1. Scope of the Problem 

Cardiovascular disease (CVD) is the leading cause of premature death in women in Canada¹. Mortality rates in men have stabilized in the last decade but have continued to increase in women in Canada² and can occur for women of all ages. Sex and gender-specific differences exist in awareness, symptom presentation, diagnosis, prognosis, and treatment³. The diagnosis of acute coronary syndrome (ACS) in women presenting to the ER can be complex and challenging. Rapid diagnosis and treatment are vital.

2. Symptoms

More than 50% of women who experience heart attacks have their symptoms unrecognized by healthcare providers⁴. In addition, women are 7x more likely to be sent home⁵. Chest discomfort is the most common presenting complaint in 90% of ACS, in BOTH men and women⁴.

Women may, however, describe their symptoms differently than men, as discomfort or pressure rather than “pain.” Anginal equivalents, such as dyspnea, epigastric pain, and upper back discomfort, are more often reported in women, and may lead to misdiagnosis and delays in treatment. Heart attacks are on the rise and can occur in women of all ages. Assessing for cardiac disease should be prioritized in women who experience chest pain/pressure.

3. Risk Factors

Cardiovascular risk assessment in women requires evaluation of traditional, sex-gender specific, and under-recognized risk factors⁶:

4. Pathophysiology

CAD, is a type of CVD that can be obstructive or non-obstructive. Obstructive coronary artery disease (ST and non-ST elevation myocardial infarction) is common in both men and women. However, in 5-15% of ACS cases, MINOCA can occur, particularly in women¹⁵. The coronary angiogram in MINOCA reveals < 50% stenosis in any major epicardial artery. Serial troponins, preferably high-sensitivity assays, using sex-specific thresholds, are critical, as initial results may be normal. Initial troponin should be followed by repeat sample collection 1-3 hours later for high-sensitiviy troponin and 3-6 hours later for conventional troponin assays¹⁶. Long term prognosis for MINOCA patients may include worse quality of life indicators, compared to obstructive MI patients.

5. Potential Causes of MINOCA

Possible causes of MINOCA include, but are not limited to, plaque rupture/erosion, coronary artery vasospasm (including ACS syndrome accompanying mast cell activation from allergic, hypersensitivity, or anaphylactic reactions: Kounis syndrome)¹⁷, microvascular dysfunction, coronary artery embolism, and spontaneous coronary artery dissection (SCAD)¹⁵. 

6. Investigations and Medical Therapy

7. Differential Diagnosis