Особенности клиники и диагностики ишемической болезни сердца у женщин. Часть 1

Abstract

В первой части обзора показаны особенности субъективной симптоматики и ЭКГ-диагностики ишемической болезни сердца (ИБС) у женщин. Заболевание ИБС у женщин чаще проявляется атипичным болевым синдромом, реже отмечается четкая связь с физической нагрузкой, чаще – с ментальным или эмоциональным стрессом. Неспецифические изменения ЭКГ в покое и меньшая способность к выполнению пробы с физической нагрузкой обусловливают меньшую чувствительность и специфичность неинвазивного тестирования у женщин; В першій частині огляду показано особливості суб’єктивної симптоматики та ЕКГ-діагностики ішемічної хвороби серця (ІХС) у жінок. Захворювання на ІХС у жінок частіше проявляється атиповим больовим синдромом, рідше відмічається чіткий зв’язок з фізичним навантаженням, частіше – з ментальним або емоційним стресом. Неспецифічні зміни ЕКГ у спокою та менша здатність до виконання проби з фізичним навантаженням зумовлюють меншу чутливість та специфічність неінвазивного тестування у жінок; Peculiarities of subjective symptoms and ECG-diagnostics of ischemic heart disease (IHD) are presented in the first part of review. Interpretation of chest pain in women, who have consulted a doctor, is more difficult than in men. Disease is manifested by atypical pain syndrome, distinct connection with physical activity is marked rarelier, but with mental or emotional stress – more often. Besides, such symptoms as nausea, dyspnea, discomfort in epigastrium, isolated pain in the left shoulder, neck are predominant in women. Prevalence of atypical pain syndrome in women is explained by more frequency of occurrence of vasospastic component, microvascular ischemia and often accompanied noncoronary heart pain (for example, in case of mitral valve prolapse) in them. Women can use “other language” for description of pain sensations, often understating or overstating their importance. The capability of female sex hormones to change pain threshold independently can be one of the possible explanation. Peculiar attention belongs to the female patients with complaints, typical for angina pectoris, and intact coronary arteries during the angiography (syndrome X). It has been shown that more often angina is the first manifestation of IHD in women, whereas male disease is more often manifested by myocardial infarction (MI) or sudden cardiac death. The women with IHD,on comparison with the men, are characterized by more evident neurosis, more intensive accentuation of personality, higher level of anxiety-depressive disorders, vegetative disturbances, and decrease of cardiac rhythm variability. In women MI occurs more often without Q wave and the ejection fraction is some higher during the first 10 days of MI. Instable angina pectoris and acute MI without segment ST elevation are diagnosed more often in women whereas acute coronary syndrome like acute MI with segment ST elevation – in men. A great amount of women with instable angina pectoris or acute MI without segment ST elevation and without apparent affection of coronary arteries testifies about a frequent occurrence of microvascular endothelial dysfunction and atherosclerosis without stricture formation. Different methods can be used for diagnostics of IHD in women: ECG-registration at rest, ECG-daily monitoring, different exercise ECG testing (treadmill-test and veloergometry), pharmacologic tests, echocardiography (Echo-CG), stress-Echo-CG, radioisotope methods, coronary angiography. Interpretation of changes of ECG at rest in female patients (with a purpose of the estimation of ECG changes’ dynamics, confirming of MI in past and degree of myocardial lesion) is more difficult than in male patients. It is caused, first of all, by the change of a hormonal background of the woman. The latter includes monthly cyclic fluctuations, changes during elongated premenopausal and climacteric periods, and effects of hormonal replacement therapy. The statement, which has been thought for a long time, that sensitivity and specificity of exercise ECG testing is equal for patients of both sexes, is disproved by means of latest researches now. It was shown that sensitivity of exercise ECG in women is less than in men, occurrence of false-positive depressions of ST segment during exercise ECG testing, in female patients with atypical pain syndrome particularly, is frequent. It is supposed, that it is connected with the peculiarities of vegetative nervous system and endocrine glands functioning, less diameter of coronary arteries and their propensity to vasospasm, detraining of the women. The hypothesis about the presence of connection between results of exercise ECG tests and hormonal status of the women on the basis of series of carried out researches look extremely logically. Different variants of increase of sensitivity and specificity of exercise ECG testing are offered.