Over the last years the awareness of gender differences in cardiovascular disease has gradually increased. Gender differences can be highlighted in the spectrum of clinical manifestations of ischemic cardiovascular disease in women and in the higher incidence in female sex of specific pathologies such as Takotsubo Syndrome (TTS), myocardial infarction without significant coronary obstruction (MINOCA) and Spontaneous coronary artery dissection (SCAD). Advanced cardiac imaging is gaining a relevant role also in the acute patient scenario and it can allows the identification of the pathologies that can most frequently cause acute chest pain in women.
We included 102 female patients admitted to our emergency department with acute chest pain who underwent advanced cardiac imaging examinations. 72 women had Cardiac Magnetic Resonance Imaging (CMR) for acute myocardial injury after excluding Acute Coronary Syndrome (ACS). 30 women underwent Coronary Computed Tomography Angiography (CCTA) for suspected ACS with low or intermediate risk of Coronary Artery Disease (CAD).
In 25/72 patients undergoing CMR was found an ischemic pattern: 19 (26.4%) patients received a diagnosis of myocardial infarction with associated afferent coronary obstruction, in 5 (7%) patients the diagnosis was compatible with MINOCA and in 1 case (4%) the diagnosis of aborted heart attack was made. A non-ischemic pattern was found in 37 patients: 12 (16.7%) patients were diagnosed with Takotsubo Syndrome, 21 (29.2%) patients were affected by myocarditis and 4 (5.5%) patients had signs of pericarditis. In 10 (13.8%) cases CMR was negative. Of the 30 patients who underwent CCTA, 11 (36.7%) had normal coronary arteries, 9 (30%) had non-obstructive CAD (stenosis <50%), 8 (26.6%) had obstructive CAD (stenosis >50%) and 2 (6.6%) patients were diagnosed with SCAD.
According to our experience, CMR can play a central role in the diagnosis and management of non-coronary ischemic heart disease which typically affects women. In fact, in females the etiopathogenesis of myocardial ischemia is much more complex and heterogeneous than in males, making non-invasive cardiac imaging decisive to identify the underlying causes of acute chest pain. Furthermore, the use of CCTA as a first-instance diagnostic test in an acute scenario allows us to improve the diagnosis of clinically significant CAD and to adequately direct the therapeutic process.
