Sex Differences in the Coronary System.
Sex Differences in the Coronary System.
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DOI：
10.1007/978-3-319-77932-4_17
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发表时间：
2018
影响因子：
--
通讯作者：
Taqueti VR
中科院分区：
文献类型：
--
作者：
Taqueti VR
心血管疾病仍然是男女发病和死亡的主要原因。新出现的证据支持缺血性心脏病（IHD）可能在女性和男性中表现不同，从疾病的临床表现，诊断和管理到心肌细胞功能和冠状动脉循环的基本生物学和生物力学。与男性相比，女性始终存在更高的症状和合并症负担，并且结局更差。这些数据已经被证明是令人困惑的，因为女性在冠状动脉造影中表现出阻塞性冠状动脉疾病（CAD）的可能性降低。报告的性别差异长期以来一直受到将心脏病主要定义为阻塞性CAD的实践的影响，但阻塞性斑块现在被认为既不必要也不足以解释IHD的症状，并且仅针对这部分患者制定诊断和治疗策略已不再足够。迄今为止，女性在改变指南的心脏病研究和试验中的代表性仍然不足，这对心血管医学的证据基础造成了重要的限制。与男性相比，女性心外膜冠状动脉较小，加上在整个生命周期内剪切应力和炎症介质的差异，可能会将易感患者的CAD发展改变为弥漫性模式，冠状动脉血管功能障碍的贡献大于局灶性阻塞。最近的研究证实，有症状的女性比男性更容易出现非阻塞性CAD和冠状动脉微血管功能障碍。当存在时，这些过程会增加女性和男性的心血管风险，但可能在一部分严重受影响的女性中构成一种特别恶性的表型，不仅对CAD的治疗有影响，而且对射血分数保留的心力衰竭的治疗也有影响。这代表了冠状动脉系统中性别差异的最新综述，着眼于不同的病理生理过程如何导致女性和男性普遍存在的IHD表型。根据目前的范例，除了为女性和男性提供公平的最佳护理外，还需要了解IHD的病理生理学，而不仅仅是传统的阻塞性CAD，以解决其预后的生物学和环境决定因素。艺术品：Piet Piraels，比利时鲁汶
Cardiovascular disease remains the leading cause of morbidity and mortality for both women and men. Emerging evidence supports that ischemic heart disease (IHD) may manifest differently in women and men, in ways ranging from the clinical presentation, diagnosis, and management of disease to the basic biology and biomechanics of cardiomyocyte function and the coronary circulation. Women consistently present with a higher burden of symptoms and comorbidities as compared with men and experience worse outcomes. These data have proved perplexing given the decreased likelihood of women to demonstrate obstructive coronary artery disease (CAD) on coronary angiography. Reported sex differences have long been influenced by the practice of defining heart disease primarily as obstructive CAD, but obstructive plaque is now recognized as neither necessary nor sufficient to explain symptoms of IHD, and it is no longer adequate to tailor diagnostic and treatment strategies only to this subset of patients. To date, women remain underrepresented in guideline-changing heart disease research and trials, creating important limitations in the evidence base for cardiovascular medicine. Smaller epicardial coronary arteries in women as compared to men, coupled with differences in shear stress and inflammatory mediators over the life span, may modify the development of CAD in susceptible patients into a diffuse pattern with more contribution from coronary vasomotor dysfunction than focal obstruction. Newer studies corroborate that symptomatic women are more likely than men to present with nonobstructive CAD and coronary microvascular dysfunction. When present, these processes increase cardiovascular risk in both women and men but may constitute an especially malignant phenotype in a subset of severely affected women, with implications for the management of not only CAD but also heart failure with preserved ejection fraction. This represents a state-of-the-art review of sex differences in the coronary system, with an eye toward how diverse pathophysiological processes may contribute to IHD phenotypes prevalent in women and men. Beyond providing women and men with equitable optimal care according to current paradigms, understanding the pathophysiology of IHD beyond a conventional focus on obstructive CAD is needed to address what is likely a combination of biological as well as environmental determinants of their prognosis. Artwork by Piet Michiels, Leuven, Belgium
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