Coronary microvascular dysfunction in menopausal women.

Cardiovascular disease (CVD) accounts for a third of all deaths, making it the leading cause of mortality globally. Coronary microvascular dysfunction (CMD) has emerged as a prominent condition in menopausal women, leading to the development of chronic coronary syndrome (CCS). Despite the significant impact on this cohort, research gaps persist which can lead to shortcomings in the delivery of care to women. CMD is more prevalent in women than men and is linked to increased risk of major adverse cardiovascular events and mortality. During the menopausal transition, there is an acceleration in vascular ageing due to hormonal shift and metabolic changes, resulting in endothelial dysfunction. A large proportion of patients with Takotsubo syndrome and heart failure with preserved ejection fraction (HFpEF) are menopausal women with CMD; however, the underlying mechanisms are not fully understood. Limited evidence of the sex-specific pathophysiology of CMD has resulted in current clinical practice relying on evidence from male-dominant or mixed cohorts. This can lead to incorrect risk stratification, treatment side effects and poor prognosis in women. In addition, there is limited research on the efficacy of diagnostic techniques addressing the sex differences in those with CMD. Tailored diagnostic thresholds and models are essential to improve prognosis in women. Further evidence is needed to bridge these knowledge gaps to tackle the sex differences, achieve sex equality in CVD research and reduce the disproportionate burden of microvascular dysfunction in menopausal women.