Posted on Fri, Mar. 03, 2006
Women need new, better tests for heart disease
BY JACOB GOLDSTEINKnight Ridder Newspapers
The very old story about heart disease in women: It doesn't happen.
The somewhat old story: It happens, and doctors and patients need to be vigilant.
The new story: Vigilance isn't enough.
The disease itself is different in women, according to a growing body of research - harder to detect and harder to treat, even when doctors and patients are on the lookout. Researchers say it will be impossible to reconcile the disparity without developing new tests and treatments.
``We just don't fit the mold,'' said Dr. Maureen Lowery, a University of Miami cardiologist who studies heart disease in women. ``But perhaps it's because the mold was defined by men in the first place.''
Heart disease is the leading killer of U.S. women; more than 200,000 women die every year from the disease, according to the Centers for Disease Control.
Yet the disease's progression in women remains mysterious.
In the classic tale, a patient comes in complaining of angina - pain or a squeezing feeling in the chest, often set off by exercise or emotional distress. If the doctor suspects heart disease, the patient may get a series of tests that includes an angiogram. In that test, a doctor injects dye into the large arteries around the heart, then takes an X-ray to see whether any of the arteries are clogged.
If there is a blockage, the patient will likely have bypass surgery or a balloon angioplasty to restore the flow of blood to the heart. If all goes well, he or she will then live happily ever after.
But at every step, the classic tale is less likely to apply to women.
Women often show up at the doctor complaining of angina, but they may also report other symptoms, such as fatigue and shortness of breath, according to Dr. Amir Lerman, a Mayo Clinic cardiologist.
Even if a doctor suspects heart disease, he or she may miss the diagnosis because some of the key tests don't work very well in women.
A recent study of more than 900 women with symptoms of heart disease found that angiograms caught disease in only about one third of the women, less than half as often as the test finds the disease in men, according to Dr. Carl Pepine, a University of Florida cardiologist who was one of the study leaders. Among the majority of women whose angiograms were clear, about half had heart disease, researchers found.
A common test in which a doctor reads the heart's electrical output while a patient is exercising catches about 60 percent of cases in women, compared with roughly 80 percent in men.
The inadequacy of these tests can cause doctors to overlook disease, Lerman said.
``If you already sent the patient for a coronary angiogram and you didn't find any obstruction, you're not supposed to stop there,'' he said. ``We have a lot of patients coming to us after they've been in multiple places and they've all been told they don't have heart disease.''
A key part of the problem is that tests such as angiography were designed to detect big blockages in the large arteries that supply the heart with blood. That works well in men, where problems tend to cluster in the major arteries. But doctors believe that women may be more likely to have more diffuse, less easily detected plaque buildup spread throughout the network of tiny arteries around the heart.
``A lot of women have very vague chest symptoms, and oftentimes they're brushed off,'' Pepine said. ``It's not because we don't believe they get disease; it's because we don't understand the early phase well enough.''
Thus, the disease is not only more difficult to find, it's more difficult to treat. Standard interventions such as bypass surgery and angioplasty correct blockages in large arteries, not diffuse problems in small arteries.
``There is no gold standard treatment if you find a disease of the microcirculation,'' Lerman said.
Doctors don't know what drives the gender-based differences in heart disease, but it likely has to do with differences in sex hormones, such as estrogen and androgen, that bind to the inner walls of blood vessels.
``Women have wide sex-hormone fluctuations that are never even approximated in men,'' Pepine said. ``What's emerging is that sex hormones actually control the remodeling process of blood vessels - the blood vessels' ability to accommodate injury.''
The relationship between sex hormones and blood vessels is likely what keeps heart disease rates low in women before menopause. That idea led doctors to recommend hormone replacement therapy to guard against heart disease after menopause - until a major study found that the therapy increased the risk. Now researchers are investigating the possibility that hormone therapy may reduce the risk of heart disease in women who begin the treatment immediately after menopause, but not those who take hormones later in life.
In the coming years, new imaging techniques, including using MRI to examine the tiny arteries around the heart, may help with diagnosis, Pepine said.
But even without understanding precisely how or why heart disease develops in women, doctors can aggressively treat risk factors, by encouraging women to exercise, avoid cigarettes and maintain a healthy weight, Lerman said. Using drugs to lower high cholesterol levels and high blood pressure can also help.
Indeed, one recent study found that women's abilities to accomplish ordinary activities such as raking leaves, scrubbing floors, and climbing a flight of stairs can be used to predict the likelihood of death or a non-fatal heart attack within five years.
Roberta Karawan, who lives in Aventura, Fla., had a heart attack 20 years ago. Karawan, 63, said she still sometimes receives ``nonchalant'' treatment from doctors, despite the fact that she has continued to have trouble with the arteries around her heart. But things have improved from the days before her heart attack, she said.
``There had been times in the past when I had gone to my doctor and said, `I'm not feeling well,' '' she said. ``He said, `You're raising children. Take a Valium.'''
Women need new, better tests for heart disease
BY JACOB GOLDSTEINKnight Ridder Newspapers
The very old story about heart disease in women: It doesn't happen.
The somewhat old story: It happens, and doctors and patients need to be vigilant.
The new story: Vigilance isn't enough.
The disease itself is different in women, according to a growing body of research - harder to detect and harder to treat, even when doctors and patients are on the lookout. Researchers say it will be impossible to reconcile the disparity without developing new tests and treatments.
``We just don't fit the mold,'' said Dr. Maureen Lowery, a University of Miami cardiologist who studies heart disease in women. ``But perhaps it's because the mold was defined by men in the first place.''
Heart disease is the leading killer of U.S. women; more than 200,000 women die every year from the disease, according to the Centers for Disease Control.
Yet the disease's progression in women remains mysterious.
In the classic tale, a patient comes in complaining of angina - pain or a squeezing feeling in the chest, often set off by exercise or emotional distress. If the doctor suspects heart disease, the patient may get a series of tests that includes an angiogram. In that test, a doctor injects dye into the large arteries around the heart, then takes an X-ray to see whether any of the arteries are clogged.
If there is a blockage, the patient will likely have bypass surgery or a balloon angioplasty to restore the flow of blood to the heart. If all goes well, he or she will then live happily ever after.
But at every step, the classic tale is less likely to apply to women.
Women often show up at the doctor complaining of angina, but they may also report other symptoms, such as fatigue and shortness of breath, according to Dr. Amir Lerman, a Mayo Clinic cardiologist.
Even if a doctor suspects heart disease, he or she may miss the diagnosis because some of the key tests don't work very well in women.
A recent study of more than 900 women with symptoms of heart disease found that angiograms caught disease in only about one third of the women, less than half as often as the test finds the disease in men, according to Dr. Carl Pepine, a University of Florida cardiologist who was one of the study leaders. Among the majority of women whose angiograms were clear, about half had heart disease, researchers found.
A common test in which a doctor reads the heart's electrical output while a patient is exercising catches about 60 percent of cases in women, compared with roughly 80 percent in men.
The inadequacy of these tests can cause doctors to overlook disease, Lerman said.
``If you already sent the patient for a coronary angiogram and you didn't find any obstruction, you're not supposed to stop there,'' he said. ``We have a lot of patients coming to us after they've been in multiple places and they've all been told they don't have heart disease.''
A key part of the problem is that tests such as angiography were designed to detect big blockages in the large arteries that supply the heart with blood. That works well in men, where problems tend to cluster in the major arteries. But doctors believe that women may be more likely to have more diffuse, less easily detected plaque buildup spread throughout the network of tiny arteries around the heart.
``A lot of women have very vague chest symptoms, and oftentimes they're brushed off,'' Pepine said. ``It's not because we don't believe they get disease; it's because we don't understand the early phase well enough.''
Thus, the disease is not only more difficult to find, it's more difficult to treat. Standard interventions such as bypass surgery and angioplasty correct blockages in large arteries, not diffuse problems in small arteries.
``There is no gold standard treatment if you find a disease of the microcirculation,'' Lerman said.
Doctors don't know what drives the gender-based differences in heart disease, but it likely has to do with differences in sex hormones, such as estrogen and androgen, that bind to the inner walls of blood vessels.
``Women have wide sex-hormone fluctuations that are never even approximated in men,'' Pepine said. ``What's emerging is that sex hormones actually control the remodeling process of blood vessels - the blood vessels' ability to accommodate injury.''
The relationship between sex hormones and blood vessels is likely what keeps heart disease rates low in women before menopause. That idea led doctors to recommend hormone replacement therapy to guard against heart disease after menopause - until a major study found that the therapy increased the risk. Now researchers are investigating the possibility that hormone therapy may reduce the risk of heart disease in women who begin the treatment immediately after menopause, but not those who take hormones later in life.
In the coming years, new imaging techniques, including using MRI to examine the tiny arteries around the heart, may help with diagnosis, Pepine said.
But even without understanding precisely how or why heart disease develops in women, doctors can aggressively treat risk factors, by encouraging women to exercise, avoid cigarettes and maintain a healthy weight, Lerman said. Using drugs to lower high cholesterol levels and high blood pressure can also help.
Indeed, one recent study found that women's abilities to accomplish ordinary activities such as raking leaves, scrubbing floors, and climbing a flight of stairs can be used to predict the likelihood of death or a non-fatal heart attack within five years.
Roberta Karawan, who lives in Aventura, Fla., had a heart attack 20 years ago. Karawan, 63, said she still sometimes receives ``nonchalant'' treatment from doctors, despite the fact that she has continued to have trouble with the arteries around her heart. But things have improved from the days before her heart attack, she said.
``There had been times in the past when I had gone to my doctor and said, `I'm not feeling well,' '' she said. ``He said, `You're raising children. Take a Valium.'''
