|Year : 2019 | Volume
| Issue : 1 | Page : 60-67
Clinical and coronary angiographic profile in women presenting with anginal chest pain: Results from a single-center prospective observational study
Kunal Mahajan1, Arvind Kandoria1, Rajeev Bhardwaj1, Prakash Chand Negi1, Sanjeev Asotra1, Gunjan Gupta2
1 Department of Cardiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Department of ENT, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||4-Feb-2019|
Department of Cardiology, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Limited data exist regarding the risk factor and angiographic profile of coronary artery disease (CAD) in Indian women presenting with anginal chest pain. Methods: In this single-center study, we prospectively analyzed data from 674 consecutive female patients who underwent coronary angiography for suspected CAD over a period of 2 years (2015–2017). Results: Patients were divided into three groups according to age as follows: Group 1 (<45 years), Group 2 (45–55 years), and Group 3 (>55 years). Women in Groups 2 and 3 were more likely to be smokers and were more likely to have diabetes, hypertension, and high-density lipoprotein-cholesterol <40 mg/dl. In contrast, younger women (Group 1) were more likely to have a positive family history of a premature CAD, Body mass index >23 Kg/m2, deranged Low density lipoprotein-cholesterol, and serum triglycerides. Obstructive CAD was seen more often in Group 3 patients (67.6%) compared to Group 2 (45%) and Group 1 (40.4%) (P < 0.0001). Normal epicardial coronaries/nonobstructive CAD and endothelial dysfunction were seen more commonly in Group 1 patients in comparison to Group 2 and 3 patients. Conclusion: The present study provides the largest contemporary data from an Indian female cohort undergoing coronary angiography. As the age advances, there occurs an increase in the number of CAD risk factors as well as the angiographic extent of disease.
Keywords: Angina, coronary angiography, women
|How to cite this article:|
Mahajan K, Kandoria A, Bhardwaj R, Negi PC, Asotra S, Gupta G. Clinical and coronary angiographic profile in women presenting with anginal chest pain: Results from a single-center prospective observational study. J Nat Sc Biol Med 2019;10:60-7
|How to cite this URL:|
Mahajan K, Kandoria A, Bhardwaj R, Negi PC, Asotra S, Gupta G. Clinical and coronary angiographic profile in women presenting with anginal chest pain: Results from a single-center prospective observational study. J Nat Sc Biol Med [serial online] 2019 [cited 2019 Jun 16];10:60-7. Available from: http://www.jnsbm.org/text.asp?2019/10/1/60/251500
| Introduction|| |
Coronary artery disease (CAD) is the major cause of mortality in women in both the developed and developing countries., Long thought of as a disease primarily affecting men, the current data show that more women than men die of CAD in the United States. More women have died of CAD than of cancers, infections, and accidents combined., Recently, we have witnessed an increase in coronary death rates among young adults of both genders, but the increase is substantially more prominent among young women. This increase in coronary deaths among young adults has closely correlated with the steady increases in unfavorable coronary risk factors, mainly diabetes, hypertension (HTN), and metabolic syndrome., Two of every three women have at least one of the classic risk factors for heart disease: age >55 years, family history of premature heart disease, tobacco smoking, HTN, dyslipidemia, obesity, and diabetes mellitus. Certain risk factors have been shown to be more causally related to CAD in women. These include diabetes, metabolic syndrome, low high-density lipoprotein-cholesterol (HDL-C) and smoking.,,, Diabetes increases the risk for CAD among women by 3–7 times, in comparison to only a 2–3 times increased risk in diabetic men. There is evidence that in patients with metabolic syndrome, the relative risk for development of CAD was 2.63 in women as compared with 1.98 in men. Similarly, smoking has been found to be more detrimental to women than in men. Female smokers die 14.5 years earlier than female nonsmokers, whereas male smokers die 13.2 years earlier than male nonsmokers. In the Framingham study, low HDL-C was shown to be a predictor of CAD, more so in women than men. Similarly, elevated triglycerides have been shown to be of greater risk to women than to men.,,
It is well documented that the presence and severity of CAD in both men and women increases as the age advances. However, in contrast to the linear increase in CAD in men as they age, there is a more exponential increase in CAD in women after the age of 60 years. Increased prevalence of established risk factors, hormonal changes and lipid abnormalities associated with menopause and depleted estrogen levels have been described as some of the possible mechanisms of the rise of CAD in elderly women, but these remain yet to be proven.,
Although CAD being the most common cause of mortality among women, limited data exist addressing the risk factor profiles and the angiographic patterns of CAD in Indian women., In the present study, we aim to prospectively assess the risk factor profile and angiographic profile of CAD in women presenting with ischemic chest pain in a tertiary care center in the sub-Himalayan state of Himachal Pradesh in northern India.
| Methods|| |
The study was performed as a prospective observational, single-center study in Indira Gandhi Medical College (IGMC), which is a tertiary care hospital in Himachal Pradesh, India.
All consecutive female patients undergoing coronary angiography in the Department of Cardiology of IGMC Shimla with chest pain secondary to suspected CAD over a period of 2 years (March 1, 2015–February 28, 2017) were considered for participation in the study. These included the patients with chronic stable angina, atypical chest pain and patients with the acute coronary syndrome (ACS). The patients who were unwilling or refused to give informed consent were excluded from the study. The other exclusion criteria included the presence of renal failure, cardiomyopathy, pulmonary arteryHTN, congenital heart disease, valvular heart disease, pregnancy, noncardiac chest pain including traumatic or infective causes of chest pain, and serious or unstable medical and psychological conditions that would compromise the patient's safety or successful participation in the study. Patients were divided into three groups as follows: <45 years of age (Group 1), 45–55 years of age (Group 2), and >55 years of age (Group 3). All the three groups were then compared with respect to their clinical profiles, risk factor profiles, and coronary angiographic profiles.
After informed written consent, detailed information regarding the cardiovascular risk factors was recorded, and meticulous physical examination was done using appropriate validated tools and methodology. All patients were subjected to structured medical history for assessing the nature of chest pain, duration of chest pain, and risk factor status. The detailed physical examination was carried out including pulse, blood pressure, and cardiovascular examination. All the patients underwent routine laboratory tests before coronary angiography. The blood samples were drawn after overnight fasting for laboratory tests. These included hemoglobin, fasting blood sugar, glycated hemoglobin (HbA1c), serum creatinine, and lipid studies (total cholesterol, HDL, low-density lipoprotein (LDL), and triglycerides) which were conducted by certified laboratory specialists using standard protocol at the laboratory Department of IGMC Shimla. Postprandial blood sugar was recorded 2 h after the meals. In patients with documented records of these tests within the preceding 3 months, repeat testing was not done. Troponin-T/I measurement was done in all the patients presenting with Non-ST-elevation myocardial infarction/unstable angina (UA/NSTEMI) at least 6 h after onset of index chest pain. If the patient had undergone treadmill test (TMT) in the preceding 1 year, details were noted from the available records. All the patients were subjected to echocardiographic examination before coronary angiography, and the details regarding the presence of regional wall abnormalities, left ventricular dysfunction (Ejection fraction <50%), valvular dysfunction, and pulmonary artery HTN were recorded.
The type of angina was classified as typical or atypical. Typical angina was labeled if all of the following criteria were met: (1) substernal chest pain described as a feeling of heaviness, squeezing, crushing, or tightness, (2) provoked by exertion or emotional stress, and (3) relieved by rest and/or nitroglycerine within minutes. If 1–2 of the criteria were present, the symptoms were classified as atypical angina. If none or of the criteria was present, the pain was classified as noncardiac chest pain. HTN was defined as patient on treatment for elevated blood pressure or a systolic pressure ≥140 mm Hg and/or diastolic pressure ≥90 mmHg. Diabetes was defined as fasting blood glucose equal to or >126 mg/dl or 2-h postprandial blood glucose >200 mg/dl or HbA1c ≥6.5% and/or patients with a history of diabetes mellitus or who are receiving antidiabetic therapy. Smoker was defined as the one who regularly smoked an average of one or more cigarettes a day for at least 1 year. Patients who had given up smoking for >12 months were considered ex-smokers. The family history of premature CAD was considered positive in the presence of CAD in a first-degree male relative 55 years or less in age and/or a first degree female relative 65 years or less in age. Patients on lipid-lowering therapy or lipid levels in the following range were considered to have dyslipidemia: total cholesterol >240 mg/dl, triglycerides >150 mg/dl, LDL-cholesterol ≥130 mg/dl and HDL-cholesterol ≤40 mg/dl. Overweight/obesity was labeled in those with a body mass index (BMI) ≥23 kg/m2. Physical activity or exercise for <150 min/week was used as the criteria for defining sedentary life style. The diagnosis of ACS was made if the patient presented with new onset symptoms suggestive of ACS within preceding 1 week, associated with any one of the following:
- Electro cardiogram (ECG) changes suggestive of myocardial ischemia/infarction
- Elevated biomarkers of myocardial necrosis (any one of creatine kinase-muscle/brain/ Troponin-T or Troponin-I)
- History of documented CAD in the past.
ACS patients were then categorized into ST-segment elevation myocardial infarction (STEMI) or NSTEMI/UA. STEMI was diagnosed if ECG showed evidence of ST-segment elevation in ≥2 contiguous leads. The rest of the cases were labeled as NSTEMI/UA based on the presence of elevated biomarkers of myocardial necrosis.
Coronary angiography was performed with Siemens Artis Zee Cath Lab Equipment through the femoral or radial artery approach. A minimum of two orthogonal views were obtained for each vessel. Quantitative coronary analysis was used for quantification of coronary lesions. All the angiograms were evaluated by two separate cardiologists and all the discrepancies were sorted out before finalizing the reports. The angiographic pattern of coronary arteries was classified according to the number of major coronary arteries involved. It was called single, double, triple vessel disease (TVD) when one, two or three major coronary arteries were with >50% luminal stenosis, respectively. The arterial segments were seen in such views that have minimal overlapping or foreshortening of the lesions. The lesions were graded as follows:
- Obstructive = ≥50% of the luminal diameter reduction
- Nonobstructive disease ≤50% of the luminal diameter reduction and/or irregularities of the lumen.
- Normal epicardial coronaries = no stenosis and no lumen irregularities.
Endothelial dysfunction was defined by a corrected TIMI frame count >27 in vessels with no stenosis and no lumen irregularities. Myocardial bridging was defined by any degree of compression of a vessel segment during systole.
The study protocol was approved by the Institutional Review Board of IGMC Shimla. The study was conducted with the patients' understanding and consent. All work was conducted in accordance with the Declaration of Helsinki (1964).
Statistical analysis was performed using EPI INFO version 3.4.3 (Center for disease control and prevention, United States). Numerical variable was reported as the mean ± standard deviation, and categorical variables were presented as proportions. Chi-square test, Student's t-test, and analysis of variance were used to compare differences between the groups. All tests of statistical significance were considered statistically significant at the value of P < 0.05.
| Results|| |
Over a period of 2 years (March 1, 2015–February 28, 2017), a total of 798 female patients underwent coronary angiography in the Department of Cardiology, IGMC Shimla. A total of 124 patients were excluded based on the predefined exclusion criteria. The final study cohort consisted of 674 patients.
Age wise distribution of study groups
The patients were divided into three groups based on their age. Group 1 consisted of 99 women (14.7%) with age <45 years of age. Women with age 45–55 years were included in Group 2 (n = 220, 36.6%) and those with age above 55 years (n = 355, 52.7%) were labeled as group 3 [Figure 1]. Overall the mean age of the study cohort was 55.60 ± 10.07 years. The mean age of patients was 40.47 ± 3.53 years, 49.80 ± 3.38 years and 63.42 ± 6.01 years in Groups 1, 2, and 3, respectively (P < 0.0001) [Table 1]. It was seen that 79.7% of total study patients had attained menopause [Table 1].
|Table 1: Baseline clinical, demographic and risk factor profile of the study population|
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Distribution of risk factors
The baseline characteristics and risk factor profiles of the study groups are listed in [Table 1]. A total of 39.8% of patients had 3 or more risk factors for CAD. It was seen that as the age advanced, the proportion of patients with 3 or more risk factors increased, although this increase was not statistically significant (P = 0.14). Sedentary lifestyle practices were observed in 60.4% of patients and were seen equally among all the three study groups (P = 0.75). Overweight/obesity defined as BMI >23 kg/m2 was recorded in 331 (49.1%) patients. It was recorded more often in Group 1 (49.5%) and Group 2 (56.8%) patients as compared to Group 3 (44.2%) patients (P = 0.01). Diabetes was present in 20.6% of the study patients, more often in Group 2 (26.8%) and 3 (19.7%), and less frequently in Group 1 (10.1%) (P < 0.01). HTN was the most prevalent risk factor, recorded in 470 (69.7%) patients. Its prevalence increased with the advancing age, recorded in 76.9% of Group 3 patients. It was significantly higher than that recorded in Group 1 patients (55.6%) and Group 2 patients (64.5%). High LDL cholesterol levels >130 mg/dl and high Triglyceride level >150 mg/dl were seen in 54.3% and 27.3% patients, respectively. These were seen more frequently in younger patients, i.e., Group 1 patients (76.8% and 39.4%, respectively) as compared to Group 2 (52.7% and 23.2%, respectively) and Group 3 patients (49% and 26.5%, respectively) (P < 0.01). On the other hand, low HDL-cholesterol levels <40 mg/dl were seen in 40.8% of the study population, more frequently in older patients, i.e., Group 2 (44.1%) and Group 3 (43.9%), in comparison to Group 1 (22.2%) patients (P < 0.001). Smoking was prevalent in almost one-third of the study population. 25% of Group 2 patients and 32.7% of Group 3 patients used to smoke, as compared to only 14.1% among Group 1 (P < 0.001). The family history of premature CAD was found in 12.9% of the study cohort, however, it was significantly more frequent in Group 1 patients (45.1%) when compared to Group 2 (11.8%) and Group 3 (4.5%) patients (P < 0.0001).
Presentation Pattern [Table 1]
431 (63.9%) patients had presented with the diagnosis of chronic stable angina and 147 (21.8%) presented with atypical angina. While 6.7% of patients presented with STEMI, 7.6% of patients had NSTEMI/UA as the presenting diagnosis before coronary angiography. Atypical angina as presenting diagnosis was significantly more common in Group 1 women (29.3%) than Group 2 (25.5%) and Group 3 (17.5%) women (P < 0.01). While STEMI was more frequent among Group 3 women, NSTEMI/UA was more frequent in Group 1 women (P < 0.01). Abnormal resting electrocardiogram was observed in 408 (60.5%) patients and was more frequently observed in Group 2 (60.5%) and Group 3 (64.8%) than Group 1 (45.5%) (P < 0.01). TMT had not done in a large proportion of patients (61.1%) and this trend was more common in Group 3 patients (72.4%). The main reasons for TMT not being done included lack of recommendation by the treating physician, patient's inability to perform the exercise test, contraindications to the exercise test and presence of various confounders on surface ECG that would have affected the results of the exercise test. Among patients who had undergone TMT, a positive result was seen in 250 (37.1%) patients before undergoing coronary angiography. Positive TMT result was seen in 54.5% of Group 1 patients, 45% of Group 2 patients and 27.3% of Group 3 patients (P < 0.001). No statistically significant difference was noted regarding left ventricular dysfunction among the study groups.
Angiographic disease pattern [Table 2]
Out of total 674 patients, 254 (37.7%) were found to have normal epicardial coronary arteries. This was more commonly seen in Group 1 patients (59.6%) than Group 2 (46.4%) and Group 3 patients (26.2%) (P < 0.0001). A small number of patients (5.8%) had nonobstructive CAD, which was mainly seen in Group 2 (7.7%) and Group 3 (6.2%) patients. None of the Group 1 patients had nonobstructive disease on coronary angiography. Among those with a normal/nonobstructive CAD, 209 (71.3%) had evidence of endothelial dysfunction on coronary angiogram. It was seen more commonly in group 1 patients (86.4%), than Group 2 (72.3%) and Group 3 (62.6%) patients (P < 0.01). On the other hand, obstructive CAD was seen in 56.5% of overall patients. It was more commonly seen with advancing age and was significantly more frequent in Group 3 (67.6%) than Groups 1 (40.4%) and 2 (45.9%) (P < 0.0001).
Among the patients with an obstructive CAD, 158 (41.4%) were found to have SVD, 105 (27.6%) had DVD, and 118 (31%) had the TVD. In Group 1 patients, SVD (70%) was much more common than DVD (15%) and TVD (15%). On the other hand, patients in Groups 2 and 3 had DVD plus TVD more frequently than SVD (66.3% vs. 33.7, P < 0.01 in Group 2 and 60% vs. 40%, P < 0.01 in Group 3). LAD was the most frequently involved vessel in the entire study cohort, as well as in the Groups 1 and 3. In Group 2, RCA was more frequently involved than LAD, the difference was however insignificant (76.8% vs. 73.3%, P = 0.15) [Figure 2]. Significant left main coronary artery (LMCA) obstruction was seen in 35 (5.2%) patients. It was seen in 11.9% and 9.7% of patients in Group 2 and Group 3, respectively, but none in Group 1 (P = 0.03). Similarly, calcific lesions were seen more commonly in Group 3 patients (21.1%), but none in Group 1 patients (P < 0.0001). Spontaneous coronary artery dissection (SCAD) was seen in only 17 (4.5%) patients. It was seen mainly in Group 1 (15%) and Group 2 (7.9%) patients and less commonly in Group 3 patients (1.3%) (P < 0.01). Myocardial bridging was noticed in 55 (8.2%) patients; however, no significant difference in its prevalence was noted among the study groups.
|Figure 2: Pattern of vessel involvement among the study groups. LMCA: Left main coronary artery, LAD: Left anterior descending, LCX: Left circumflex, RCA: Right coronary artery|
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Finally, on analyzing the TMT results with the angiographic data [Figure 3], false positive results (positive TMT without obstructive CAD) were seen in 154 (61.6%) patients. This rate was significantly high in Group 1 (77.8%) and Group 2 (71.7%) patients as compared to Group 3 patients (42.3%) (P < 0.0001).
| Discussion|| |
The present study provides the largest contemporary data from India describing the clinical and angiographic profile of female patients undergoing coronary angiography for suspected CAD.
Striking differences in the clinical and angiographic profiles were noted between young and senior women. Patients were divided into three groups according to their age: less than 45 years, 45–55 years and >55 years. While assessing the age-related differences, most of the past studies have taken a maximum of two groups, usually above and below 55 years of age as elderly and young. The present study cohort was divided into 3 age-stratified groups to minimize the confounding effect of age on other risk factors in the causation of CAD. Most of the patients (79.4%) were postmenopausal. This is similar to the data from the past studies which have also shown the majority of women undergoing coronary angiography for suspected CAD to be postmenopausal.,
Overweight/obesity (BMI >23 kg/m2) was seen more commonly (49.1%) in our study as compared to the past studies which have reported it to be around 29.1%. The difference is mainly due to the use of the latest criteria for the definition of overweight (BMI >23 kg/m2) in Asian populations. In one study, Abed and Jamee reported 17% Palestinian women undergoing Coronary angiography to be overweight (BMI 25–29.9 kg/m2) and 80.5% to be obese with BMI >30 kg/m2. These striking differences across populations are probably the result of variations in ethnic and eating habits of these populations.
The age-related increase in the prevalence of HTN and diabetes observed in our study was consistent with the findings of previous studies., Past studies have shown that younger CAD patients suffer from dyslipidemia more commonly than the older ones. Most of the past studies have studied the prevalence of dyslipidemia as a whole. However, in the present study, we have compared the different cut-off values of LDL-cholesterol, HDL-cholesterol, and triglycerides to find their association in the causation of CAD in female patients. It was observed that low HDL-cholesterol levels <40 mg/dl were significantly more common in Group 2 and 3 patients in comparison to Group 1 patients. On the other hand, LDL-cholesterol >130 mg/dl and serum triglyceride level >150 mg/dl were commonly seen in Group 1 patients and less commonly in Group 3 patients. Smoking was more prevalent among the Group 3 patients as compared to Group 1 and 2 patients. Unfortunately, very few prior studies have documented the smoking prevalence among women undergoing coronary angiography., The family history of premature CAD was more commonly recorded in Group 1 patients than the other two groups. This highlights the significant role of family history, especially in young women. The results of the RATIO study indicate that women with at least one parent who suffered from myocardial infarction are at 4 times higher risk of ACS. The association is more pronounced in mother-daughter relationships than in father-daughter relationships. The phenomenon has not been observed in men. Furthermore, the research conducted by Patel et al. indicates that women whose parents suffered from coronary events during young age (<50 years for men, <55 years for women) have higher coronary calcium scores.
Regarding the presentation patterns, the atypical presentation was more commonly seen in group one patients than the Group 2 and 3 patients. This highlights the concept that women especially young are more likely to present with atypical symptoms., In the present study, diagnosis of STEMI was more common in senior women, while NSTEMI/UA was more common in the younger women. This finding could be related to the pathophysiology of the vulnerable plaques (i.e., erosion vs. rupture) among young versus older age. Furthermore, the discrepancy may attribute to the differences in thrombotic and fibrinolytic activity, variability in the extent and severity of coronary lesions and the presence of collateral blood flow.,, However, the previous Indian studies have not shown much difference in the pattern of ACS among female patients as per age.
Coronary angiography was found to be normal in 37.7% of female patients undergoing evaluation for suspected ischemic heart disease. This was significantly more common in Group 1 patients, who also had higher rates of the positive treadmill test, atypical chest pain, and endothelial dysfunction on coronary angiogram. This was indirect evidence of the higher prevalence of microvascular angina/Cardiac syndrome X (CSX) in young females presenting with chest pain. Demographic and clinical factors associated with CSX have largely been derived from smaller mechanistic and observational studies. Reports suggest that women with CSX are older and more frequently postmenopausal, but other larger studies, such as the WISE cohort, describe these women to be younger and more commonly premenopausal than those with an obstructive CAD, a result which was very similar to the present study. Pilot phase data from the angiographic analysis of women with suspected ischemic chest pain revealed that 34% of women had no detectable CAD, which was quite similar to the results of the present study. In the present study, obstructive CAD was seen in 56.5% of patients and was more common in elderly patients. In the pilot phase data from the WISE study, 43% of patients had significant CAD. Abed and Jamee showed that 55.2% of 688 female patients had obstructive CAD. Similarly, data from Indian study by Ezhumalai and Jayaraman revealed that 45.4% of patients had obstructive CAD, and this was more commonly seen in elderly women (>55 years age) in comparison to younger women.
Analysis of angiographic disease pattern revealed that among Group 1 patients, single vessel disease was more frequently seen. On the other hand, among Group 2 and three patients, double vessel disease, and TVD were seen more frequently. Similar pattern of involvement with more SVD in younger women and more DVD and TVD among senior women has been documented in the past Indian studies by Dave et al. and Ezhumalai and Jayaraman, Very few studies have focussed on the prevalence of LMCA involvement among Indian women. LMCA disease was seen in 5.2% of women in the present study, all in women aged 45 years and above. This was consistent with the results of a retrospective study of 500 women undergoing coronary angiography by Ezhumalai and Jayaramanin which LMCA was involved in 3.4% of women, and was more commonly seen in elderly women >55 years of age. Many other studies have also shown that LMCA disease incidence during diagnostic coronary angiography ranges between 4% and 7% and increases with age.
SCAD was seen in young women, mainly in Group 1 and 2 and rarely in Group 3. Past studies have shown that SCAD generally occurs in patients without conventional cardiovascular risk factors, predominantly women (82%–98% of SCAD cases) with an average age in their early 40 s to early 50 s.
First, inherent to the nature of observational study design, chances of potential residual confounders always persist. Second, this was a single-center study, and the sample size was small. Therefore, the results require further validation from larger multicenter prospective studies. Third, TMT was not done in a large number (61.1%) of the patients with chronic stable angina/atypical chest pain before subjecting them to coronary angiography. While it was mainly due to the patients' inability to perform the treadmill test and the presence of contraindications, but still it may represent a physician's inertia in getting a TMT done before coronary angiogram. Finally, only the conventional risk factors for CAD were studied. Novel risk factors such as serum lipoprotein (a), serum homocysteine, etc., were not studied. Newer mechanistic insights regarding CAD in women could have been derived from them.
| Conclusion|| |
This prospective, tertiary care hospital based observational study comprising 674 female patients illustrates significant age-related differences in the clinical risk profile and angiographic disease pattern among women presenting with suspected CAD. The present study provides the largest contemporary data from an Indian female cohort undergoing coronary angiography. The present study demonstrated that as the age advances, there occurs an increase in the number of CAD risk factors as well as the angiographic extent and severity of the disease. On the contrary, younger women present more commonly with atypical angina, positive treadmill test, yet normal epicardial coronary arteries. Understanding the risk profile and pattern of CAD among women would help in the formulation of evidence-based interventions to prevent and treat it optimally.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]