Coronary microvascular dysfunction in women

It is important to be aware of the atypical pathology and manifestation of coronary artery disease in women. This case shows the inappropriate withholding of heart medications in an 83-year-old female due to ischemic nonobstructive coronary artery disease, also called INOCA. Coronary microvascular dysfunction (CMD) is considered the main pathogenesis of INOCA.

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Case Report

March 2019

Background

Recognizing and treating women with signs and symptoms of ischemia and non-obstructive coronary artery disease (INOCA) with coronary microvascular dysfunction (CMD) is a challenge for physicians.

Case

An 83-year-old female with history of hypertension, hyperlipidemia presented with exertional angina. Fifteen years prior she had an abnormal stress echocardiogram with subsequent open arteries on coronary angiogram. We referred her for an adenosine stress cardiac MRI that showed subendocardial hypoperfusion and invasive coronary reactivity test confirmed CMD.

She was started on optimal medical therapy which improved angina and exercise capacity. Recently she was admitted at an outside hospital for abdominal surgery and her cardiac medications were held.

Postoperative day 1, she developed chest pain, ischemic ECG changes (image E), and peak troponin of 0.21 ng/mL. Regadenoson SPECT showed a reversible anterior defect (image F), however the treating physician explained that this was artifact and did not restart her cardiac medications

Decision-making

  • Anti-ischemic cardiac medications should be continued in women with CMD prior to surgery unless contraindicated.

  • Abnormal stress perfusion in the setting of CMD with INOCA is not artifact.

  • The patient met criteria for acute myocardial infarction supporting starting cardiac medications as per guidelines.

Conclusion

This case stresses the importance of physician education to recognize and treat women with INOCA with CMD.