29 Although the reasons for atypical symptoms experienced by wome

29 Although the reasons for atypical symptoms experienced by women remain open for debate, the literature suggests physiological,

anatomical and psychosocial differences could all play a role. Women are more likely to experience plaque erosion (as opposed to the plaque eruption found in men) and microvascular unless coronary disease (MVD); they also have smaller coronary arteries.3 8 30–33 Plaque refers to the different types of cholesterol-rich lipid deposits within the coronary artery walls (30), each with a variable risk of thrombosis. The highest risk is linked to plaque deposits covered by a thin fibrous cap,30 31 which is vulnerable to cracking (plaque rupture), exposing lipid plaque to the luminal blood flow, initiating a clotting cascade which ultimately occludes or severely restricts arterial blood flow potentially resulting in myocardial infarction (heart attack).31 Plaque erosion has a different pathological process—an area of the endothelial cellular covering of

the tunica intima layer of an artery wall is absent, exposing blood flow to inner layers of artery wall, initiating the clotting cascade and thrombosis. The clotting process in plaque erosion is less aggressive than rupture and is as associated with less luminal stenosis (smaller artery blockage).30 31 MVD is the result of diffuse plaque in coronary arterioles (smaller arteries), as opposed to the wider coronary artery tree. The arterioles are too small to be visualised by angiography.32–34 The plaque

build-up in these arterioles does not lead to obstruction but causes endothelial damage, resulting in a thickening of the smooth muscle of the arteriole wall. This arterial remodelling results in wall stiffness and consequent loss of ability to dilate in response to emotional and physical stimuli, reducing myocardial blood flow (even though the arteriole lumen remains patent). It is thought that such differences in the disease pathway may account, at least in part, for how women experience atypical cardiac symptoms. MVD (which is more common in women as stated above) is not amenable to percutaneous coronary intervention to provide symptom relief for chest pain.33 Additionally, MVD was once thought to be clinically insignificant,34 35 but recent studies have shown links to increased morbidity and mortality.3 36 37 Smaller coronary arteries GSK-3 in women, which are independent of body size,38 are notoriously difficult to revascularise (reopen) and are considered to be a significant contributor to worse clinical outcomes in women.3–5 It is also possible that psychosocial factors mediate symptom perception. For instance, in one study of a condition linked to cardiovascular disease (CVD; heart failure), it was found that women generally perceive their health to be better than men, and seem to adjust better to living with heart failure, viewing it as second chance.

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