In Heart Disease, the Focus Shifts to Women
- From: William Wagner <not-to-here-williamwag@xxxxxxxxx>
- Date: Tue, 18 Apr 2006 10:33:09 -0400
http://www.nytimes.com/2006/04/18/health/18hear.html?8dpc
In Heart Disease, the Focus Shifts to Women
By DENISE GRADY
Published: April 18, 2006
Kim Kachmann-Geltz did everything right. She ran five miles a day,
dutifully ate oatmeal and wheat toast, stayed slim, never smoked. Her
blood pressure was perfect. Her genes, she thought, were lucky: her
great-grandmother had lived to 102.
Perry Baker for The New York Times
"I'm the last person in the world I could ever imagine having heart
disease," said Ms. Kachmann-Geltz, of Hilton Head, S.C., who is 39 and
the mother of three children.
But since 2003 she has suffered from angina, chest pain caused by
inadequate blood flow to the heart. In addition, one chamber of her
heart has shown signs of enlargement, and her heart valves do not work
properly. She takes four heart medicines and may eventually need more.
Even with the drugs, chest pain keeps her from running. She walks
instead, and does yoga.
"It's not a death sentence," she said. "You don't have to live your life
depressed."
But her outlook is a mixed message. She describes her prognosis as good
and yet also says the disease may shorten her life.
"We just don't know," she said. "That much has been made clear to me."
Her case is unusual: angina more often strikes older women. Still,
coronary artery disease is the leading cause of death in women over 25,
killing more than 250,000 a year in the United States. Before they reach
their 60's, women are less likely than men to develop heart problems,
but once the disease does occur, women often fare worse than men.
Since 1984, more women than men have died each year from heart disease,
and though overall coronary death rates have dropped in recent decades,
most of the improvements have been in men.
Puzzling differences have emerged between men and women with heart
disease, making it plain that past studies, mostly done on men, do not
always apply to women. Researchers have come to realize that to improve
diagnosis and treatment for women, they must sort out the differences.
"Every time we turn around, we find more gender differences, so it's
important to study," said Dr. C. Noel Bairey Merz, a cardiologist at
Cedars-Sinai Medical Center in Los Angeles.
Among the differences are these:
¶Women with chest pain and other heart symptoms are more likely than men
to have clear coronary arteries when tests are performed, a surprising
result that suggests there may be another cause for their problems.
¶When women do have blocked coronary arteries, they tend to be older
than men with similar blockages and to have worse symptoms, including
more chest pain and disability. These women are also more likely to have
other problems like high blood pressure, high cholesterol and diabetes,
which may make surgery riskier. And they are more likely than men to
develop heart failure, a weakening of the heart muscle that can be
debilitating and ultimately fatal.
¶When women have bypass surgery or balloon procedures for coronary
blockages, they are less likely than men to have successful outcomes,
and they are more likely to suffer from bad side effects.
¶Blood tests that reliably pick up signs of heart damage in men do not
always work in women.
¶Women seem much more likely than men to develop a rare, temporary type
of heart failure in response to severe emotional stress.
"We don't have good explanations for these gender differences," said Dr.
Alice K. Jacobs, a cardiologist at Boston University.
She said that one reason women have not fared as well as men after
bypass surgery and balloon procedures may be that women are smaller, and
so are their blood vessels, and the vessels may tend to clog up again
more easily after the procedures.
In addition, surgeons performing bypasses in women have been less likely
to use an artery from inside the chest wall, because it is smaller and
harder to work with ? even though using the chest artery instead of a
leg vein gives most patients better odds of long-term survival.
In the past, Dr. Jacobs said, cardiologists had only big balloons and
bulky tubing to open blocked vessels, and some of the equipment may have
been too large for women.
"Now we have tiny wires, balloons and stents, and it's less of an
issue," she said, adding that success rates in women were improving.
Women like Ms. Kachmann-Geltz have become an important focus of study.
Her doctors believe she has an insidious type of heart disease, more
common in women than men, that researchers are just beginning to
understand.
These patients have chest pain and abnormal stress tests. Their heart
muscle is starved and aching for oxygen ? and yet their coronary
arteries look wide open on an angiogram, the test in which doctors
inject the vessels with dye and then X-ray them to spot blockages.
Some of these women also score poorly on a simple survey ? the Duke
Activity Status Index ? that gauges their strength and ability to
exercise by asking questions like whether they can walk up a flight of
stairs or run a short distance. A low score is a reliable predictor of
more heart problems to come.
For those with symptoms, the real, underlying problem may be a disorder
called microvascular disease, a narrowing or stiffening of the smaller
arteries that nourish the heart, vessels too tiny to show up on an
angiogram.
"These little arterioles are deciding where relatively low and higher
blood flow should occur," said Dr. Bairey Merz, explaining that the
smaller vessels are more muscular than large ones, and their walls
contract or relax to regulate blood flow.
In microvascular disease, the small vessels lose their ability to dilate
and increase blood flow to the heart. The cause does not seem to be
fatty deposits like the ones that can block the coronary arteries.
Rather, the muscles in the arterioles thicken, a process called
remodeling, and the walls may stiffen and begin to close in. The result
is ischemia, lack of blood flow. Over time, it increases the risk of
heart failure and heart attacks.
Three million women in the United States may have microvascular heart
disease, said Dr. Bairey Merz, chairwoman of a government-sponsored
study of the disorder, called Wise, for Women's Ischemia Syndrome
Evaluation.
That study, begun in 1996, included 936 women who had angiograms because
of symptoms like chest pain. Their average age was 58, but a quarter
were younger and premenopausal.
The angiograms found that only a third had blockages in their coronary
arteries. In men with similar symptoms, three-quarters or more would
have had severe blockages, said Dr. Carl J. Pepine, an investigator in
the study and the chief of cardiovascular medicine at the University of
Florida.
Another third of the women had no blockages but did have low blood flow
to the heart, most likely a result of microvascular disease. The
deficiency was found by a test in which doctors first measured blood
flow through the heart and then injected a drug that should have made
the arteries dilate and increased the flow. If the flow did not rise,
the patient most likely had microvascular disease.
Among those judged to have the disorder, the rate of deaths or heart
attacks was 10 percent after four years ? much higher than would be
expected for women with normal angiograms.
The findings call for a major shift in the treatment of women with chest
pain or other symptoms and normal angiograms, said Dr. George Sopko of
the National Heart, Lung and Blood Institute. "Instead of tossing aside
the angiogram and saying you're O.K., let's make sure we are not missing
anything."
Doctors should use the Duke survey and consider other tests that can
pick up signs of ischemia. And since recent studies have also suggested
that women who score high on measures of hostility have an increased
risk of heart problems, Dr. Sopko said: "If a woman comes in and has
symptoms, let's be careful when we evaluate her. Let's listen to her,
look at all the risk factors and include the psychosocial evaluation."
High cholesterol and high blood pressure are almost certainly among the
causes of microvascular disease, and it is essential to treat them
aggressively in women with chest pain, Dr. Pepine said, and to urge
women to exercise, avoid smoking and lose weight if they are too heavy.
Recent studies have found that high blood pressure ? particularly high
readings in the top number, the systolic pressure ? is a more serious
risk factor in women before menopause than after, and researchers say it
should be monitored and treated.
"You don't want to be disabled and lead a miserable life," Dr. Pepine
said. "Women who develop heart failure tolerate it much more poorly than
men, and they tolerate heart attacks and bypass surgery more poorly than
men. We don't want them to get to that stage."
The meaning of other findings is less clear, Dr. Sopko said, adding that
researchers were debating what if anything to do for women who had high
levels of a substance called C-reactive protein, a marker for
inflammation, which is thought to play a role in heart disease.
"We know it appears to be a marker for atherosclerosis," Dr. Sopko said,
"but that is far from saying we have to act on that marker with such and
such strategies. Simple, fairly appealing strategies may not work out
that well. We have to go back and get better knowledge."
Why microvascular disease might be more common in women than men is
unknown. Inflammation and anemia, both more common in women, have been
suggested as possible factors, along with hormonal fluctuations, but
none have been proved.
Some researchers think microvascular disease may help explain some of
the other gender differences ? why, for instance, women tend to have
worse symptoms than would be expected based on the condition of their
coronary arteries.
But microvascular disease is not easy to detect. When doctors see clean
coronary arteries on an angiogram, they may not take a patient's chest
pain seriously or recommend more tests or treatment.
"I was treated like a crazy woman," Ms. Kachmann-Geltz said, noting that
one doctor offered her tranquilizers, implying that her problems were
all in her head.
Her symptoms began during her third pregnancy, and her heart function
deteriorated so much that she nearly died during labor, she said,
recalling that a nurse in the delivery room actually asked whether she
was an organ donor.
After her son was born, she suffered from angina for almost two years
and had attacks that woke her up at night, before she found her way to
Dr. Pepine.
Tests showed a blood flow deficit in her heart.
"It was 30 seconds that changed my life," she said. "It was the first
time I felt acknowledged. This is real, it's not in my head, it's not
some pregnancy thing. I shake when I think about it."
It is impossible to say why the disease developed, but she noted that
her mother also has heart disease. In any case, Ms. Kachmann-Geltz she
began treatment with a diuretic and other medicines to control her blood
pressure and cholesterol.
"My world started coming back to me," she said. "It took about four
months. I started to regain energy, and stopped having nighttime sweats
and chest pain. I was able to start living my life again."
Copyright 2006 The New York Times Company
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This article is posted under fair use rules in accordance with
Title 17 U.S.C. Section 107, and is strictly for the educational
and informative purposes. This material is distributed without profit.
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