Coronary microvascular dysfunction and heart failure with preserved ejection fraction as female-pattern cardiovascular disease: the chicken or the egg?

Abstract

A variety of observations suggest that coronary microvascular dysfunction (CMD) is related to the pathogenesis of cardiovascular disease, including myocardial ischaemia and heart failure.1,2 CMD is due to changes in the function and structure of the coronary microcirculation and, in the absence of obstructive coronary artery disease (CAD), is more prevalent among women, is poorly understood mechanistically, and therefore represents a major unmet therapeutic need.3 While termed ischaemia with no obstructive CAD (INOCA) and myocardial infarction with no obstructive CAD (MINOCA),3 it is also sometimes called ‘female-pattern’ cardiovascular disease along with heart failure with preserved ejection fraction (HFpEF) because these occur more commonly in women, and the relative paucity of studies of women has resulted in therapeutic deserts for these conditions. Notably, the ‘female-pattern’ terminology may soon be irrelevant, as INOCA, MINOCA, and HFpEF are increasingly being diagnosed in men.3