Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
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Women and Ischemic Heart Disease: Recognition, Diagnosis and Management

  • Park, Seong-Mi (Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine) ;
  • Merz, C. Noel Bairey (Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center)
  • Received : 2015.12.18
  • Accepted : 2016.01.28
  • Published : 2016.07.30
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Abstract

Cardiovascular disease is one of the most frequent causes of death in both males and females throughout the world. However, women exhibit a greater symptom burden, more functional disability, and a higher prevalence of nonobstructive coronary artery disease (CAD) compared to men when evaluated for signs and symptoms of myocardial ischemia. This paradoxical sex difference appears to be linked to a sex-specific pathophysiology of myocardial ischemia including coronary microvascular dysfunction, a component of the 'Yentl Syndrome'. Accordingly, the term ischemic heart disease (IHD) is more appropriate for a discussion specific to women rather than CAD or coronary heart disease. Following the National Heart, Lung, and Blood Institute Heart Truth/American Heart Association, Women's Ischemia Syndrome Evaluation and guideline campaigns, the cardiovascular mortality in women has been decreased, although significant gender gaps in clinical outcomes still exist. Women less likely undergo testing, yet guidelines indicate that symptomatic women at intermediate to high IHD risk should have further test (e.g. exercise treadmill test or stress imaging) for myocardial ischemia and prognosis. Further, women have suboptimal use of evidence-based guideline therapies compared with men with and without obstructive CAD. Anti-anginal and anti-atherosclerotic strategies are effective for symptom and ischemia management in women with evidence of ischemia and nonobstructive CAD, although more female-specific study is needed. IHD guidelines are not "cardiac catheterization" based but related to evidence of "myocardial ischemia and angina". A simplified approach to IHD management with ABCs (aspirin, angiotensin-converting enzyme inhibitors/angiotensin-renin blockers, beta blockers, cholesterol management and statin) should be used and can help to increases adherence to guidelines.

Keywords

Acknowledgement

Supported by : Gustavus and Louis Pfeiffer Research Foundation

References

  1. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling ofmortality rates. J Am Coll Cardiol 2007;50: 2128-32. https://doi.org/10.1016/j.jacc.2007.05.056
  2. Dreyer RP, Wang Y, Strait KM, et al. Gender differences in the trajectory of recovery in health status among young patients with acute myocardial infarction: results from the variation in recovery: role of gender on outcomes of young AMI patients (VIRGO) study. Circulation 2015;131:1971-80. https://doi.org/10.1161/CIRCULATIONAHA.114.014503
  3. Proudfit WL. Shirey EK, Sones FM Jr. Selective cine coronary arteriography. Correlation with clinical findings in 1,000 patients. Circulation 1966;33:901-10. https://doi.org/10.1161/01.CIR.33.6.901
  4. Kemp HG, Kronmal RA, Vliestra RE, Frye RL. Seven year survival of patients with normal or near normal coronary arteriograms: a CASS registry study. J Am Coll Cardiol 1986;7:479-83. https://doi.org/10.1016/S0735-1097(86)80456-9
  5. Sharaf BL, Pepine CJ, Kerensky RA, et al. Detailed angiographic analysis of women with suspected ischemic chest pain (pilot phase data from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation [WISE] Study Angiographic Core Laboratory). Am J Cardiol 2001;87:937-41;A3. https://doi.org/10.1016/S0002-9149(01)01424-2
  6. Moriel M, Rozanski A, Klein J, Berman DS, Merz CN. The limited efficacy of exercise radionuclide ventriculography in assessing prognosis of women with coronary artery disease. Am J Cardiol 1995;76:1030-5. https://doi.org/10.1016/S0002-9149(99)80290-2
  7. Bairey Merz CN, Shaw LJ, Reis SE, et al. Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006;47(3 Suppl):S21-9. https://doi.org/10.1016/j.jacc.2004.12.084
  8. Shaw LJ, Bairey Merz CN, Pepine CJ, et al. Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol 2006;47(3 Suppl):S4-20. https://doi.org/10.1016/j.jacc.2005.01.072
  9. Shaw LJ, Shaw RE, Bairey Merz CN, et al. Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology-National Cardiovascular Data Registry. Circulation 2008;117:1787-801. https://doi.org/10.1161/CIRCULATIONAHA.107.726562
  10. Glaser R, Selzer F, Jacobs AK, et al. Effect of gender on prognosis following percutaneous coronary intervention for stable angina pectoris and acute coronary syndromes. Am J Cardiol 2006;98:1446-50. https://doi.org/10.1016/j.amjcard.2006.06.044
  11. Bugiardini R, Bairey Merz CN. Angina with "normal" coronary arteries: a changing philosophy. JAMA 2005;293:477-84. https://doi.org/10.1001/jama.293.4.477
  12. Smilowitz NR, Sampson BA, Abrecht CR, Siegfried JS, Hochman JS, Reynolds HR. Women have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: an autopsy study. Am Heart J 2011;161:681-8. https://doi.org/10.1016/j.ahj.2010.12.022
  13. Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med 1991;325:221-5. https://doi.org/10.1056/NEJM199107253250401
  14. Steingart RM, Packer M, Hamm P, et al. Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators. N Engl J Med 1991;325:226-30. https://doi.org/10.1056/NEJM199107253250402
  15. Healy B. The Yentl syndrome. N Engl J Med 1991;325:274-6. https://doi.org/10.1056/NEJM199107253250408
  16. Johnston N, Schenck-Gustafsson K, Lagerqvist B. Are we using cardiovascular medications and coronary angiography appropriately in men and women with chest pain? Eur Heart J 2011;32:1331-6. https://doi.org/10.1093/eurheartj/ehr009
  17. Merz CN. The Yentl syndrome is alive and well. Eur Heart J 2011;32:1313-5. https://doi.org/10.1093/eurheartj/ehr083
  18. Lee DH, Jeong MH, Rhee JA, et al. Predictors of long-term survival in acute coronary syndrome patients with left ventricular dysfunction after percutaneous coronary intervention. Korean Circ J 2012;42:692-7. https://doi.org/10.4070/kcj.2012.42.10.692
  19. Merz CN, Kelsey SF, Pepine CJ, et al. The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report. J Am Coll Cardiol 1999;33:1453-61. https://doi.org/10.1016/S0735-1097(99)00082-0
  20. Johnson BD, Shaw LJ, Pepine CJ, et al. Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women's Ischaemia Syndrome Evaluation (WISE) study. Eur Heart J 2006;27:1408-15.
  21. Reis SE, Holubkov R, Conrad Smith AJ, et al. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J 2001;141:735-41. https://doi.org/10.1067/mhj.2001.114198
  22. Gulati M, Cooper-DeHoff RM, McClure C. et al. Adverse cardiovascular outcomes in women with nonobstructive coronary artery disease: a report from the Women's Ischemia Syndrome Evaluation Study and the St James Women Take Heart Project. Arch Intern Med 2009;169;843-50. https://doi.org/10.1001/archinternmed.2009.50
  23. Kothawade K, Bairey Merz CN. Microvascular coronary dysfunction in women: pathophysiology, diagnosis, and management. Curr Probl Cardiol 2011;36:291-318. https://doi.org/10.1016/j.cpcardiol.2011.05.002
  24. Sharaf B, Wood T, Shaw L, et al. Adverse outcomes among women presenting with signs and symptoms of ischemia and no obstructive coronary artery disease: findings from the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) angiographic core laboratory. Am Heart J 2013;166:134-41. https://doi.org/10.1016/j.ahj.2013.04.002
  25. von Mering GO, Arant CB, Wessel TR. Abnormal coronary vasomotion as a prognostic indicator of cardiovascular events in women: results from the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation 2004;109:722-5. https://doi.org/10.1161/01.CIR.0000115525.92645.16
  26. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities Study. JAMA 2002;287:1153-9.
  27. Burke AP, Farb A, Malcolm GT, Liang Y, Smialek J, Virmani R. Effects of risk factors on the mechanism of acute thrombosis and sudden coronary death in women. Circulation 1998;97:2110-16. https://doi.org/10.1161/01.CIR.97.21.2110
  28. Burke AP, Virmani R, Galis Z, Haudenschild CC, Muller JE. 34th Bethesda Conference: Task force #2--What is the pathologic basis for new atherosclerosis imaging techniques? J Am Coll Cardiol 2003;41:1874-86. https://doi.org/10.1016/S0735-1097(03)00359-0
  29. Novack V, Cutlip DE, Jotkowitz A, Lieberman N, Porath A. Reduction in sex-based mortality difference with implementation of new cardiology guidelines. Am J Med 2008;121:597-603.
  30. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J 2000;21:1502-13. https://doi.org/10.1053/euhj.2000.2305
  31. McSweeney JC, Cody M, O'Sullivan P, Elberson K, Moser DK, Garvin BJ. Women's early warning symptoms of acute myocardial infarction. Circulation 2003;108:2619-23. https://doi.org/10.1161/01.CIR.0000097116.29625.7C
  32. DeVon HA, Ryan CJ, Ochs AL, Shapiro M. Symptoms across the continuum of acute coronary syndromes: differences between women and men. Am J Crit Care 2008;17:14-24;quiz 25.
  33. Johnson BD, Kelsey SF, Bairey Merz CN. Chapter 10. Clinical risk assessment in women: chest discomfort. Report from the WISE study. In: Shaw LJ, Redberg RF, eds. Coronary Disease in Women: Evidence-Based Diagnosis and Treatment. Totowa, NJ: Humana Press; 2003. p.129-41.
  34. Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation 2005;111:682-96. https://doi.org/10.1161/01.CIR.0000155233.67287.60
  35. Mieres JH, Gulati M, Bairey Merz N, et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014;22;130:350-79. https://doi.org/10.1161/CIR.0000000000000061
  36. Alexander KP, Shaw LJ, Shaw LK, Delong ER, Mark DB, Peterson ED. Value of exercise treadmill testing in women. J Am Coll Cardiol 1998;32:1657-64. https://doi.org/10.1016/S0735-1097(98)00451-3
  37. Shaw LJ, Mieres JH, Hendel RH, et al. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Circulation 2011;124:1239-49. https://doi.org/10.1161/CIRCULATIONAHA.111.029660
  38. Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation 2005;111:682-96. https://doi.org/10.1161/01.CIR.0000155233.67287.60
  39. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/ PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-164. https://doi.org/10.1016/j.jacc.2012.07.013
  40. Shaw LJ, Vasey C, Sawada S, Rimmerman C, Marwick TH. Impact of gender on risk stratification by exercise and dobutamine stress echocardiography: long-term mortality in 4234 women and 6898 men. Eur Heart J 2005;26:447-56. https://doi.org/10.1093/eurheartj/ehi102
  41. Arruda-Olson AM, Juracan EM, Mahoney DW, McCully RB, Roger VL, Pellikka PA. Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference? J Am Coll Cardiol 2002;39:625-31. https://doi.org/10.1016/S0735-1097(01)01801-0
  42. Shaw LJ, Hage FG, Berman DS, Hachamovitch R, Iskandrian A. Prognosis in the era of comparative effectiveness research: where is nuclear cardiology now and where should it be? J Nucl Cardiol 2012;19:1026-43. https://doi.org/10.1007/s12350-012-9593-y
  43. Gargiulo P, Petretta M, Bruzzese D, et al. Myocardial perfusion scintigraphy and echocardiography for detecting coronary artery disease in hypertensive patients: a meta-analysis. Eur J Nucl Med Mol Imaging 2011;38:2040-9. https://doi.org/10.1007/s00259-011-1891-0
  44. Bateman TM, Heller GV, McGhie AI, et al. Diagnostic accuracy of rest/ stress ECG-gated Rb-82 myocardial perfusion PET: comparison with ECG-gated Tc-99m sestamibi SPECT. J Nucl Cardiol 2006;13:24-33. https://doi.org/10.1016/j.nuclcard.2005.12.004
  45. Kay J, Dorbala S, Goyal A, et al. Influence of sex on risk stratification with stress myocardial perfusion Rb-82 positron emission tomography: results from the PET (Positron Emission Tomography) Prognosis Multicenter Registry. J Am Coll Cardiol 2013;62:1866-76. https://doi.org/10.1016/j.jacc.2013.06.017
  46. Min JK, Dunning A, Lin FY, et al. Age-and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 2011;58:849-60. https://doi.org/10.1016/j.jacc.2011.02.074
  47. Lin FY, Shaw LJ, Dunning AM, et al. Mortality risk in symptomatic patients with nonobstructive coronary artery disease: a prospective 2-center study of 2,583 patients undergoing 64-detector row coronary computed tomographic angiography. J Am Coll Cardiol 2011;58:510-9. https://doi.org/10.1016/j.jacc.2010.11.078
  48. Pepine CJ, Anderson RD, Sharaf BL, et al. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 2010;55:2825-32. https://doi.org/10.1016/j.jacc.2010.01.054
  49. Chandra NC, Ziegelstein RC, Rogers WJ, et al. Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 1998;158:981-8. https://doi.org/10.1001/archinte.158.9.981
  50. Nohria A, Vaccarino V, Krumholz HM. Gender differences in mortality after myocardial infarction. Why women fare worse than men. Cardiol Clin 1998;16:45-57. https://doi.org/10.1016/S0733-8651(05)70383-0
  51. Scott LB, Allen JK. Providers' perceptions of factors affecting women's referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehabil 2004;24:387-91. https://doi.org/10.1097/00008483-200411000-00005
  52. O'Meara JG, Kardia SL, Armon JJ, Brown CA, Boerwinkle E, Turner ST. Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study. Arch Intern Med 2004;164:1313-8. https://doi.org/10.1001/archinte.164.12.1313
  53. Hendrix KH, Riehle JE, Egan BM. Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients. Ethn Dis 2005;15:11-6.
  54. Cho L, Hoogwerf B, Huang J, Brennan DM, Hazen SL. Gender differences in utilization of effective cardiovascular secondary prevention: a Cleveland clinic prevention database study. J Womens Health (Larchmt) 2008;17:515-21. https://doi.org/10.1089/jwh.2007.0443
  55. Chou AF, Scholle SH, Weisman CS, Bierman AS, Correa-de-Araujo R, Mosca L. Gender disparities in the quality of cardiovascular disease care in private managed care plans. Womens Health Issues 2007;17:120-30. https://doi.org/10.1016/j.whi.2007.03.002
  56. Reis SE, Holubkov R, Lee JS, et al. Coronary flow velocity response to adenosine characterizes coronary microvascular function in women with chest pain and no obstructive coronary disease. Results from the pilot phase of the Women's Ischemia Syndrome Evaluation (WISE) study. J Am Coll Cardiol 1999;33:1469-75. https://doi.org/10.1016/S0735-1097(99)00072-8
  57. Wessel TR, Arant CB, McGorray SP, et al. Coronary microvascular reactivity is only partially predicted by atherosclerosis risk factors or coronary artery disease in women evaluated for suspected ischemia: results from the NHLBI Women's Ischemia Syndrome Evaluation (WISE). Clin Cardiol 2007;30:69-74. https://doi.org/10.1002/clc.19
  58. LaBresh KA, Fonarow G, Ellrodt AG, et al. Get with the guidelines improves cardiovascular care in hospitalized patients with CAD. (Abstract). Circulation 2003;108(Suppl 4):722.
  59. Lanza GA, Colonna G, Pasceri V, Maseri A. Atenolol versus amlodipine versus isosorbide-5-mononitrate on anginal symptoms in syndrome X. Am J Cardiol 1999;84:854-6, A8. https://doi.org/10.1016/S0002-9149(99)00450-6
  60. Pizzi C, Manfrini O, Fontana F, Bugiardini R. Angiotensin-converting enzyme inhibitors and 3-hydroxy-3-methylglutaryl coenzyme A reductase in cardiac Syndrome X: role of superoxide dismutase activity. Circulation 2004;109:53-8. https://doi.org/10.1161/01.CIR.0000116209.25597.AE
  61. Kayikcioglu M, Payzin S, Yavuzgil O, Kultursay H, Can LH, Soydan I. Benefits of statin treatment in cardiac syndrome-X1. Eur Heart J 2003;24:1999-2005. https://doi.org/10.1016/S0195-668X(03)00478-0
  62. Chen JW, Hsu NW, Wu TC, Lin SJ, Chang MS. Long-term angiotensin-converting enzyme inhibition reduces plasma asymmetric dimethylarginine and improves endothelial nitric oxide bioavailability and coronary microvascular function in patients with syndrome X. Am J Cardiol 2002;90:974-82. https://doi.org/10.1016/S0002-9149(02)02664-4
  63. Manfrini O, Pizzi C, Morgagni G, Fontana F, Bugiardini R. Effects of pravastatin on myocardial perfusion after percutaneous transluminal coronary angioplasty. Am J Cardiol 2004;93:1391-3, A6. https://doi.org/10.1016/j.amjcard.2004.02.037
  64. Eriksson BE, Tyni-Lenne R, Svedenhag J, et al. Physical training in Syndrome X: physical training counteracts deconditioning and pain in Syndrome X. J Am Coll Cardiol 2000;36:1619-25. https://doi.org/10.1016/S0735-1097(00)00931-1
  65. Alexander KP, Chen AY, Newby LK, et al. Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/ AHA guidelines) initiative. Circulation 2006 ;114:1380-7. https://doi.org/10.1161/CIRCULATIONAHA.106.620815
  66. Ambrosioni E, Borghi C, Magnani B. The effect of the angiotensin-converting-enzyme inhibitor zofenopril on mortality and morbidity after anterior myocardial infarction. The Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study Investigators. N Engl J Med 1995;332:80-5. https://doi.org/10.1056/NEJM199501123320203
  67. Hjalmarson A, Elmfeldt D, Herlitz J, et al. Effect on mortality of metoprolol in acute myocardial infarction. A double-blind randomised trial. Lancet 1981;2:823-7.
  68. Gluckman TJ, Sachdev M, Schulman SP, Blumenthal RS. A simplified approach to the management of non-ST-segment elevation acute coronary syndromes. JAMA 2005;293:349-57. https://doi.org/10.1001/jama.293.3.349
  69. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;130:e344-426. https://doi.org/10.1161/CIR.0000000000000134
  70. Timmis AD, Chaitman BR, Crager M. Effects of ranolazine on exercise tolerance and HbA1c in patients with chronic angina and diabetes. Eur Heart J 2006;27:42-8. https://doi.org/10.1093/eurheartj/ehi495
  71. Chaitman BR, Pepine CJ, Parker JO, et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004;291:309-16. https://doi.org/10.1001/jama.291.3.309
  72. Chaitman BR, Skettino SL, Parker JO, et al. Anti-ischemic effects and long-term survival during ranolazine monotherapy in patients with chronic severe angina. J Am Coll Cardiol 2004;43:1375-82. https://doi.org/10.1016/j.jacc.2003.11.045
  73. Belardinelli L, Shryock JC, Fraser H. Inhibition of the late sodium current as a potential cardioprotective principle: effects of the late sodium current inhibitor ranolazine. Heart 2006;92(Suppl 4):iv6-14.
  74. Hochman JS, Tamis JE, Thompson TD, et al; Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. N Engl J Med 1999;341:226-32. https://doi.org/10.1056/NEJM199907223410402
  75. Glaser R, Herrmann HC, Murphy SA, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA 2002;288:3124-9. https://doi.org/10.1001/jama.288.24.3124
  76. Diver DJ, Bier JD, Ferreira PE, et al. Clinical and arteriographic characterization of patients with unstable angina without critical coronary arterial narrowing (from the TIMI-IIIA Trial). Am J Cardiol 1994;74:531-7. https://doi.org/10.1016/0002-9149(94)90739-0

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