Ischemic Heart Disease

Ischemic Heart Disease

Also known as Coronary Artery Disease, Coronary Heart Disease, Coronary Microvascular Disease

Heart disease is a catch-all phrase for a variety of conditions that affect the heart’s structure and function. Ischemic heart disease occurs when the arteries of the heart cannot deliver enough oxygen-rich blood to the heart. It is the leading cause of death in the United States, with most deaths occurring from coronary heart disease, also known as coronary artery disease—the most common type of ischemic heart disease.

Coronary heart disease is caused by the buildup of plaque, a waxy substance, inside the coronary arteries. This buildup can partially or totally block blood flow in the large arteries of the heart. Some types of this condition may be caused by disease or injury affecting how the arteries work in the heart. Coronary microvascular disease is another type of ischemic heart disease. It occurs when the heart’s tiny arteries do not function normally.

Symptoms of ischemic heart disease may be different from person to person even if they have the same type of ischemic heart disease. However, because many people have no symptoms, they do not know they have ischemic heart disease until they experience complications such as a heart attack or sudden cardiac arrest.

To diagnose ischemic heart disease, your doctor may order blood, exercise, and imaging tests. If you have ischemic heart disease, your doctor will recommend heart-healthy lifestyle changes, medicines, surgery, or a combination of these approaches to treat your condition and prevent complications such as a heart attack.

Types- Ischemic Heart Disease

There are three main types of ischemic heart disease: obstructive coronary artery disease; nonobstructive coronary artery disease; and coronary microvascular disease. Coronary artery disease affects the large arteries on the surface of the heart and many people have both obstructive and nonobstructive forms of this disease. Coronary microvascular disease affects the tiny arteries in the heart muscle. It may occur with or without coronary artery disease.

- Obstructive

Obstructive coronary artery disease occurs when plaque builds up in the large arteries, causing them to narrow gradually. This reduces the supply of oxygen-rich blood to the heart. Obstructive coronary artery disease means the heart’s arteries are more than 50 percent blocked. The blood flow may eventually be completely blocked in one or more of the three large coronary arteries.

- Non Obstructive

In nonobstructive coronary artery disease, the large arteries are narrowed by plaque, but not as much as they are in obstructive disease. It is diagnosed if imaging studies show less than 50 percent obstruction of the heart’s large arteries caused by plaque buildup. Between 20 and 50 percent of people undergoing heart imaging studies have nonobstructive coronary artery disease. This condition can also be caused by disease or injury to the lining of the large arteries, affecting the arteries’ ability to expand in response to physical, chemical, or electrical signals that normally would stimulate more blood flow to the heart. Damage to the inner walls of the coronary arteries can cause them to spasm, leading to temporarily decreased blood flow to the heart.

- Coronary microvascular disease

Coronary microvascular disease affects the heart’s smallest arteries. Coronary microvascular disease can happen either alone or with obstructive or nonobstructive coronary artery disease or other heart diseases. This type of heart disease most often occurs when molecular changes in the microvascular system—the tiny blood vessels—of the heart prevent normal blood flow through the small arteries.

Causes- Ischemic Heart Disease

The cause of ischemic heart disease depends on which type you have. Ischemic heart disease may also have more than one cause, including plaque buildup or molecular changes in the blood vessels.'

Plaque buildup

Plaque buildup in the arteries is called atherosclerosis. When this buildup happens in the heart's arteries over many years, the arteries become narrower and harden, reducing blood flow to the heart. The result is coronary artery disease.

Small pieces of plaque or blood clots can also stick in the small arteries, causing coronary microvascular disease. This can happen when pieces of plaque or blood clots break off during a medical or surgical procedure and travel to the small arteries.

Plaque can attract platelets and white blood cells to the area of buildup in the large coronary arteries, causing inflammation. Inflammation can also prevent the small arteries of the heart from responding to the physical, electrical, and chemical signals that tell the arteries when the heart needs more oxygen-rich blood. This can lead to coronary microvascular disease. Research suggests that inflammation may also reduce levels of HDL cholesterol.

Molecular changes in the small blood vessels

The causes of coronary microvascular disease are not fully clear, but they may involve molecular changes in the small vessels of the heart that are part of the normal aging process. They may also involve damage to the small vessels from chronic inflammation, high blood pressure, or diabetes. Molecular changes affect the way genes and proteins are controlled inside cells. These changes mean that the small arteries of the heart may not respond correctly when they receive signals indicating that the heart needs more oxygen-rich blood, such as when a person is physically active. Instead of expanding to allow more blood flow, the size of these arteries does not change or may even decrease.

Risk Factors- Ischemic Heart Disease

There are many risk factors for ischemic heart disease. Your risk of ischemic heart disease increases with the type and number of risk factors you have and how serious they are. Some risk factors—such as high blood pressure and high blood cholesterol—can be changed through heart-healthy lifestyle changes. Other risk factors, such as sex, older age, family history and genetics, and race and ethnicity, cannot be changed.

- Ischemic Heart Disease

Over time, unhealthy lifestyle habits increase your risk for developing coronary artery disease because they can lead to plaque buildup in the heart's blood vessels. These habits also may increase the risk for coronary microvascular disease. Unhealthy lifestyle habits that are risk factors include the following:

• Being physically inactive, which can worsen other heart disease risk factors, such as high blood cholesterol and triglyceride levels, high blood pressure, diabetes and prediabetes, and overweight and obesity.
• Smoking tobacco or long-term exposure to secondhand smoke, which can damage the blood vessels. This increases your risk of atherosclerosis, which itself raises the risk for ischemic heart disease.
• Stress, which can trigger the tightening of your arteries, which increases your risk of ischemic heart disease, especially coronary microvascular disease. Stress may also indirectly raise your risk of ischemic heart disease if it makes you more likely to smoke or overeat foods high in fat and added sugars.
• Unhealthy eating patterns, such as consuming high amounts of saturated fats or trans fats, which can lead to overweight and obesity, high blood cholesterol, atherosclerosis, and plaque buildup in the heart's arteries.

Screening and Prevention- Ischemic Heart Disease

Genetic or lifestyle factors cause plaque to build up in your arteries as you age. In men, the risk for ischemic heart disease starts to increase around age 45. Before menopause, women have a lower risk for ischemic heart disease than men. After around age 55, however, the risk increases at the same rate in both women and men. This is likely because the protective effects of the female hormone estrogen diminish after menopause. Also, changes in the small blood vessels of the heart as you age increase the risk for coronary microvascular disease.

Risk factors

- Life style

Air pollution can increase your risk of ischemic heart disease. The increase in risk is mostly for older adults, women, and people who have diabetes or obesity. Air pollution may cause or worsen other conditions, such as atherosclerosis and high blood pressure, which are known to increase your risk for ischemic heart disease.

Your work life can affect your risk for ischemic heart disease in several ways, such as if it involves or exposes you to certain conditions, including:

• Hazards such as toxins or radiation
• High stress
• Long periods of sitting or inactivity
• Limitations on the time available for you to sleep

- Age

Working more than 55 hours per week is also associated with a higher risk for ischemic heart disease.

- Family history

A family history of early cardiovascular disease is a risk factor for ischemic heart disease. This is especially true if your father or brother was diagnosed before age 55, or if your mother or sister was diagnosed before age 65. Research shows that some genes are linked with a higher risk for ischemic heart disease.

- Environment and occupation

Air pollution can increase your risk of ischemic heart disease. The increase in risk is mostly for older adults, women, and people who have diabetes or obesity. Air pollution may cause or worsen other conditions, such as atherosclerosis and high blood pressure, which are known to increase your risk for ischemic heart disease.

Your work life can affect your risk for ischemic heart disease in several ways, such as if it involves or exposes you to certain conditions, including:

• Hazards such as toxins or radiation
• High stress
• Long periods of sitting or inactivity
• Limitations on the time available for you to sleep

Working more than 55 hours per week is also associated with a higher risk for ischemic heart disease.

- Family history

A family history of early cardiovascular disease is a risk factor for ischemic heart disease. This is especially true if your father or brother was diagnosed before age 55, or if your mother or sister was diagnosed before age 65. Research shows that some genes are linked with a higher risk for ischemic heart disease.

- Race

Ischemic heart disease is the leading cause of death for people of most racial and ethnic groups in the United States, including African Americans, Hispanics, and whites. For Asian Americans or Pacific Islanders and American Indians or Alaska Natives, heart disease is second only to cancer. However, some of these populations have higher rates than whites do for known risk factors of ischemic heart disease such as high blood pressure, diabetes, and obesity.

Many Americans have risk factors for heart disease, including a higher body weight, lack of regular physical activity, smoking, and high levels of blood pressure, sugar, or cholesterol. This includes more than half of whites, 3 in 4 Mexican Americans, and 8 in 10 African Americans.

- Sex

Ischemic heart disease affects men and women. Obstructive coronary artery disease is more common among men than women. Nonobstructive coronary artery disease is more common among women.

Women may have a higher than normal risk for developing ischemic heart disease if they have one of the following conditions:

• Diabetes
• Endometriosis, which raises the risk for heart disease in younger women
• Gestational diabetes, which can increase the risk for diabetes and metabolic syndrome even after pregnancy, and the risk of developing ischemic heart disease
• HIV infection
• Polycystic ovary syndrome, an endocrine condition that causes large ovaries and prevents proper ovulation, which can reduce fertility
• Preeclampsia, a condition that can happen during pregnancy and is linked to an increased lifetime risk for ischemic heart disease

Screening and Prevention

Screening tests and risk assessments for developing ischemic heart disease should start around age 20 for people who do not have any ischemic heart disease risk factors. Children may need screening if they have risk factors, such as obesity, low levels of physical activity, or a family history of heart problems.

To screen for ischemic heart disease, your doctor will determine whether you have any known risk factors, test your cholesterol and blood sugar levels, and check your blood pressure. Your doctor may use a risk calculator to determine whether you are in a low-, intermediate-, or high-risk group. Your doctor may recommend treatments such as heart-healthy lifestyle changes to help prevent ischemic heart disease.

Signs, Symptoms, and Complications- Ischemic Heart Disease

- Screening Tests

To screen for ischemic heart disease, your doctor will review your medical history and perform some tests. The screening may include:

• Assessment of risk factors to help evaluate your risk of developing ischemic heart disease
• Blood pressure readings to see whether you have high blood pressure
• Calculation of your body mass index to see whether you have an unhealthy weight
• Blood tests to see whether you have high blood cholesterol, high blood triglycerides, or diabetes

Screening usually occurs in a doctor's office, but sometimes screenings are done at health fairs, drug stores, or other places. Blood samples might be collected at your doctor's office, a hospital, or a laboratory.

Do not eat or drink anything besides water for eight to 10 hours before blood tests for diabetes or cholesterol. Ask your doctor whether you need to do anything to prepare for any other tests that will be done.

Your doctor may evaluate your risk using a calculator such as the Atherosclerotic Cardiovascular Disease Estimatorexternal link. This calculator estimates your risk of having a heart attack or stroke in the next 10 years. It considers your total and HDL cholesterol levels, age, and systolic blood pressure. It also factors in whether you have diabetes, smoke, or use medicines to control high blood pressure. The calculator uses your ischemic heart disease risk factors to estimate your risk.

• High risk: A greater than 20 percent risk that you will develop a heart attack or die from coronary disease in the next 10 years.
• Intermediate risk: A 10 to 20 percent risk that you will develop a heart attack or die from coronary disease in the next 10 years.
• Low risk: Less than 10 percent risk that you will develop a heart attack or die from coronary disease in the next 10 years.

- Risk Calculators

Risk calculators can be useful to help people understand their risk factors and encourage them to make healthy lifestyle changes. Your doctor will consider your 10-year risk calculation in association with other factors, such as your family history, when deciding how best to manage your risk of cardiovascular complications from ischemic heart disease. Risk assessments should be repeated every 4 to 6 years in adults 20 to 79 years of age who do not have cardiovascular disease.

Risk calculators may not be as accurate for certain populations, including women, Asian, Americans, Hispanics, Native Americans, and people taking statins.

Commonly used risk calculators might not accurately estimate risk in certain situations, such as when you are taking a statin for high blood cholesterol, or for certain populations. Your doctor may need to use a special risk calculator for predicting risk of ischemic heart disease if you are a woman or a member of a racial or ethnic minority.

Ask your doctor about your risk factors and how your risk is evaluated.

- Heart healthy lifestyle

To prevent ischemic heart disease, or if you have certain risk factors, your doctor may recommend that you adopt heart-healthy lifestyle changes, including eating healthy, being physically active, aiming for a healthy weight, quitting smoking, and managing stress. Studies support these changes as an effective approach to preventing ischemic heart disease and its complications.

Signs and Symptoms

Signs, symptoms, and complications will vary based on the type of ischemic heart disease you have. Some people report severe symptoms of ischemic heart disease, but others have no signs or symptoms at all. If you have “silent” ischemic heart disease, you may not experience any symptoms until you have complications, such as acute coronary events including a heart attack.

- Ischemic Heart Disease

An acute coronary event, such as a heart attack, may cause symptoms such as:

• Angina, which can feel like pressure, squeezing, burning, or tightness during physical activity. The pain or discomfort usually starts behind the breastbone, but it can also occur in the arms, shoulders, jaw, throat, or back. The pain may feel like indigestion.
• Cold sweats
• Dizziness
• Light-headedness or dizziness
• Nausea or a feeling of indigestion
• Neck pain
• Shortness of breath, especially with activity
• Sleep disturbances
• Weakness

Chronic ischemic heart disease can cause signs and symptoms such as the following:

• Angina
• Anxiety or nervousness
• Fatigue
• Neck pain

The severity of these symptoms can vary. They may get worse as the buildup of plaque continues to narrow the coronary arteries. Chest pain or discomfort that does not go away or occurs more often or while you are resting might be a sign of a heart attack. If you do not know whether your chest pain is angina or a heart attack, call 9-1-1 immediately. All chest pain should be checked by a doctor.

How may symptoms differ for women?

Doctors usually rely on descriptions of chest pain when diagnosing ischemic heart disease. Men commonly report squeezing chest pain that occurs with exertion and stops with rest. Although women’s symptoms may be similar to men’s, women are less likely to describe pain; instead, they may mention feeling pressure or tightness in the chest. Women often report other symptoms, such as nausea, abdominal pain, vomiting, fatigue, and dizziness. Women are also more likely than men to have no symptoms of ischemic heart disease.

- Complications

Ischemic heart disease can cause serious complications including the following:

• Acute coronary syndrome, including angina or heart attack
• Arrhythmia
• Cardiogenic shock
• Heart failure
• Stroke
• Sudden cardiac arrest

Diagnosis- Ischemic Heart Disease

Your doctor will diagnose ischemic heart disease based on your symptoms, your medical and family history, your risk factors, and the results from tests and procedures.

Because women and their doctors may not recognize ischemic heart disease symptoms that are different from men's, women may not be diagnosed and treated as quickly as men. It is important to seek care right away if you have symptoms of ischemic heart disease.

- Ischemic Heart Disease

Your doctor will ask about your eating and physical activity habits, family history, and risk factors for ischemic heart disease. Your doctor may ask whether you have any other signs or symptoms. This information can help your doctor determine whether you have complications or other conditions that may cause ischemic heart disease.

Depending on your risk factors, your doctor may recommend diagnostic tests for ischemic heart disease even if you do not have symptoms.

- Diagnostic tests and procedures

To diagnose ischemic heart disease, your doctor may order some of the following tests:

• Blood tests to check the levels of cholesterol, triglycerides, sugar, lipoproteins, or proteins that are markers of inflammation. Abnormal levels are risk factors for ischemic heart disease.
• Echocardiography (echo) to check the heart's pumping capacity and observe the function of its valves and chambers. This imaging study can also show areas of poor blood flow that could be caused by narrowing or blockages in the coronary arteries. A type of echo called transthoracic Doppler ultrasound can show how well your heart's small arteries respond to a drug given to increase blood flow. This test can help diagnose coronary microvascular disease.
• Electrocardiogram (EKG or ECG) to determine whether the heart's rhythm is steady or irregular. An EKG also records the strength and timing of electrical signals as they pass through the heart.
• Stress tests to check how your heart works during physical stress. During stress testing, you walk or run on a treadmill or pedal a stationary bike to make your heart work hard and beat fast. Tests are done on your heart while you exercise. If you have a medical problem that prevents you from exercising, your doctor may give you medicine to make your heart work hard, as it would during exercise.
• Cardiac CT (computed tomography) scan to detect or evaluate the presence and extent of coronary artery disease. This test may also be used to follow up on abnormal findings from chest X-rays or other tests.
• Cardiac MRI (magnetic resonance imaging) to detect tissue damage or problems with blood flow in the heart or coronary arteries. It can help your doctor diagnose coronary microvascular disease or nonobstructive or obstructive coronary artery disease. Cardiac MRI can help explain results from other imaging tests such as chest X-rays and CT scans.
• Cardiac positron emission tomography (PET) scanning, a type of nuclear heart scan, with radioactive tracers to diagnose coronary microvascular disease by assessing blood flow through the small arteries and into the heart tissues.
• Coronary calcium scan to detect and measure the amount of calcium in the walls of your coronary arteries. Buildup of calcium can be a sign of atherosclerosis, coronary artery disease, or coronary microvascular disease. Coronary calcium scans can also help assess ischemic heart disease risk for people who smoke or for people who do not have heart symptoms.
• Coronary angiography to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. This procedure is often used if other tests show that you are likely to have coronary artery disease. Standard angiography cannot be used to diagnose coronary microvascular disease, because the tiny blood vessels are too small to visualize. However, it is possible to indirectly assess the function of the small arteries by tracking the amount of time it takes for the dye to travel from the large arteries into the small arteries.
• Coronary guidewire sensor technology to assess microvascular function in the heart. A guidewire equipped with sensors is inserted into the heart's arteries with cardiac catheterization. The sensors can detect coronary blood pressure and temperature to measure how easily blood flows through the small arteries. Usually measurements are done before and after giving you medicine to enhance blood flow in your heart. Your doctor may diagnose coronary microvascular disease if your small arteries do not respond to the drug by increasing blood flow. This type of technology can also show nonobstructive disease in the larger coronary arteries if the arteries spasm or narrow when exposed to a drug called acetylcholine.

Why may it take longer to diagnose nonobstructive coronary artery disease and coronary microvascular disease?

Nonobstructive coronary artery disease and coronary microvascular disease can be missed because patients or doctors may not recognize symptoms as warning signs. This can lead to missed or delayed diagnoses, especially for women, who are less likely to have typical chest pain and are more likely to report other symptoms, such as nausea, abdominal pain, vomiting, fatigue, and dizziness.

Your doctor may recommend diagnostic tests such as standard stress tests, imaging procedures, and risk assessments to detect obstructive coronary artery disease. Diagnosing nonobstructive coronary artery disease and coronary microvascular disease often requires more invasive tests or specialized testing procedures, such as cardiac PET scanning, that are not widely available.

Treatment- Ischemic Heart Disease

Treatment depends on the type and severity of your disease and other complications or health conditions you may have. Possible treatments for ischemic heart disease include heart-healthy lifestyle changes, medicines, or procedures such as coronary artery bypass grafting or percutaneous coronary intervention.

Your doctor will consider your 10-year risk calculation when deciding how best to treat your ischemic heart disease.

- Heart Healthy Lifestyle

Your doctor may recommend that you adopt lifelong heart-healthy lifestyle changes, including:

• Aiming for a healthy weight. Losing just 3 percent to 5 percent of your current weight can help you manage some ischemic heart disease risk factors, such as high blood cholesterol and diabetes. Greater amounts of weight loss can also improve blood pressure readings.
• Being physically active. Routine physical activity can help manage ischemic heart disease risk factors such as high blood cholesterol, high blood pressure, or overweight and obesity.
• Heart-healthy eating, such as the DASH (Dietary Approaches to Stop Hypertension) eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, trans fats, sodium, added sugars, and alcohol.
• Managing stress. Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.
• Quitting smoking. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute's Your Guide to a Healthy Heart. Although these resources focus on heart health, they include basic information about how to quit smoking

- Medicines

Your doctor may recommend medicines to manage your risk factors or treat underlying causes of ischemic heart disease. Some medicines can reduce or prevent chest pain and control other medical conditions that may be contributing to your ischemic heart disease.

• ACE inhibitors and beta blockers to help lower blood pressure and decrease the heart's workload.
• Calcium channel blockers to reduce blood pressure by allowing blood vessels to relax.
• Medicines to control blood sugar, such as empagliflozin, canagliflozin, and liraglutide, to help lower your risk for complications if you have ischemic heart disease and diabetes.
• Metformin to control atherosclerosis if you have diabetes.
• Nitrates, such as nitroglycerin, to relieve or prevent chest pain from angina. Nitroglycerin dissolves under your tongue or between your cheek and gum.
• Ranolazine to treat coronary microvascular disease and the chest pain it may cause.
• Statins or non-statin therapies to control high blood cholesterol. Your doctor may recommend statin therapy if you have a higher risk for ischemic heart disease complications or stroke or if you have diabetes and are between ages 40 and 75. Non-statin therapies may be used to reduce cholesterol when statins do not lower cholesterol enough or cause side effects. Your doctor may prescribe non-statin drugs, such as gemfibrozil, ezetimibe, bile acid sequestrants, fenofibrate, alirocumab, evolocumab, or omega-3 fatty acids.

- Procedures and or surgery

You may need a procedure or heart surgery to treat more advanced ischemic heart disease.

• Coronary artery bypass grafting (CABG) to improve blood flow to the heart by using normal arteries from the chest wall and veins from the legs to bypass the blocked arteries,. Surgeons typically use CABG to treat people who have severe coronary artery disease in multiple coronary arteries.
• Percutaneous coronary intervention (PCI) to open coronary arteries that are narrowed or blocked by the buildup of atherosclerotic plaque. A small mesh tube called a stent is usually implanted after PCI to prevent the artery from narrowing again.
• Transmyocardial laser revascularization to treat severe angina associated with ischemic heart disease when other treatments are too risky or did not work.

Living With- Ischemic Heart Disease

If you have been diagnosed with ischemic heart disease, it is important that you continue your treatment plan. Get regular follow-up care to control your condition and prevent complications.

- Cardiac Rehab

It is important to get routine medical care and to take all medicines regularly, as your doctor prescribes. Do not change the amount of your medicine or skip a dose unless your doctor tells you to. Talk with your doctor about how often you should schedule office visits and blood tests. Between visits, call your doctor if you have any new symptoms, if your symptoms worsen, or if you have problems with your blood pressure or blood sugar.

- Prevent Complications

Your doctor will consider your 10-year risk calculation when deciding how best to manage your risk of cardiovascular complications. He or she will work with you to manage medical conditions that can raise your risk for heart problems and complications.

• You will likely be given a statin to lower your LDL cholesterol, especially after a heart attack.
• Your doctor may recommend aspirin to prevent a heart attack or stroke. Low-dose aspirin may help prevent blood clots and reduce the risk for heart attacks and other complications of ischemic heart disease for most people, including those with diabetes.Being physically inactive
• If you have diabetes, you will need to check your blood sugar and keep taking any prescribed medicines.
• If your ischemic heart disease has gotten worse or led to a heart attack or sudden cardiac arrest, your doctor may recommend a pacemaker or defibrillator to detect and treat certain types of serious arrhythmias.
• Anemia treatment may help if you have been diagnosed with coronary microvascular disease and also have anemia. Anemia is thought to slow the growth of cells needed to repair damaged blood vessels.

Your doctor will likely also suggest heart-healthy lifestyle changes, such as eating heart-healthy foods, being physically active, and quitting smoking. Your doctor may refer you to other professionals, such as a registered dietitian or exercise physiologist, to help you meet your goals.

There are benefits to quitting smoking no matter how long or how much you have smoked. Ischemic heart disease risk associated with smoking begins to decrease soon after you quit, and it generally continues to decrease over time.

- Emotional Health

Living with heart disease may cause fear, anxiety, depression, and stress. You may worry about having heart problems or making lifestyle changes that are necessary for your health. Talk with your health care team about how you feel. Your doctor may recommend you take steps that include:

• Talking to a professional counselor. If you are depressed, your doctor also may recommend medicines or other treatments that can improve your quality of life.
• Joining a patient support group. This may help you adjust to living with heart disease. You can find out how other people who have the same symptoms as yours have coped with them. Your doctor may be able to recommend local support groups, or you can check with an area medical center.
• Seeking support from family and friends. Letting your loved ones know how you feel and what they can do to help you can help relieve stress and anxiety.

Ischemic heart disease in women

What Should Women Know? - Ischemic Heart Disease

Heart disease is the leading cause of death for women. Women who have symptoms of ischemic heart disease are less likely than men to have obstructive coronary artery disease. However, they may be at greater risk for coronary microvascular disease and for serious complications of coronary artery disease, including blood clots in the heart's arteries.

Eighty percent of women ages 40 to 60 have one or more risk factors for ischemic heart disease. Having multiple risk factors significantly increases a woman's chance of developing ischemic heart disease.

Learn more about how the causes, risk factors, symptoms, diagnosis, and treatment of ischemic heart disease may be different for women than for men.

Why does ischemic heart disease affect women differently?

Ischemic heart disease is different for women than men because of hormonal and anatomical differences.

• Hormonal changes affect a woman’s risk for ischemic heart disease. Before menopause, the hormone estrogen provides women with some protection against ischemic heart disease. Estrogen raises “good” HDL cholesterol and helps keep the arteries flexible so they can widen to deliver more oxygen to the tissues of the heart in response to chemical and electrical signals. After menopause, estrogen levels drop, increasing a woman’s risk for ischemic heart disease.
• The size and structure of the heart is different for women and men. A woman’s heart and blood vessels are smaller, and the muscular walls of women’s hearts are thinner.

- What Conditions Affect Risk Differently in Women?

Women are more likely than men to have medical conditions or life issues that raise their risk for ischemic heart disease.

• Anemia, especially during pregnancy
• Hormonal birth control
• Endometriosis
• High blood pressure after age 65
• Inflammatory and autoimmune diseases
• Lack of physical activity
• Mental health issues, such as stress, marital stress, anxiety disorders, depression, or low social support
• Overweight and obesity
• Problems during pregnancy, including gestational diabetes and preeclampsiaexternal link and eclampsiaexternal link

Some factors raise women's risk for ischemic heart disease more than they increase risk in men.

• Diabetes
• Low levels of HDL cholesterol
• Smoking

- Can Symptoms Be Different For Women?

Although men and women can experience the same symptoms of ischemic heart disease, women often experience no symptoms or have other symptoms than men do:

• Activity that brings on chest pain. In men, angina tends to worsen with physical activity and go away with rest. Women are more likely than men to have angina while they are resting or sleeping. In women who have coronary microvascular disease, angina often happens during routine daily activities, such as shopping or cooking, rather than during exercise.
• Location and type of pain. Women are more likely to describe their chest pain as crushing, or they say it feels like pressure, squeezing, or tightness. Men say their pain is aching or dull. Women more often say they have pain in the neck and throat. Men usually describe pain in the chest.
• Mental stress. Mental stress is more likely to trigger angina pain in women than in men.
• Other symptoms. Common signs and symptoms for women include nausea, vomiting, shortness of breath, abdominal pain, sleep problems, fatigue, and lack of energy.

What do women need to know about diagnosis and treatment?

Tests and procedures for diagnosing ischemic heart disease are very similar for women and men. But women may experience delays in diagnosis or treatment. Learn about important diagnostic tests and treatment options.

• Ask about important diagnostic tests. Doctors are less likely to refer women for diagnostic tests for ischemic heart disease. When women go to the hospital for heart symptoms, they are more likely than men to experience delays receiving an initial EKG, are less likely to receive care from a heart specialist during hospitalization, and are less likely to receive certain types of therapy and medicines. Younger women are more likely than men to be misdiagnosed and sent home from the emergency department after cardiac events that occur from undiagnosed and untreated vascular heart disease.
• Ask about treatment options that are effective for men and women. Women may be less likely than men to receive aspirin, statins, and beta blockers for treating their heart disease. Although women may be as likely as men to benefit from a pacemaker or a defibrillator, women are less likely to receive these treatments for complications of ischemic heart disease. Women are often less likely to receive coronary artery bypass grafting or percutaneous coronary intervention than men are, even though research shows that both men and women can benefit from these procedures.
• Know and share your risk factors. Doctors may not recognize women's risk for ischemic heart disease. Commonly used risk-scoring systems may not accurately predict risk in women. Also, in one survey, fewer than one in four women reported that their doctors had ever discussed their risk for heart disease.
• Learn the symptoms and seek medical care right away. Being familiar with the symptoms of ischemic heart disease and how they may differ in women may help you recognize when to talk to your doctor or when to seek medical care. Immediate care may help prevent complications such as heart attack or sudden cardiac arrest.

Ischemic Heart Disease Resources
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