Wednesday, February 01, 2006

Word from the WISE on women and heart disease

The word from the WISE investigators is that doctors are missing the diagnosis in up to three million women with coronary heart disease because their clinical and diagnostic signs differ from a male presentation.

Gender differences in cardiovascular risk factors and in the clinical presentation of coronary artery disease may explain why some women with coronary arteries that appear to be clear on angiography are actually at high risk for ischemic heart disease, reported investigators who analyzed data from the Women's Ischemia Syndrome Evaluation, or WISE study.

The lack of angiographic evidence of frank stenosis in women may cause them to be overlooked as candidates for more aggressive interventions, the researchers said.

"When there are no blockages, everybody slacks off, including the patient, and we don't want to do that," said Dr. George Sopko of the National Heart, Lung and Blood Institute. Such patients almost certainly need treatment, he said.

Women may complain of chest discomfort, dizziness, shortness of breath, or fatigue, have a negative stress test, and then a negative angiogram which only spots large blockages. Doctors offer no treatment and may even give a patient the impression that she is neurotic or needs to be treated for depression.

In the government-sponsored study, only a third of a group of women had obvious blockages in their coronary arteries. In a similar group of men, three-quarters or more would have a severe blockage, said Dr. Carl J. Pepine, the chief of cardiovascular medicine at the University of Florida in Gainesville.

In the remaining two-thirds of the women, those without blockages, more than half had abnormalities in their arteries, like an inability to dilate when needed, that could cause ischemia, Dr. Pepine said. The abnormalities occurred in both the coronary arteries and smaller ones that feed the heart, a network of tiny vessels called the microvasculature. Tests showed that the artery walls were full of plaque but had grown outward to accommodate it, so that the opening appeared normal. But eventually, the condition may progress enough to start pinching the artery shut, Dr. Pepine said.

After four years, the rate of deaths or heart attacks in the group without blockages was 10 percent.

"That's much too high for somebody with a normal coronary angiogram," Dr. Pepine said.

It is not clear why women seem more prone to the hidden vascular disease, the researchers said, though it may be linked to hormonal imbalances and a greater tendency to suffer from inflammation, which plays a role in artery disease.

What to do?

  • Identify candidates for exercise stress testing vs. medication stress testing: Using the evaluative tool Duke Activity Status Index (DASI) in women with heart disease symptoms prior to stress testing can help determine who would be eligible for an exercise stress test versus a stress test using intravenous medications to increase the heart load instead of exercise. Current guidelines offer physicians little guidance on how to identify women who would not be able to sufficiently complete the exercise test.
  • Determine Role of Pre-menopausal Hypertension in Disease Risk: Women who have high blood pressure before menopause, especially high systolic blood pressure, should be considered at a higher risk and treated accordingly.
  • Recommend stress echocardiography and single positron-emission computed tomography studies. They appear to be much better at estimating near-term prognosis (event-free survival) in women with chest pain symptoms.

Finally, patients with microvascular disease, who have gone through an entire battery of tests, with positive or negative results, are often treated with medications. All tests may be negative, but if the medication helps you with your symptoms, then physicians will want you to stick with the medications.

It's often a tough nut to crack. Don't ignore symptoms. Gain knowledge of the condition, be assertive, and work closely with your healthcare givers. The result should be in your favor.

Friday is National Wear Red day.

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