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Two-thirds of women who present with persistent symptoms and clinical signs of ischemia have no evidence of obstructive coronary artery disease (INOCA) on angiography.1 Cardiac ischemia can be manifested by chest discomfort, shortness of breath, decreased exercise tolerance, and ST-segment or imaging abnormalities at rest or with stress. Although women with a clinical presentation suggesting ischemic heart disease are often reassured after having a “normal” angiogram that their symptoms are not likely cardiac in etiology, 1 in 13 of these women die from a cardiac cause within 10 years of the angiographic evaluation,2 and the most frequent adverse cardiac event is hospitalization for heart failure with preserved ejection fraction with an observed 10-fold higher rate compared with asymptomatic women (3.3% vs 0.3%).1 For these women with INOCA, clinicians should consider the important, yet often overlooked, diagnosis of coronary microvascular dysfunction (CMD)—a small vessel disorder that confers an adverse prognosis in women for which there are available and continuously evolving diagnostic and treatment strategies.
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Corresponding Author: C. Noel Bairey Merz, MD, Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S San Vicente Blvd, #A3906, Los Angeles, CA 90048 (firstname.lastname@example.org).
Published Online: November 18, 2019. doi:10.1001/jama.2019.15736
Conflict of Interest Disclosures: Dr Bairey Merz reported receiving honoraria, consulting fees, and grants from various companies societies, academic institutions, and federal agencies paid to Cedars-Sinai and serving on the board of directors for iRhythm. No other disclosures were reported.
Funding/Support: This work was supported by the Barbra Streisand Women's Heart Center and grants from the NIH.
Role of the Funder/Sponsor: The funder had no role in the preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.
Disclaimer: This work is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Additional Contributions: We thank Elizabeth Kim, BA (Smidt Heart Institute, Cedars-Sinai Medical Center), for her assistance in formatting the figures.
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