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Doctors Focus New Attention
On Heart Disease in Women
Latest Studies Spur Calls
For Better Testing, Treatment;
Exploring the Use of MRIs
By RON WINSLOW (Wall Street Journal)
February 14, 2006; Page D1
Recent research into how heart disease differs between the sexes is prompting calls for fresh approaches to improve its detection and treatment in women.
Provocative findings from a decade-long study argue that many women have a form of heart disease that is fundamentally different and harder to diagnose than in men. Thus, problems are often missed early on in women, when prevention and treatment strategies might be more effective in preventing heart attacks, heart failure and other serious consequences of heart disease.
To counter this, researchers say that women and their doctors need to be especially persistent in tracking down the problem when chest pain and other symptoms arise. Doctors also need to pay more attention to symptoms that occur more frequently in women, such as fatigue and shortness of breath. In addition, doctors are looking closely at certain tests, such as magnetic resonance imaging, that aren't commonly used now but could help detect hidden heart disease in women.
The findings are expected to stimulate new research into treatments. Women are more likely than men to report recurrent chest pain after such standard remedies as bypass surgery and balloon angioplasty, partly because those procedures don't always reach areas where disease occurs in women. But drugs such as statins, aspirin or ACE-inhibitors, already standard for high-risk patients, may be helpful for women who have the more-hidden form of disease.
Overall, researchers say, women need to be especially vigilant about strategies that can reducing the risk of heart disease, including staying fit, eating a healthy diet and avoiding or quitting smoking.
The impetus behind these messages is growing recognition that for many women, chest pain and other symptoms arise not from obstructions in the large arteries of the heart, as commonly found in men, but from tiny vessels that branch off those arteries to deliver blood to heart tissue.
As a result, disease in women is often not detectable via standard diagnostic techniques, including treadmill stress tests and angiograms, which use X-ray technology to let doctors watch how blood flows through key arteries. Indeed, based on such tests, doctors often tell women their arteries are clear and their hearts are fine. But, too often, the symptoms persist and women either muddle through or embark on a frustrating series of additional tests, researchers say. When the disease is finally diagnosed, it is often at an advanced stage, when its toll on women can be particularly harsh.
"So often these women who have open arteries [on an angiogram] are told they have no problem," says C. Noel Bairey Merz, a cardiologist and medical director of women's health at Cedars-Sinai Medical Center, Los Angeles. "We need to stop reassuring them."
Dr. Bairey Merz is chairwoman of the Women's Ischemic Syndrome Evaluation, a major study sponsored by the National Institutes of Health to examine gender differences in diagnosis and the role of sex hormones in heart disease. The study, launched in 1996, involved 936 women who were referred for angiograms because of chest pain.
In reports published earlier this month in the Journal of the American College of Cardiology, Dr. Bairey Merz and her colleagues identified a disorder of the small vessels in women, which they called "microvascular dysfunction."
The heart's primary job is to circulate freshly oxygenated blood to the brain and other organs throughout the body. To keep healthy, the muscle that does the work needs some of that blood too, and it is supplied by the coronary arteries. Blockages in those arteries starve the muscle of oxygen, leading to chest pain. Major obstructions in the large vessels often causes a heart attack.
Blockages in much smaller vessels, whether caused by disease or by functional problems in cells lining the vessel walls, similarly deprive heart muscle of oxygen-rich blood and can also cause heart attacks -- though not typically in the classic fashion of plaque that ruptures in a large vessel. Exactly how the obstructions in large and small vessels might lead to different outcomes for women isn't yet understood, researchers say. The main issue for now is that when the disease is hidden from conventional diagnostic techniques and the patients are given a clean bill of health, the problem is likely to get much worse before it gets treated, with more potentially dire consequences.
Estimates based on WISE data suggest that blockages in the tiny vessels that branch off the arteries may be the major culprit in as many as three million women. One likely reason for the gender differences is the impact of the sex hormone estrogen, which may protect women against heart disease in their younger years, but make them particularly vulnerable when levels plummet after menopause.
Researchers do note that some six million women in the U.S. have heart disease based on the conventional diagnosis of obstructions in the large arteries. Moreover, some men also develop disease in smaller vessels. Accurately evaluating chest pain symptoms is often daunting for doctors in both men and women patients.
But many heart experts are calling for more research to make sense of emerging differences. "We need to take this knowledge and create a systematic plan for how to deal with it," says George Sopko, project officer for the study at the NIH's National Heart, Lung and Blood Institute.
Researchers have long reported that women often lack the tell-tale chest pain that typically predicts serious disease in men. In women fatigue, trouble sleeping and shortness of breath may be symptoms of impending heart trouble that doctors miss. In addition, says Dr. Sopko, radiating chest pain that often accompanies the onset of a heart attack in men appears to occur less often in women, who are more likely to feel pain in the shoulder or arm. Women are also less likely to experience a fluttering of the heart, he says.
To detect heart disease in small vessels, doctors have a number of diagnostic tools to explore besides traditional angiogram and treadmill stress tests. Widely available techniques, such as thallium stress tests and stress echocardiograms can help doctors determine whether adequate blood flow is getting to heart tissue in patients whose chest pain persists despite having clear large arteries, Dr. Sopko says.
Researchers are also looking at other approaches that use magnetic resonance technology. One such test, known as phosphorous-31 nuclear spectroscopy, was a strong predictor of women in the WISE study who were likely to develop future heart trouble in women with chest pain but clear arteries on an angiogram. That test isn't routinely used, but is available at some research centers. In addition, WISE researchers are pilot testing a coronary angiography procedure using MR technology instead of X-rays in hopes that will also prove effective in detecting disease hidden from the conventional exam.
The issue of how to treat women with disease in the small vessels is still being explored. Dr. Sopko and other researchers recommend treatment with statins, ACE-inhibitors and aspirin in women with microvascular dysfunction even as they await results from future studies on whether they reduce heart attacks in such patients.
Another hindrance is awareness. Both the NIH and the American Heart Association have launched campaigns in the past couple of years to educate women about heart risks, but a recent study indicates only about half of women know that it is the leading killer of women.
On Heart Disease in Women
Latest Studies Spur Calls
For Better Testing, Treatment;
Exploring the Use of MRIs
By RON WINSLOW (Wall Street Journal)
February 14, 2006; Page D1
Recent research into how heart disease differs between the sexes is prompting calls for fresh approaches to improve its detection and treatment in women.
Provocative findings from a decade-long study argue that many women have a form of heart disease that is fundamentally different and harder to diagnose than in men. Thus, problems are often missed early on in women, when prevention and treatment strategies might be more effective in preventing heart attacks, heart failure and other serious consequences of heart disease.
To counter this, researchers say that women and their doctors need to be especially persistent in tracking down the problem when chest pain and other symptoms arise. Doctors also need to pay more attention to symptoms that occur more frequently in women, such as fatigue and shortness of breath. In addition, doctors are looking closely at certain tests, such as magnetic resonance imaging, that aren't commonly used now but could help detect hidden heart disease in women.
The findings are expected to stimulate new research into treatments. Women are more likely than men to report recurrent chest pain after such standard remedies as bypass surgery and balloon angioplasty, partly because those procedures don't always reach areas where disease occurs in women. But drugs such as statins, aspirin or ACE-inhibitors, already standard for high-risk patients, may be helpful for women who have the more-hidden form of disease.
Overall, researchers say, women need to be especially vigilant about strategies that can reducing the risk of heart disease, including staying fit, eating a healthy diet and avoiding or quitting smoking.
The impetus behind these messages is growing recognition that for many women, chest pain and other symptoms arise not from obstructions in the large arteries of the heart, as commonly found in men, but from tiny vessels that branch off those arteries to deliver blood to heart tissue.
As a result, disease in women is often not detectable via standard diagnostic techniques, including treadmill stress tests and angiograms, which use X-ray technology to let doctors watch how blood flows through key arteries. Indeed, based on such tests, doctors often tell women their arteries are clear and their hearts are fine. But, too often, the symptoms persist and women either muddle through or embark on a frustrating series of additional tests, researchers say. When the disease is finally diagnosed, it is often at an advanced stage, when its toll on women can be particularly harsh.
"So often these women who have open arteries [on an angiogram] are told they have no problem," says C. Noel Bairey Merz, a cardiologist and medical director of women's health at Cedars-Sinai Medical Center, Los Angeles. "We need to stop reassuring them."
Dr. Bairey Merz is chairwoman of the Women's Ischemic Syndrome Evaluation, a major study sponsored by the National Institutes of Health to examine gender differences in diagnosis and the role of sex hormones in heart disease. The study, launched in 1996, involved 936 women who were referred for angiograms because of chest pain.
In reports published earlier this month in the Journal of the American College of Cardiology, Dr. Bairey Merz and her colleagues identified a disorder of the small vessels in women, which they called "microvascular dysfunction."
The heart's primary job is to circulate freshly oxygenated blood to the brain and other organs throughout the body. To keep healthy, the muscle that does the work needs some of that blood too, and it is supplied by the coronary arteries. Blockages in those arteries starve the muscle of oxygen, leading to chest pain. Major obstructions in the large vessels often causes a heart attack.
Blockages in much smaller vessels, whether caused by disease or by functional problems in cells lining the vessel walls, similarly deprive heart muscle of oxygen-rich blood and can also cause heart attacks -- though not typically in the classic fashion of plaque that ruptures in a large vessel. Exactly how the obstructions in large and small vessels might lead to different outcomes for women isn't yet understood, researchers say. The main issue for now is that when the disease is hidden from conventional diagnostic techniques and the patients are given a clean bill of health, the problem is likely to get much worse before it gets treated, with more potentially dire consequences.
Estimates based on WISE data suggest that blockages in the tiny vessels that branch off the arteries may be the major culprit in as many as three million women. One likely reason for the gender differences is the impact of the sex hormone estrogen, which may protect women against heart disease in their younger years, but make them particularly vulnerable when levels plummet after menopause.
Researchers do note that some six million women in the U.S. have heart disease based on the conventional diagnosis of obstructions in the large arteries. Moreover, some men also develop disease in smaller vessels. Accurately evaluating chest pain symptoms is often daunting for doctors in both men and women patients.
But many heart experts are calling for more research to make sense of emerging differences. "We need to take this knowledge and create a systematic plan for how to deal with it," says George Sopko, project officer for the study at the NIH's National Heart, Lung and Blood Institute.
Researchers have long reported that women often lack the tell-tale chest pain that typically predicts serious disease in men. In women fatigue, trouble sleeping and shortness of breath may be symptoms of impending heart trouble that doctors miss. In addition, says Dr. Sopko, radiating chest pain that often accompanies the onset of a heart attack in men appears to occur less often in women, who are more likely to feel pain in the shoulder or arm. Women are also less likely to experience a fluttering of the heart, he says.
To detect heart disease in small vessels, doctors have a number of diagnostic tools to explore besides traditional angiogram and treadmill stress tests. Widely available techniques, such as thallium stress tests and stress echocardiograms can help doctors determine whether adequate blood flow is getting to heart tissue in patients whose chest pain persists despite having clear large arteries, Dr. Sopko says.
Researchers are also looking at other approaches that use magnetic resonance technology. One such test, known as phosphorous-31 nuclear spectroscopy, was a strong predictor of women in the WISE study who were likely to develop future heart trouble in women with chest pain but clear arteries on an angiogram. That test isn't routinely used, but is available at some research centers. In addition, WISE researchers are pilot testing a coronary angiography procedure using MR technology instead of X-rays in hopes that will also prove effective in detecting disease hidden from the conventional exam.
The issue of how to treat women with disease in the small vessels is still being explored. Dr. Sopko and other researchers recommend treatment with statins, ACE-inhibitors and aspirin in women with microvascular dysfunction even as they await results from future studies on whether they reduce heart attacks in such patients.
Another hindrance is awareness. Both the NIH and the American Heart Association have launched campaigns in the past couple of years to educate women about heart risks, but a recent study indicates only about half of women know that it is the leading killer of women.
