Study Points

Women and Coronary Heart Disease

Course #33224 - $90 -

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  1. The economic cost of CHD for 2015 was estimated to be

    OVERVIEW OF WOMEN AND CHD

    The older adult population is changing the demography of CHD in the United States. In 2018, 16% of the U.S. population was 65 years of age and older [5]. This number is projected to grow to 20% of the U.S. population (approximately 72 million people) by 2030 [6]. Individuals who are 85 years of age and older are the most rapidly growing subgroup of older adults. Approximately 6.3 million Americans are 85 years of age and older, with a projected increase to more than 19 million expected by 2060 [7,8]. These trends will clearly influence the diagnosis and treatment of CHD in women. For the year 2015, the total economic cost of this health problem in the United States was estimated to be $351.2 billion [3]. Given the fact that the incidence of CHD in women increases with age, coupled with the projected increase in the older population, this economic burden will continue to grow.

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  2. Among American women, CHD is the

    OVERVIEW OF WOMEN AND CHD

    CHD is the leading cause of death in American women [9]. Although the risk of breast cancer has been the focus of intense media coverage for several years, CHD is responsible for more deaths among women in the United States each year than all forms of cancer, including breast cancer [9]. However, CHD mortality has been declining for men and women since 1979. In a 1979–2011 analysis, mortality rates declined consistently for adults older than 65 years of age, with steep declines observed between 2000 and 2011. While adults younger than 55 years of age showed initial declines in mortality, these improvements eventually plateaued, with younger women experiencing the least improvement [345]. The rate of CHD death increased 6% from 2011 to 2017 [10]. In 2019, CHD was the cause of death in 420,812 women, representing 48.1% of all CHD deaths [1].

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  3. Compared to men, women's sex-specific anatomic differences include

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Several anatomic and physiologic differences exist in the cardiovascular system of women compared to men. Because women's bodies are generally smaller in stature, the female heart and thoracic cavity are smaller and lighter. A woman's heart weighs approximately 229 grams, whereas a man's heart weighs 285 grams. The female heart also has smaller coronary arteries than a man's heart. The right coronary artery appears to be more dominant in women [1,17,18,19,20].

    In addition to anatomic differences in male and female cardiovascular systems, research indicates that women may deposit plaque differently than men. The Women's Ischemia Syndrome Evaluation (WISE) Study, supported by the National Heart, Lung, and Blood Institute, evaluated sex differences in the presentation and treatment of obstructive CHD [21,22]. Researchers found that women's atherosclerotic plaque deposition was more diffuse than men's. This physiologic difference results in scalloping or artery irregularities, rather than the large, obstructive blockages that are commonly associated with CHD and MI. A 2019 study also analyzed plaque characteristics in male and female patients with suspected CHD. A total of 1,050 patients were matched for sex, age, and known coronary risk factors. All patients underwent CT angiography analysis to assess for stenosis, plaque types (i.e., noncalcified, mixed, or calcified), and high-risk plaque features [23]. The men had significantly more plaques and a larger proportion of calcified plaques, whereas women had more mixed and noncalcified plaques. These findings support the need for a differentiated plaque analysis to improve the accuracy of risk stratification for both sexes [23].

    Microvessels and vasodilator response also appear to be impaired more frequently in the female population. These less obvious changes are more difficult to detect from a traditional angiogram and may result in different symptoms. These characteristics may partially account for the differences in presentation and subsequent treatment of CHD in women.

    On the electrocardiogram (ECG), women's resting heart rate is higher, PR and QRS intervals tend to be shorter, and the amplitude of the R, S, and T waves across the precordium are smaller. Left ventricular end-diastolic pressure and volume are also lower in women, yet stroke volume and resting ejection fractions (EF) tend to be higher in women than in men [24]. Up to 30% of women with normal coronary arteries do not have an increase in EF with exercise, a finding that has important implications for exercise testing [1,17,19,25,26,27].

    Hematologic differences also exist. Women's hematocrit and blood volumes tend to be lower, along with their oxygen-carrying capacity. Cholesterol levels tend to rise in women around 55 years of age; however, the natural estrogens of perimenopause are believed to provide protection against CHD by conferring beneficial effects to the lipid profile. It has also been suggested that estrogen receptors located within the walls of blood vessels may affect the proliferation of smooth muscle cells, reduce platelet aggregation, and alter the degradation of collagen and elastin [22,28,29].

    The last anatomic and physiologic difference between men and women is body fat percentage. The percentage of body fat is higher in women and may be distributed differently. Women who have a large waist, also referred to as abdominal obesity or central adiposity, tend to have an increased risk of an MI at an earlier age [19,20,28]. Studies have suggested that, in particular, waist-to-hip ratio measures of abdominal adiposity may be strong indicators of mortality in women [30,31,32]. Other studies have indicated that waist-to-height ratio may be an accurate predictor of CHD in women [33,34]. Patterns of fat distribution and associated cardiovascular health risks will be discussed in further detail in the following section on traditional coronary risk factors. Table 2 summarizes how women's physiologic profile differs from men's.

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  4. Compared with the risk level of a man the same age with comparable risk factors, a premenopausal woman's risk of a coronary event is

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Traditional cardiovascular risk factors increase the likelihood of the development of CHD in both men and women. However, the weight given to these risk factors may not be the same between the sexes. Furthermore, the traditional diagnostic tests, which generally focus on obstructive disease, are not as effective in women as compared to men [21]. At comparable levels of cardiovascular risk factors, the risk of a cardiac event in a premenopausal woman is 50% the risk level for a man the same age. The relative protection of women from CHD may be due to better tolerance of cardiovascular risk factors, as well as hormonal and metabolic differences [21,35].

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  5. Hyperlipidemia, hypertension, and cigarette smoking are what type of CHD risk factors?

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Again, alterable cardiovascular risk factors require the most attention when counseling female patients. These factors include smoking, hypertension, hyperlipidemia, diabetes, obesity, metabolic syndrome, sedentary lifestyle, obstructive sleep apnea, and psychosocial wellness.

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  6. Which of the following groups are at an increased risk of developing hypertension?

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Like smoking, hypertension is a powerful independent risk factor for the development of CHD in men and women. Compared with men, hypertension is twice as prevalent in women with CHD. Additionally, women with hypertension have three to four times the risk of developing CHD than women with normal blood pressure [56]. Among non-Hispanic Black women, hypertension tends to occur at an earlier age, be more severe and treated less adequately, and result in more significant morbidity and mortality rates. More than 57.6% of non-Hispanic Black women in the United States have hypertension, compared with 40.5% of White women [1]. In addition to Black women, pregnant women and postmenopausal women older than 65 years of age are also at high risk for developing hypertension [57].

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  7. Effects of obesity on metabolic processes include

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Obesity is another traditional risk factor. In 2016, 39.8% of U.S. adults were obese, an incidence that has greatly increased in the last 20 years [74,75]. As of 2018, every state had a prevalence of obesity greater than 20%. Twenty-two states reported an obesity prevalence of 30% to 35%, and nine states reported rates greater than 35% prevalence [75].

    If a woman is 30% overweight, she is at increased risk for developing an MI, heart failure, stroke, and even death. Mild-to-moderate obesity (i.e., 5% to 15% overweight) may also be detrimental. Women who are overweight have a two to three times greater risk of an MI compared to lean women [77]. Fluctuations in weight may also impact a women's overall risk for metabolic syndrome and CHD [78]. Like the other cardiovascular risk factors, CHD risk increases with certain risk factor combinations, such as obesity and smoking [20,36,42,48,79]. Obesity unfavorably influences other metabolic processes, including elevation of blood pressure, triglyceride, and uric acid levels; reduction of HDL cholesterol; and alteration of glucose tolerance and insulin sensitivity [20].

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  8. Which of the following psychosocial factors is predictive of CHD?

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    Psychosocial CHD risk factors include stress/anxiety, anger/hostility, cynicism, depression, and social isolation While single psychosocial risk factors are generally unrelated to level of CHD or its progression, depression is predictive of CHD [358]. Two times more prevalent in women than men, depression increases women's CHD risk by at least 50%. As a powerful risk factor, depression has been associated with early-onset MI, especially in younger and middle-aged women [338,358]. Additionally, social isolation increases with age. New evidence demonstrates such isolation is a risk factor for heart failure independent of traditional cardiovascular risk factors. Social isolation may influence heart failure risk by inducing a negative psychological state that reduces protective hormones, leading to adverse effects on the heart, blood pressure, and blood vessel wall repair, as well as immune function. As socially isolated individuals lack social support, they may also experience more stress and depression, influencing their engagement in health-promotion activities [357].

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  9. At the time of menopause

    CARDIOVASCULAR RISK PROFILE IN WOMEN

    At the time of menopause, serum estrogen levels decrease. The absence of estrogen increases a postmenopausal woman's vulnerability to CHD due to the effects on lipoprotein metabolism. These changes include a decrease in HDL levels and an increase in LDL levels. In addition, blood vessels become less flexible due to the reduction in circulating estrogen after menopause [107]. Premature menopause enhances this risk for women [340].

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  10. As a general guideline, cholesterol screening should initially be done when a patient is

    PRIMARY CHD PREVENTION

    Primary prevention begins in youth and early adulthood with general screening of family history of CHD and cardiovascular risk factors. This is also an opportunity to reinforce lifelong heart healthy habits. With regard to total cholesterol, the initial screen should be done at 20 years of age and followed up thereafter every five years. With female patients, obstetrician/gynecologists play a key role in this screening process. If cholesterol levels are greater than 200 mg/dL, additional testing of lipoproteins, specifically HDL and LDL, and annual checks are warranted [73].

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  11. Guidelines for cardiac nutrition should emphasize that approximately what percentage of daily calories should come from saturated fat?

    PRIMARY CHD PREVENTION

    CLINICAL RECOMMENDATIONS FOR PRIMARY CHD PREVENTION IN WOMEN

    Lifestyle Interventions
    Cigarette smoking
    Women should not smoke and should avoid environmental tobacco smoke.
    Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or formal smoking cessation program (Class I, Level B).
    Dietary intakeWomen should consume a diet rich in fruits and vegetables (5 servings/day), whole-grain, high-fiber foods, nuts and legumes, low-fat dairy products and omega-3 fatty acids (in the form of oily fish at least twice a week); limit sweets, sugar-sweetened beverages, red meats, saturated fat (<7% of total energy intake), cholesterol <150 mg/d, alcohol intake no more than 1 drink per day, sodium intake <1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty acids (Class I, Level B).
    Weight maintenance/reductionWomen should maintain or lose weight through an appropriate balance of caloric intake, physical activity, and formal behavioral programs when indicated to maintain/achieve a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist circumference ≤35 in (Class I, Level B).
    Physical activity
    Women should accumulate at least 150 minutes/week of moderate exercise, 75 minutes/week of vigorous exercise, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week (Class I, Level B).
    Women should be advised of additional cardiovascular benefits by increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5 hours/week of vigorous-intensity physical activity, or an equivalent combination of both (Class I; Level of Evidence B).
    Women should engage in muscle-strengthening activities involving all major muscle groups on ≥2 days/week (Class I; Level of Evidence B).
    Women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of at least moderate-intensity physical activity (e.g., brisk walking) on most (and preferably all) days of the week (Class I, Level B).
    Major Risk Factor Interventions
    Blood pressure—optimal level and lifestyleEncourage an optimal blood pressure of <120/80 mm Hg through lifestyle approaches such as weight control, increased consumption of fresh fruits, vegetables and low-fat dairy products, sodium restriction, increased physical activity, and alcohol moderation (Class I, Level B).
    Lipid and lipoprotein levels—optimal levels and lifestyleLifestyle approaches should be encouraged to achieve the following levels of lipids and lipoproteins: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I, Level B).
    DiabetesLifestyle and pharmacotherapy should be used in women with diabetes to achieve a HbA1c <7% without significant hypoglycemia (Class IIa, Level B).
    Preventive Drug Interventions
    Omega 3 fatty acid supplementationCapsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered with hypercholesterolemia and/or hypertriglyceridemia. Note: Fish oil dietary supplements may have widely variable amounts of EPA and DHA (likely the only active ingredients) (Class IIb, Level B).
    Blood pressure—pharmacotherapyPharmacotherapy is indicated when blood pressure is ≥140/90 mm Hg or ≥130/80 mm Hg) in women with diabetes or chronic kidney disease. Thiazide diuretics should be part of the drug regimen for most women (unless contraindicated) or if there are compelling indications for other agents in specific vascular diseases.
    Aspirin or clopidogrel
    High-risk women: Aspirin therapy (75–325 mg/d)a should be used (unless contraindicated) (Class I, Level A). If a high-risk woman is intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B).
    Women with diabetes: Aspirin therapy (75–325 mg/d) is reasonable (unless contraindicated) (Class IIa, Level B).
    Women 40 to 59 years of age with an estimated 10-year cardiovascular risk of at least 10% per ACC/AHA equations: The net benefit is small and should be considered through shared decision-making.
    Women 60 to 69 years of age with at least 20% 10-year cardiovascular risk or with diabetes and an estimated risk of at least 10%: Aspirin therapy should be considered in the context of no excess risk of bleeding and shared decision-making (USPSTF Grade C).
    Class III Interventions (Not Useful/Effective and May Be Harmful)
    Antioxidant supplementsAntioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should not be used for primary CHD prevention (Class III, Level A).
    Folic acidFolic acid, with or without B6 and B12 supplementation, should not be used for primary CHD prevention (Class III, Level A).
    Aspirin for MI in women <65 years of ageRoutine use of aspirin therapy in healthy women is not advised (Class III, Level B; USPSTF Grade D).
    Hormone replacement therapyHormone therapy and selective estrogen-receptor modulators should not be used for primary CHD prevention (Class III, Level A).
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  12. Lifestyle changes that may assist in achieving healthy blood pressure include

    PRIMARY CHD PREVENTION

    CLINICAL RECOMMENDATIONS FOR PRIMARY CHD PREVENTION IN WOMEN

    Lifestyle Interventions
    Cigarette smoking
    Women should not smoke and should avoid environmental tobacco smoke.
    Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or formal smoking cessation program (Class I, Level B).
    Dietary intakeWomen should consume a diet rich in fruits and vegetables (5 servings/day), whole-grain, high-fiber foods, nuts and legumes, low-fat dairy products and omega-3 fatty acids (in the form of oily fish at least twice a week); limit sweets, sugar-sweetened beverages, red meats, saturated fat (<7% of total energy intake), cholesterol <150 mg/d, alcohol intake no more than 1 drink per day, sodium intake <1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty acids (Class I, Level B).
    Weight maintenance/reductionWomen should maintain or lose weight through an appropriate balance of caloric intake, physical activity, and formal behavioral programs when indicated to maintain/achieve a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist circumference ≤35 in (Class I, Level B).
    Physical activity
    Women should accumulate at least 150 minutes/week of moderate exercise, 75 minutes/week of vigorous exercise, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week (Class I, Level B).
    Women should be advised of additional cardiovascular benefits by increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5 hours/week of vigorous-intensity physical activity, or an equivalent combination of both (Class I; Level of Evidence B).
    Women should engage in muscle-strengthening activities involving all major muscle groups on ≥2 days/week (Class I; Level of Evidence B).
    Women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of at least moderate-intensity physical activity (e.g., brisk walking) on most (and preferably all) days of the week (Class I, Level B).
    Major Risk Factor Interventions
    Blood pressure—optimal level and lifestyleEncourage an optimal blood pressure of <120/80 mm Hg through lifestyle approaches such as weight control, increased consumption of fresh fruits, vegetables and low-fat dairy products, sodium restriction, increased physical activity, and alcohol moderation (Class I, Level B).
    Lipid and lipoprotein levels—optimal levels and lifestyleLifestyle approaches should be encouraged to achieve the following levels of lipids and lipoproteins: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I, Level B).
    DiabetesLifestyle and pharmacotherapy should be used in women with diabetes to achieve a HbA1c <7% without significant hypoglycemia (Class IIa, Level B).
    Preventive Drug Interventions
    Omega 3 fatty acid supplementationCapsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered with hypercholesterolemia and/or hypertriglyceridemia. Note: Fish oil dietary supplements may have widely variable amounts of EPA and DHA (likely the only active ingredients) (Class IIb, Level B).
    Blood pressure—pharmacotherapyPharmacotherapy is indicated when blood pressure is ≥140/90 mm Hg or ≥130/80 mm Hg) in women with diabetes or chronic kidney disease. Thiazide diuretics should be part of the drug regimen for most women (unless contraindicated) or if there are compelling indications for other agents in specific vascular diseases.
    Aspirin or clopidogrel
    High-risk women: Aspirin therapy (75–325 mg/d)a should be used (unless contraindicated) (Class I, Level A). If a high-risk woman is intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B).
    Women with diabetes: Aspirin therapy (75–325 mg/d) is reasonable (unless contraindicated) (Class IIa, Level B).
    Women 40 to 59 years of age with an estimated 10-year cardiovascular risk of at least 10% per ACC/AHA equations: The net benefit is small and should be considered through shared decision-making.
    Women 60 to 69 years of age with at least 20% 10-year cardiovascular risk or with diabetes and an estimated risk of at least 10%: Aspirin therapy should be considered in the context of no excess risk of bleeding and shared decision-making (USPSTF Grade C).
    Class III Interventions (Not Useful/Effective and May Be Harmful)
    Antioxidant supplementsAntioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should not be used for primary CHD prevention (Class III, Level A).
    Folic acidFolic acid, with or without B6 and B12 supplementation, should not be used for primary CHD prevention (Class III, Level A).
    Aspirin for MI in women <65 years of ageRoutine use of aspirin therapy in healthy women is not advised (Class III, Level B; USPSTF Grade D).
    Hormone replacement therapyHormone therapy and selective estrogen-receptor modulators should not be used for primary CHD prevention (Class III, Level A).
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  13. Exercise increases

    PRIMARY CHD PREVENTION

    Reports on physical activity and CHD in women have been conflicting. While some studies have found no reduction in CHD risk, many other studies have demonstrated lower all-cause mortality in women and men with higher levels of fitness. A study published in 2001 reported that even light-to-moderate amounts of exercise (i.e., at least one hour of walking a week) were associated with a lowered risk of CHD in women [297]. This correlation extended to women with heightened risk for CHD, including those who were overweight, had high cholesterol, or smoked.

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  14. The Nurse's Health Study demonstrated that low-dose aspirin is associated with what percentage reduction in heart attack risk in women?

    PRIMARY CHD PREVENTION

    As with men, low-dose aspirin therapy may play a role in the primary prevention of CHD in women. Aspirin works as a thromboxane inhibitor keep blood platelets from sticking together and forming clots [281]. The NHS demonstrated a 32% reduction in risk of first MI in women who took low-dose aspirin (i.e., one to six aspirin per week) [303]. While low-dose aspirin may be associated with a somewhat lower cardiovascular and total mortality rate in women, its cardioprotective role is not without limitations. The benefit of such therapy should be weighed against the risk of stroke and gastrointestinal bleeding [304]. In 2022, the U.S. Preventive Services Task Force issued updated guidance regarding the use of aspirin for cardioprotection [304]. They recommend against initiating low-dose aspirin use for the primary prevention of cardiovascular disease in adults 60 years or older. The decision to initiate low-dose aspirin use for the primary prevention of cardiovascular disease in adults 40 to 59 years of age who have a 10% or greater 10-year risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit [304].

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  15. Noncoronary causes of anginal-type symptoms in women include

    CARDIAC DIAGNOSTIC TESTS

    The diagnosis of CHD is a more complex process in women for two primary reasons: age at presentation and differences in presenting symptoms. As noted, women are typically 5 to 10 years older than men when presenting with CHD, which may be due either to delays in diagnosis or presentation. When women do present, other conditions, such as osteoporosis, diabetes, or hypertension, as well as the provider's interpretation of the woman's chest pain, may obscure the indications of disease. Noncoronary causes of chest pain are also more prevalent in the female population. Chest pain in women is frequently accompanied by abdominal pain, dyspnea, nausea, fatigue, and greater functional disability [138,139,140]. Additionally, a variety of intrathoracic and extrathoracic structures may cause symptoms localizing to the chest, such as mitral valve prolapse, pericarditis, or gallbladder disease. Therefore, the differential diagnosis of chest pain must include a number of conditions to prevent a false-positive diagnosis of CHD in women [140,141]. Table 5 outlines the differential diagnosis to first rule out the most critical problems.

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  16. In the diagnosis of CHD in women, clinical history and physical examination

    CARDIAC DIAGNOSTIC TESTS

    To further complicate the picture, the clinical history and physical exam have limited value in women older than 65 years of age with definite angina [139]. The history and physical exam do provide information on the occurrence of prior events and risk factors and also uncover symptoms of more advanced disease. However, these diagnostic clues often only partially indicate disease likelihood, which makes further diagnostic tests important and necessary [139,145,146]. The presence of new physical assessment findings, such as dysrhythmias, mitral regurgitation, a fourth heart sound (atrial gallop), or bibasilar crackles, increases the chances of a positive diagnosis of CHD [147]. The diagnosis is also favored by the presence of other cardiovascular risk factors or by ECG changes at rest or during anginal episodes [147].

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  17. Which of the following noninvasive tests for CHD is considered controversial in women?

    CARDIAC DIAGNOSTIC TESTS

    Exercise ECG (also referred to as the stress test or exercise treadmill test) may not be as accurate in the diagnosis of CHD in women as in men [347]. However, the ACCF and the AHA recommend the routine use of the exercise ECG (when combined with traditional analysis of ST-segment and heart rate changes) for evaluating suspected CHD in women who have a normal resting ECG and good exercise tolerance [150]. Women with nonobstructive disease and stress test abnormalities are no longer defined as having a false-positive test. Instead, their test is classified as abnormal, and they are noted as being at an elevated risk of obstructive CHD [150]. A test result that is clearly negative has been found to be equally reliable in both women and men [141]. Better diagnostic results are seen in women with multivessel involvement versus single vessel or no disease. With multivessel disease, an overall accuracy of 84% has been reported [150].

    Even in women with CHD, the accuracy of using exercise ECG for diagnosis alone is not recommended. When test results are clearly positive or not clearly positive or negative, additional risk stratification with cardiac imaging is recommended [150]. The ACCF/AHA have recommended cardiac imaging for symptomatic women with established CHD, women who have an indeterminate or intermediate-risk exercise ECG test, and women with an intermediate-risk Duke treadmill score. Cardiac imaging has also been recommended for women with diabetes, metabolic syndrome, and polycystic ovary syndrome because of their increased risk of cardiovascular death [122,150].

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  18. With nuclear myocardial perfusion scans

    CARDIAC DIAGNOSTIC TESTS

    The nuclear medicine myocardial perfusion scan is another noninvasive test that may be used in women. At peak exercise, a small amount of radioactive tracer is injected and a series of images of myocardial blood flow are then evaluated. Normal myocardial blood flow is indicated by a homogeneous distribution of thallium throughout the myocardium, while myocardial ischemia and/or infarction is suggested by either a transient or persistent defect in tracer uptake. Compared with exercise ECG, nuclear medicine perfusion tests have better accuracy with fewer false-positive results in women, especially in patients with multivessel disease [141,151,152,153].

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  19. Major drawbacks associated with cardiac catheterization include all of the following, EXCEPT:

    CARDIAC DIAGNOSTIC TESTS

    Coronary angiogram is the definitive diagnostic test to detect CHD despite major drawbacks, such as its invasive nature, cost, and potential complications [11]. While the number of catheterizations performed on women has increased, men are more likely to be referred for catheterization than women, possibly because women may be at greater risk of adverse events after angiogram, including death [167,168,169,170]. One study found that men were 40% more likely to undergo angiography than women, despite angiography data indicating women have more functional impairment and unstable symptoms than men [171,172].

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  20. In women, CHD most commonly presents as

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    After menopause, the clinical manifestations of CHD increase in women. The most common CHD manifestation in both men and women is angina [178]. Approximately 9.1 million women in the United States are currently living with CHD; 35,000 are younger than 65 years of age, and 4 million suffer from angina [1,56]. The basic forms of angina include stable angina, unstable angina, and variations of angina. In terms of incidence, stable angina occurs more frequently in women in the United States than in men, with an estimated female-to-male ratio of 1.7:1 [178,179].

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  21. Women with what type of angina have the greatest likelihood of three-vessel or left main CHD?

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    Stable anginal episodes often worsen and become more severe, leading to unstable angina. Unstable angina is a type of chest pain that radiates more widely, may occur at rest, and is difficult to relieve. Women who suffer from unstable angina have the greatest likelihood of significant coronary artery stenosis and three-vessel or left main CHD. Consequently, these women are at greatest risk to experience more serious cardiac events, such as an MI or sudden cardiac death [180].

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  22. Microvascular angina

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    By definition, microvascular angina is characterized by the presence of angiographically normal coronary arteries. In women with this syndrome, plaque accumulates in very small arteries of the heart, causing arterial narrowing, reduced oxygen flow to the heart, and pain that may be similar to that experienced by patients with blocked major coronary arteries. As noted, the difficulty with microvascular angina is that plaque does not appear when using standard tests. Rather, PET scan or magnetic resonance imaging are the primary diagnostic tools, as discussed [347]. The exact etiologic mechanism of microvascular angina is not known. It has been speculated that up to 80% of cases may be due to hypersensitivity in the nerves that lead to the heart, esophagus, and chest, making women acutely aware of sensations in their heart. Another possibility is that the syndrome is caused by a disorder of the small blood vessels that feed the heart, wherein the vessels fail to dilate in response to physical and/or emotional stress. The syndrome could also be due to a hormonal imbalance induced by a deficiency of estrogen. Women with this type of angina have less of a likelihood of significant CHD, and therefore a better prognosis, compared to other forms of angina. However, these women are still at risk of suffering an MI or, at a minimum, of experiencing a reduced quality of life [183,184,185,186]. Many women respond to risk factor modification through cardiac rehabilitation and to pharmacotherapy with beta blockers, calcium channel blockers, and nitrates.

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  23. Which of the following cardiac symptoms is more common in women than in men?

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    Women may complain of classic substernal pain or have variations in their chest pain syndromes for reasons that are not completely understood. Women frequently report pain centered in the chest, pain in one or both arms, pain in the neck and/or jaw, or pain centered in the back and/or shoulders. Women also frequently report nausea, back pain, dizziness, generalized fatigue, shortness of breath, and palpitations [139,145,187,189,190]. Recognition of these sex differences in symptom reporting may result in more prompt and accurate diagnosis and treatment, as well as preventable deaths.

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  24. Which of the following is a factor that places women at increased risk for silent MIs and/or sudden cardiac death?

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    Unrecognized or silent MIs are more frequent in women (54%) than men (33%), accounting for more than 50% of all infarctions in women 55 years of age and older [201]. Factors that place women at increased risk include older age, hypertension, and diabetes [201]. As mentioned previously, sudden cardiac death generally occurs about 5 to 10 years later in women compared to men.

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  25. Which of the following explains why cardiac enzyme elevations may be lower in women than in men?

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    Accurate diagnosis of myocardial injury and/or infarction is aided by measurement of serial cardiac enzymes [166]. Due to smaller body size, enzyme elevations may not be as high in women as those seen in men. This information is important to know when analyzing and interpreting enzyme rises in female patients presenting with cardiac symptoms. Further research is needed to explore sex-specific cardiac enzyme activity patterns [19].

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  26. Which of the following complications occur more frequently in women post-MI than in men?

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    Heart failure tends to be more severe in women despite their higher left-ventricular EF and less severe ventricular dysfunction, perhaps due to the adverse effects of diabetes and hypertension on left ventricular diastolic function [11,19,35,338]. Furthermore, the incidence of supraventricular and ventricular dysrhythmias, as well as heart block, appears to be similar in women and men [56,338]. However, more ventricular dysrhythmias have been reported in young women with MI who use hormonal contraceptives. Women also have a much higher risk of stroke post-MI and death from stroke compared with men [56].

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  27. Compared with other women post-MI, young women who use hormonal contraceptives are at an increased risk for

    CLINICAL MANIFESTATIONS OF CHD IN WOMEN

    Heart failure tends to be more severe in women despite their higher left-ventricular EF and less severe ventricular dysfunction, perhaps due to the adverse effects of diabetes and hypertension on left ventricular diastolic function [11,19,35,338]. Furthermore, the incidence of supraventricular and ventricular dysrhythmias, as well as heart block, appears to be similar in women and men [56,338]. However, more ventricular dysrhythmias have been reported in young women with MI who use hormonal contraceptives. Women also have a much higher risk of stroke post-MI and death from stroke compared with men [56].

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  28. Women are less likely to receive thrombolytic therapy in the treatment of MI due to

    THERAPEUTIC INTERVENTIONS

    Thrombolytic therapy is frequently given to patients within the first six hours of presenting with possible cardiac symptoms. It has proved beneficial in restoring vessel patency and improving clinical outcomes in both men and women (i.e., 25% to 30% reduction in short-term mortality) [209,216]. However, women are less likely to receive thrombolysis to restore vessel patency in the management of acute MI for several reasons, including advanced age, delayed arrival at the hospital, and medical contraindications [216]. Even in those eligible, women are less likely to receive thrombolytic therapy [217]. The Gruppo Italiano per lo Studio della Streptochinasi nell'infarto Miocardico (GISSI-1) first validated streptokinase as an effective therapy and reported a significant reduction in the 21-day mortality in women who received IV streptokinase within six hours post-MI. Despite these promising outcomes, treated women's mortality rates remain higher than men's [217,218,338]. The AHA recommends thrombolytic therapy be used at non-PCI centers when a significant delay to performing a primary PCI within 120 minutes of first medical contact is anticipated [338].

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  29. What is the treatment of choice for patients with single-vessel CHD?

    THERAPEUTIC INTERVENTIONS

    PCI is the treatment of choice for patients with single-vessel disease [207]. It offers patients a lower 30-day mortality rate compared with thrombolytic therapy [338]. An estimated 35% of PCIs in the United States are performed in women [208]. At the time this procedure was first performed, women tended to be on average nine years older than men, with more cardiovascular risk factors and severe unstable angina [208]. However, angiographically documented CHD has not been found to be more extensive in women compared to men [209]. On a per-lesion basis, angiographic success rates have been found to be similar between men (88%) and women (89%), as were clinical success rates [209,210]. Determinants of PCI success include lesion-specific angiographic features, such as the severity of stenosis, coronary calcification, and intralesional thrombosis-factors that are not influenced by either age or sex [211]. In treating left anterior descending disease, CABG surgery is an attractive option due to the high rate of post-PCI restenosis [208].

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  30. All of the following factors place female patients with CHD at increased surgical risk compared with men, EXCEPT:

    THERAPEUTIC INTERVENTIONS

    The Coronary Artery Surgery Study (CASS) investigated 2,800 women and 5,300 men who were experiencing severe enough chest pain to warrant a coronary angiogram. This study revealed a number of differences in the preoperative status of men and women. As discussed earlier, women were found to be at increased surgical risk because they tend to be older, have more unstable angina, frequent cardiac enlargement on chest x-ray, severe mitral regurgitation, and more symptoms and comorbidities, such as hypertension, diabetes, and heart failure. Factors that place women at lower risk include they tend to have fewer diseased arteries and less myocardial damage. In other words, women generally have better EFs and ventricular wall motion, as well as less left main stenosis and three-vessel disease [11,19,26,27,35]. It has been suggested these differences in preoperative status may be less related to sex than to delays in the initial diagnosis and treatment of symptomatic CHD in women. This delay translates into an older age and more frequent comorbidity in women at surgical presentation [219,220].

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  31. Surgical intervention referral patterns in women with CHD indicate that women are most often referred

    THERAPEUTIC INTERVENTIONS

    CABG surgery continues to be the criterion standard in the treatment of multi-vessel CHD in both men and women. However, women tend to be referred for surgery much later in relation to men. In one study, fewer women with symptoms were referred for angiogram, and men underwent CABG four times as often as women. Women were referred more for symptoms of unstable angina, heart failure, and post-MI angina, while men were referred on the basis of a positive exercise ECG [19,26]. As a result, women are more likely to have surgery on an emergency basis, with potentially fewer techniques available to the surgeon, rather than on an elective basis, as is common in men. For example, the use of left internal mammary artery (LIMA) grafts is accepted as the criterion standard for surgical revascularization. Many studies have demonstrated better long-term patency rates and survival in patients undergoing CABG with LIMA [223,224]. The benefit of LIMA grafts has been observed consistently regardless of age, sex, stenosis severity, or LV function. Although a number of risk factors have been identified to result in LIMA graft failure, they are less common than for other grafts [224]. Nevertheless, the risk-to-benefit question is of increasing importance as the proportion of high-risk subgroups continues to rise [223,225].

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  32. During the first four weeks of recovery post-CABG surgery, women were more likely than men to report

    THERAPEUTIC INTERVENTIONS

    An interesting study compared the symptoms experienced by men and women during the first four weeks of recovery post-CABG surgery. Women reported numbness and discomfort in their breasts, while men reported more fatigue, incisional pain, and negative emotions. Both men and women felt their recovery emotions were related to their social roles and circumstances [225]. For instance, women were concerned and anxious about who would care for them during their home recovery, as they tended to be older and live alone. In contrast, men were more concerned first with their immediate physical recovery symptoms and secondly with return to work issues [233]. Researchers have noted that women tend to find strength for the postoperative recovery phase from their own spirituality and relationships with others, especially their families, friends, and social networks [234]. One study found that women's primary concerns shifted over the course of one year after CABG surgery [235]. In the first postoperative month, women were most concerned with issues related to future plans, such as progress in recovery and resuming their lifestyle. By one year after surgery, women were most concerned about diet, and more than half of the women were exercising more.

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  33. Women are reported to drop out of formal cardiac rehabilitation programs due to

    THERAPEUTIC INTERVENTIONS

    A number of factors account for the lower program completion rates among women. These factors include family commitments, financial concerns such as insurance barriers, and lack of spousal support. Other reasons for decreased program attendance in both men and women include transportation problems, distance, cost, work conflicts, medical reasons, and having a sense of personal control over their condition [238,243]. Societal barriers, such as low education, may also impede enrollment in a rehabilitation program [244]. However, women's attendance at cardiac rehabilitation programs is more often affected by medical reasons compared to men, with complaints of increased angina and other associated symptoms, comorbidities such as arthritis and peripheral vascular disease, and/or a need for admission to transitional care postdischarge. This trend may be due to the presence of more cardiovascular risk factors and increasing cardiac symptoms in women [26,241,245]. On the other hand, men usually receive more family support and are accompanied by their spouse to cardiac rehabilitation programs more often than women, a finding that may partially explain women's higher dropout rates.

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  34. Assessment to determine which women are at an increased risk for not participating in cardiac rehabilitation program should include all of the following, EXCEPT:

    THERAPEUTIC INTERVENTIONS

    Nurse-led coordination of care after hospital discharge may have a role in improving rehabilitation uptake [248]. Some experts advocate giving nurses more responsibility to educate and motivate women to complete their recovery by participating in outpatient cardiac rehabilitation [249]. By assessing each woman prior to discharge, those women who are at increased risk for not participating may be identified and targeted for follow-up. This assessment should include a woman's psychological state, namely anxiety and depression, as well as other factors like functional status; education, employment and socioeconomic status; and availability of social support.

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  35. Which of the following areas should be covered in patient education for women with CHD?

    IMPLICATIONS FOR NURSING PRACTICE

    Patient education for women with CHD should incorporate several components, including the disease process, diagnostic tests, medications, the recovery process, and risk-factor modification. In relation to the disease process, female patients should be taught symptom recognition and early treatment of complications. The positive long-term outcomes of women with angina and post-PCI and CABG surgery should be stressed when counseling patients regarding the recovery process. Medication teaching should include a description of the action and effects of the cardiac medication, along with the dosage, frequency, and possible side effects. The nurse may also act as a patient advocate with regard to diagnostic testing. Attempt to ensure that the appropriate diagnostic tests and treatment procedures are provided to the patient. Finally, risk factor modification enhances the patient's progress and quality of life [271].

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  36. Which of the following is recommended for the primary or secondary prevention of CHD?

    IMPLICATIONS FOR NURSING PRACTICE

    CLINICAL RECOMMENDATIONS FOR SECONDARY CHD PREVENTION IN WOMEN

    Blood Pressure
    Beta blockers
    All women after MI or acute coronary syndrome with normal left ventricular function: Beta blockers should be used for up to 12 months (unless contraindicated): (Class I, Level A).
    Women with left ventricular failure: Long-term beta-blocker therapy should be used indefinitely (unless contraindicated) (Class I, Level A) and may be considered in other women with coronary or vascular disease and normal left ventricular function (Class IIb, Level C).
    ACE inhibitorsWomen after MI and in those with clinical evidence of heart failure or an LVEF ≤40% or with diabetes: ACE inhibitors should be used (unless contraindicated) (Class I, Level A).
    ARBsWomen after MI and in those with clinical evidence of heart failure or an LVEF ≤40% or with diabetes who are intolerant of ACE inhibitors: ARBs should be used (Class I, Level B).
    Aldosterone blockadeAfter MI in women without significant hypotension, renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor and beta blocker and have LVEF ≤40% with symptomatic heart failure: Use aldosterone blockade (Class I, Level B).
    Lipids
    Pharmacotherapy for high-risk womenVery-high-risk women with CHD plus multiple major risk factors, severe and poorly controlled risk factors or diabetes to achieve an LDL <100 mg/dL (Class I, Level A), and women with other atherosclerotic CHD or diabetes or 10-year absolute risk >20%: Utilize LDL-lowering drug therapy simultaneously with lifestyle therapy (Class I, Level B).
    Pharmacotherapy for low HDL, or elevated non-HDL, high-risk womenVery-high-risk women with CHD who may require an LDL-lowering drug combination: Utilize niacin or fibrate therapy when HDL is low or non-HDL is elevated in high-risk women after LDL goal is reached (reduction to <70 mg/dL is reasonable) (Class IIa, Level B).
    Pharmacotherapy for low HDL or elevated non-HDL, other at-risk womenWomen with multiple risk factors and a 10-year absolute risk 10% to 20%: Consider niacin or fibrate therapy when HDL is low (<50 mg/dL) or non-HDL is elevated (>130 mg/dL) after LDL goal is reached (Class IIb, Level B).
    Pharmacotherapy for other at-risk women
    Women with or without CHD risk factors on lifestyle therapy: Utilize LDL-lowering therapy if LDL ≥190 mg/dL (Class I, Level B).
    Women with multiple risk factors even if 10-year absolute risk is <10%: Utilize LDL-lowering therapy if LDL level is>160 mg/dL with lifestyle therapy (Class I, Level B).
    Women older than 60 years of age with an estimated CHD risk 10%: Statins could be considered if hs-CRP is >2 mg/dL after lifestyle modification and no acute inflammatory process is present (Class IIb, Level B).
    Women with multiple risk factors and 10-year absolute risk 10% to 20%: Utilize LDL-lowering therapy if LDL is ≥130 mg/dL with lifestyle therapy (Class I, Level B).
    Antiplatelet Therapy
    Aspirin or clopidogrel
    High risk women: Aspirin therapy (75–325 mg/d)a should be used (unless contraindicated) (Class I, Level A). If intolerant of aspirin therapy, clopidogrel should be substituted (Class I, Level B).
    Women with diabetes: Aspirin therapy (75–325 mg/d) is reasonable (unless contraindicated) (Class IIa, Level B).
    Class III Interventions (Not Useful/Effective and May Be Harmful)
    Menopausal therapyHormone therapy and selective estrogen-receptor modulators should not be used for secondary CHD prevention (Class III, Level A).
    Antioxidant supplementsAntioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should not be used for secondary CHD prevention (Class III, Level A).
    Folic acidFolic acid, with or without B6 and B12 supplementation, should not be used for secondary CHD prevention (Class III, Level A).
    Lifestyle Interventions
    Cardiac rehabilitationWomen with a recent acute coronary syndrome or coronary intervention, new-onset or chronic angina, recent cerebrovascular event, or peripheral arterial disease (Class I, Level A), or current/prior symptoms of heart failure and a left ventricular EF (LVEF) <35%: Comprehensive risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program should be recommended (Class I, Level B).
    aAfter PCI with stent placement or CABG surgery within previous year and in women with noncoronary forms of CHD, use current guidelines for aspirin and clopidogrel.
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  37. Women have formerly been excluded from large-scale clinical trials related to CHD due to

    IMPLICATIONS FOR FURTHER RESEARCH

    Women of reproductive age have been excluded from cardiovascular studies due to the possible risks to any potential fetus, while older women have been excluded because they often have multiple health problems that may create health risks or confuse the research findings. As a result, women have had restrictions in clinical care, such as the underutilization of thrombolytic therapy for the management of evolving MIs. Age-based exclusions of women from clinical trials on invasive diagnostic or therapeutic techniques have also limited the participation of women [7,325,326].

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  38. Difficulties regarding the current base of research related to CHD include

    IMPLICATIONS FOR FURTHER RESEARCH

    Additionally, sample sizes of existing studies have traditionally been too small to either evaluate effects or draw conclusions about care for women. As a result, the findings of studies conducted with men, as well as with younger populations, have been used to diagnose and treat women and older adults. In other words, studies done on men were driving clinical practice with female patients. Yet, research indicates that differences exist in cardiovascular risk factors, disease presentation, diagnosis, and response of women to various CHD treatments [122,327].

    At the federal level, two major initiatives have been instituted to expand the base of research related to women-specific health issues. The NIH has mandated investigators include women and minorities in clinical research populations for health-related studies. At the very least, the investigator must adequately justify any decisions to exclude potential subjects from these studies [328]. A second factor that has influenced the research base related to women's health is the development of the NIH Interdisciplinary Women's Health Research Center, formed to encourage studies related to issues affecting women's health [329]. In a 2016 AHA Scientific Statement, Mehta and colleagues discuss the need to develop strategies to increase the inclusion of women of all ages in clinical cardiovascular research [338]. Examples of possible strategies include raising the mandatory inclusion rates and requiring sex-stratified data reporting.

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  39. The Women's Health Initiative addresses all of the following major health issues of women, EXCEPT:

    IMPLICATIONS FOR FURTHER RESEARCH

    The Women's Health Initiative (WHI), a 15-year study of 160,000 women, was undertaken as the largest NIH clinical trial to answer questions regarding postmenopausal women's health. The WHI specifically addressed the major health problems of menopausal women, including CHD, cancer, and osteoporosis [330]. In relation to CHD, the WHI studied the effects of low-fat diets for prevention as well as the risks and benefits of hormone replacement therapy [330]. As discussed, the WHI trials investigated both combination (estrogen plus progestin) and unopposed estrogen hormone therapy. Both trials were cut short prior to the projected completion dates. In July 2002, the WHI halted the combination therapy trials due to a significantly increased incidence of breast cancer. In February 2004, the unopposed estrogen study was stopped when researchers determined that the heightened risk of stroke was unacceptable to continue the trial. In the case of the combination hormone study, researchers found an increased risk for MI, stroke, and venous thromboembolism. The estrogen-only study resulted in increased risk of stroke and venous thromboembolism, but no difference in the risk of MI [316,317]. There is some controversy regarding the trials' designs and whether the findings are universally applicable [331,332]. However, the FDA continues to recommend against the routine use of hormone replacement therapy as preventive treatment for CHD in postmenopausal women [333].

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  40. Further research studies are needed on

    IMPLICATIONS FOR FURTHER RESEARCH

    Beyond the large NIH trials that have been initiated, other research by various disciplines is needed about women and CHD. This research involves asking questions such as those listed in Table 8, related to cardiovascular risk factors, the impact of CHD on the patient and family, the clinical course of women with CHD, and intervention studies. For instance, why do women fail to receive diagnostic studies or therapeutic interventions to the same extent that men do? Many studies have shown less active or aggressive diagnosis and management of CHD in women. Fewer women with positive noninvasive cardiac tests are catheterized and fewer women have revascularization by either PCI or CABG surgery compared to men [122,205,225,334]. The question remains: Are men overtreated, or are women undertreated?

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