes
It isn't practical or economically viable to do costly perfusion testing onall women suspected of having coronary artery disease (CAD). Instead,researchers suggest clinicians use the Duke Activity Status Index(DASI) to identify patients who may benefit from perfusiontesting.1
The DASI is a 12-item self-administerequestionnaire.2One's score elicits information about impaired function resulting fromCAD.
A PDF copy of the DASI questionnaire is available from MontefioreRehabilitation Medicine Associates Cardiac Rehabilitation Center atwww.montefiore.org/pdfs/duke-activity-index.pdf.
References
2. Hlatky M, Boineau R, Higginbotham M, et al.: A briefself-administered questionnaire to determine functional capacity (the DukeActivity Status Index). Am J Cardiol 64: 651–654, 1989.[Medline]
1. Shaw LJ, Bairey Merz CN, Pepine CJ, et al.: Insights from theNHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study: Part I:Gender differences in traditional and novel risk factors, symptom evaluation,and gender-optimized diagnostic strategies. J Am CollCardiol 47 (Suppl. 3):S4–S20, 2006.
2. Bairey Merz CN, Shaw LJ, Reis SE, et al.: Insights from theNHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study, Part II.Gender differences in presentation, diagnosis, and outcome with regard togender-based pathophysiology of atherosclerosis and macrovascular andmicrovascular coronary disease. J Am Coll Cardiol 47 (Suppl. 3): S21–S29, 2006.
3. Pepine CJ, Kerensky RA, Lambert CR, et al.: Some thoughts on thevasculopathy of women with ischemic heart disease. J Am CollCardiol 47 (Suppl. 3):S30–S35, 2006.
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