Women's symptoms often are different than men's, too, contributing to under-diagnosis. As the disease is progressing, women may describe non-specific symptoms such as fatigue, sleep disturbance and shortness of breath. The WISE researchers recommend that clinicians become more aware and aggressive in investigating these early complaints.

The journal articles on WISE studies, accompanied by discussions provided by several experts in the field, provide insight on a wide variety of subjects, including the array of gender-specific factors contributing to women's manifestation of heart disease and implications for innovative diagnostic and evaluation procedures. Among topics and findings:

• The major roles of sex hormones. "High estrogen levels before menopause and decreasing estrogen and progesterone levels after menopause are believed to influence IHD in women."

• Premenopausal estrogen deficiency due to ovarian dysfunction may be a significant risk factor for IHD for younger women. Women with disruption of ovulation and decreased estrogen production had a greatly increased risk of coronary artery disease.
• The use of nuclear-based heart studies is recommended. Nuclear SPECT (single-photon emission computed tomography) imaging, for example, has resulted in dramatic improvement in diagnostic accuracy for women.
• Functional capacity is one of the strongest and most consistent estimators of cardiac prognosis, but treadmill stress testing is not suitable or effective for many women. Tests that induce stress chemically should be considered. Also, a 12-item questionnaire, the Duke Activity Status Index (DASI), provides a valuable risk assessment using self-re
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