M. G . Modena摩德纳医科大学心内科医生，在女性冠心病、冠心病介入治疗及高血压诊疗方面发表过多篇论文。
　　女性冠心病临床症状
　　★女性冠心病患者可表现为背痛、呼吸困难、恶心、呕吐等非典型症状，也可表现为冠状动脉微血管病变/内皮功能紊乱、冠状动脉夹层、心肌病及心外膜冠心病。
　　Coronary microvascular/endothelial dysfunction (ED). We conducted an observational study of 45 consecutive women (mean age: 57.6 ± 8.7 years) with symptoms and negative traditional tests. Myocardial perfusion at rest and during stress test using magnetic resonance imaging (MRI) revealed “fixed” perfusion defects on the MRI， probably due to permanent damage of coronary microcirculation. This may precede typical atherosclerotic epicardial CAD， as we saw in our follow-up.
　　Coronary dissection， the most common presentation of acute myocardial infarction (AMI) in fertile life and in pregnancy， rare but dramatic， probably due to a media-intimal progesterone   induced edema.
　　Takotsubo cardiomyopathy. In our registry of 130 post-menopausal hypertensive patients (mean age 68± 6 years )， stress-induced AMI with normal CAD was present in 87%. It represents an example of stunned myocardium， an example of extreme reversible ED.
　　The same clinical presentation may characterize older women with epicardial CAD， but there are still gender differences. From pathologic data we see women present more positive wall remodeling and more plaque erosion than rupture/explosion. Finally， women experience more periprocedural complications when undergoing percutaneous coronary interventions (PCI)， due to small and more fragile coronary vessels.
　　The same clinical atypical presentation therefore may mask several substrates， with different therapeutic approaches.
　　女性冠心病检查方法
　　★与男性相比，女性冠心病患者接受传统冠心病辅助检查的效果并不理想。一些间接证据表明，对女性冠心病患者进行疾病风险评估可能比单纯诊断疾病带来更多获益。目前，常用的检查方法有：ECG运动试验、负荷超声心动图、SPECT、心脏磁共振、冠状动脉钙化检测、多层计算机断层扫描和冠状动脉造影术。
　　心电图运动试验
　　One of the difficulties of detecting CAD in women is that the main diagnostic test， is the exercise test， which is less sensitive and it has lower diagnostic accuracy in women than in men and it has low diagnostic accuracy.
　　Its use and indications for women are limited to those with a relatively normal 12-lead ECG and capabilities of performing moderate-to-high levels of exercise
　　This diminished accuracy in women is related， in part， to their lower CAD prevalence as well as greater comorbidity and functional impairment that preclude women from achieving maximal levels of exercise when compared with more active men. Other reasons posited for a diminished accuracy of the ECG in women include a lower QRS voltage and hormonal factors. The accuracy of exercise testing in women may be enhanced by attention to features other than the absolute level of ST depression .
　　The exercise test provides a wealth of other material， including exercise capacity， hemodynamic response to exercise， and the presence of cardiac symptoms， which are used in interpretation of the test result. The accuracy of exercise testing was significantly increased by the use of a multivariate model compared with ST-segment evaluation alone .However， exercise stress test risk scores (e.g.， Duke treadmill score) have been shown to improve prognostication in women but， of all the factors noted during testing， the strongest predictive parameter from the treadmill test is exercise duration.Women who cannot achieve 5 METs are at increased risk of cardiac events. Although there are false-positive test results and important limitations， ECG exercise test is considered the initial test for CHD in women. The American Guidelines recommend ECG exercise test in women with intermediate risk.
　　负荷超声心动图
　　Evidence suggests that accurate risk assessment for CAD is possible with traditional testing including functional capacity， evaluation of extent and severity of myocardial perfusion defects by radionuclide techniques and stress-induced wall motion abnormalities by echocardiography  .Stress echocardiography， the most commonly applied test for wall motion assessment， has advantages due to its lower cost， absent radiation exposure， and ability to image both cardiac structures as well as ventricular function. Despite these advantages， echocardiographic techniques can be suboptimal in women due to obesity or lung disease limiting acoustic windows and reducing exercise tolerance
　　Women who are incapable of maximal exercise are commonly referred to dobutamine (in the U.S.) or dipyridamole (in Europe) pharmacologic stress echocardiography .
　　Stress echocardiography (either with exercise or with pharmacological stress) is an effective and highly accurate non invasive tool for detecting CAD in women and it provides incremental prognostic value over exercise ECG and clinical parameters in women with suspected or known coronary disease (sensitivity 84% and specificity 76%).
　　Echocardiographic measures of inducible wall motion abnormalities and global and regional left ventricular function are highly predictive of long-term outcome for women and men alike. For exercising women the annual risk of dying is approximately 1 per 1000 if the results are negative and increases to 1 per 100 for those with high-risk ischaemia.]
　　单光子发射计算机断层显像（SPECT）
　　SPECT are nuclear techniques which allow visualization of global and regional perfusion defects， function and volumes of the ventricles. This method can improve diagnostic accuracy in women with coronary disease， but this method may result in false positives because of  the presence of breast tissue and because the heart is smaller in women than in men. SPECT imaging has high diagnostic and prognostic accuracy in the evaluation of women with chest pain. A number of large observational studies have shown that myocardial perfusion SPECT imaging adds incremental prognostic value to clinical and exercise variables in women
　　A normal stress SPECT study is associated with a ’low risk’ for cardiac events (< 1%/year risk of cardiac death or myocardial infarction). This exam， in conjunction with clinical information， can provide risk stratification of diabetic patients.
　　Thus， diabetic women with a normal SPECT scan have a higher risk that non-diabetic women， probably because diabetes causes important alterations in the regulation of coronary vasodilator function in both epicardial and resistance coronary vessels， and these functional abnormalities precede the appearance of obstructive CAD .
　　心血管核磁共振成像（MRI）
　　MRI may lend itself to the evaluation of women due to excellent soft tissue characterization and contrast， three-dimensionality， an absolute quantitation of blood flow， and overall superior temporal and spatial resolution to image vascular and myocardial abnormalities   Although not in common practice， MRI techniques have been applied for the evaluation of suspected myocardial ischemia in female patients with chest pain symptoms and to lower risk cohorts. MRI perfusion was reported to be highly accurate to the detection of single-vessel obstructive CAD .MRI delineates subendocardial perfusion (an initial manifestation of myocardial ischemia) from epicardial perfusion and may provide corollary evidence as to the aetiology of chest pain symptoms in women， particularly in the absence of obstructive CAD. In patients with Syndrome X， cardiovascular MRI  demonstrates subendocardial hypoperfusion during the intravenous administration of adenosine， which is associated with intense chest pain.
　　However， MRI has its own limitations， with the closed bore magnet causing claustrophobia in certain patients.
　　冠状动脉钙化（CSA）
　　Computed tomography (CT) evaluates and quantifies the amount of calcium (early marker of coronary disease) in coronary arteries. Coronary artery calcium (CSA) is currently recognized as an independent and incremental predictor of events in patients at intermediate risk of coronary artery disease， and several guidelines support selective screening in these patients . In a study of 539 women undergoing coronary angiography with a normal coronary tree， as many as 220 had coronary calcification with a negative predictive value of 100%. When the calcium score was between 100 and 400， women had a higher prevalence of stenosis .There are few data on calcium score for risk stratification in asymptomatic women. A low or absent EBCT calcium score may also prove useful in determining a low likelihood of developing CAD. This may be particularly beneficial in elderly asymptomatic patients in whom the management of other risk factors may be modified according to the calcium score. Selected use of coronary calcium scores when a physician is faced with the patient with intermediate coronary disease risk may be appropriate.
　　A recent study of patients (45% women) under investigation for a chest pain syndrome showed that， despite the high known negative predictive value of CSA for coronary events， a low or even 0 CSA did not exclude clinically important obstructive CAD with of an acute or long-term chest pain syndrome. The authors concluded that contrast-enhanced multidetector computed tomography should be the noninvasive CT test of choice when possible in these patients .
　　多层螺旋CT（MSCT）
　　MSCT is a rapidly evolving coronary imaging technique， and a potential alternative to established non invasive tests for coronary artery disease. The diagnostic accuracy of MSCT in women has not been investigated per se， but is extrapolated from reports that were performed in populations largely consisting of men.
　　Sensitivity for detecting significant coronary stenoses on a patient-by-patient analysis was 100% with specificity 75%. Positive and negative predictive values were 96%  and 100% respectively.
　　64-slice CTCA has a high sensitivity for detecting significant coronary stenoses， and is reliable to exclude the presence of significant coronary artery disease in patients who present with a non-ST elevation ACS. The sensitivity and negative predictive value to detect significant CAD were very good， both for women and men， whereas there are conflicting data on diagnostic accuracy， specificity， and positive predictive value in female patients. Thus further studies are needed to better validate this method in women.
　　冠状动脉造影（CA）
　　CA represents nowadays the reference diagnostic tool for CAD diagnosis in both genders. Often  women undergo CA after many inconclusive tests due to uncertain data from non invasive tests.CA must be performed in all inconclusive examinations. New data suggest that for inconclusive CAs， IVUS and OCT may help， reinforcing the concept that the coronary artery and physiopathology of CAD and ACS are difference between genders， with an important on therapy and prognosis.
　　如何改善女性冠心病的治疗
　　★对女性冠心病的治疗应遵循循证医学证据，将女性患者体重指数和药物动力学有别于男性患者，但对心血管事件的应答反应与男性相同的特点作为制定治疗方案的考虑因素之一。
　　Unfortunately， data from observation and RCT studies generally is derived from a male population， with only post-hoc analysis on the female population. Since it is impossible to reproduce such studies for economic and ethical reasons， in my opinion we should apply this evidence in the medical treatment of women， taking into account that women have a different body mass index and different pharmacokinetics， but similar response after a cardiac event. It is imperative that we work on women patients’， cardiologists’ and GPs’ prevention sensitivity.