Unique female indicators of coronary heart disease: do they exist?

Disease: Do They Exist? To the Editor: In the article “Women’s early warning symptoms of acute myocardial infarction,” Dr Jean McSweeney and coworkers1 renew the attention to prodromal symptoms of acute coronary events. In 1975, Alonzo et al2 observed that “unusual fatigue and weakness” were the most prevalent symptoms of myocardial infarction, followed by dyspnea and angina. Many authors replicated those findings and added loss of energy, increased irritability, and sleep disturbances to the list. According to McSweeney et al, “it is unknown whether prodromal symptoms themselves predict future [coronary heart disease] events.”1 This statement is in contrast with the fact that 6 epidemiological studies have shown that these prodromal symptoms increase the risk of coronary events in both healthy populations and those with heart disease.3,4 Pathophysiological mechanisms that may underlie this increased risk include viral reactivation, increased inflammation, disturbances in coagulation and fibrinolysis, and hypoactivity of the hypothalamic-pituitary-adrenocortical (HPA) axis (lowered ACTH and cortisol).5 Hypoactivity of the HPA axis activates inflammation. These observations fuel the debate as to whether or not these prodromal symptoms reflect depression (ie, a mental disorder). The frequently observed association between depression and future coronary events might be due to the fact that these prodromal symptoms are markers of inflammation and/or viral reactivation. McSweeney et al1 made a valuable contribution by replicating old observations, including the fact that both sexes present prodromal symptoms in a slightly different way. However, there is no reason to believe that there are unique female indicators of coronary heart disease as they suggest, because the same symptoms have been found to predict coronary events in men.