Heart disease is the leading cause of death and morbidity in Western countries, and ischaemic heart disease (IHD) accounts for most cardiac deaths in both sexes.1 This review focuses on gender related issues concerning the epidemiology, pathogenesis, presentation and treatment of IHD.

GENERAL EPIDEMIOLOGY

The prevalence and incidence of IHD at all ages tends to be higher in males than in females, increasing with age in both genders (fig 1, table 1).^w1

However, since the female elderly population is larger than that of males, beyond 75 years of age the absolute number of women discharged for IHD overcomes the number of males (364 000 vs 326 000 per year in the USA).1 At the time of a first coronary event, women are approximately 10 years older than men.2 ^w2 In the Framingham Heart Study (FHS), angina was the initial diagnosis of IHD in 61% of women but only in 38% of men; in contrast, men more often exhibit myocardial infarction (MI) or sudden death as first manifestations.2 ^w3 Among patients with suspected acute coronary syndrome (ACS), the discharge diagnosis in women is more commonly unstable angina compared to men.3 4 Over the past three decades, the relative risk (RR) of coronary death has declined similarly in both genders.^w4 Thus, in women compared to men the overall prevalence of IHD is lower and the age at presentation is delayed; however, among the elderly, women outnumber men, so that the absolute number of elderly female IHD patients is greater than that of men.

CARDIOVASCULAR RISK FACTORS

In the case–control INTERHEART study of 15152 patients with MI and 14820 controls, 90% of the population attributable risk for MI in both genders was accounted for by the presence of nine modifiable risk factors: raised serum lipoprotein apoB/A1 ratio, smoking, diabetes, psychosocial stress, …