by Carolyn Thomas ♥ @HeartSisters
In your average garden-variety textbook heart attack, the cause is typically a sudden lack of oxygenated blood supply feeding the heart muscle, caused by a significant blockage in one of your coronary arteries. This blockage is what doctors call the culprit lesion.
But in a new study led by Yale University cardiologist Dr. Erica Spatz, researchers remind us that although this “culprit lesion” classification of heart attack applies to about 95% of men under age 55, only 82.5% of younger women experience this kind of heart attack.(1)
Dr. Spatz and her team have in fact come up with five new classifications of heart attack they call the VIRGO taxonomy (based on data from the large international VIRGO* study). Two of these new classifications are particularly applicable to women.
Here’s how Dr. Spatz explained the new taxonomy to me:
“Young women with heart attacks are a diverse group.
“Many have distinct features that are different from the classic heart attack. But the current classification system does not fully accommodate diverse types of heart attack. As such, one in eight women cannot be classified; in these women, we don’t know what caused the heart attack.
“The VIRGO taxonomy identifies the diversity that exists among young adults with heart attack, and puts them into a more nuanced classification system that can be used to improve our understanding of the different mechanisms of heart attack. It can help us facilitate more personalized treatment approaches to improve outcomes.
“The VIRGO taxonomy may be especially important for young women, in whom the ‘classic’ heart attack resulting from plaque rupture with complete blockage of a heart artery is less often seen.”
There are a number of ways, says Dr. Spatz, that women can show up in the Emergency Department with heart attacks that are NOT caused by a complete blockage.
One is a non-obstructive (no blockage) heart attack caused by what’s known as a supply-demand mismatch. Dr. Spatz explains:
“Supply-demand mismatch is a medical term used to describe any acute stress that results in lack of oxygen to the heart muscle.
“This can result from either a decreased supply of oxygen to the heart (e.g., as with anemia) or an increased demand for oxygen by the heart (e.g., as with severe infection or surgery).
“These kinds of heart attacks are different from the classic heart attack, in which there is an abrupt blockage of one of the heart arteries usually due to the rupture of a plaque.”
In the old days (i.e. last week) of using the current classification system of identifying heart attacks, a supply-demand mismatch would have been classified as a Class 2 MI (myocardial infarction).
But in this new VIRGO taxonomy, researchers demonstrated that not all Class 2 MIs are the same.
Some people who are experiencing a heart attack, according to Dr. Spatz, have significant coronary artery disease (Class 2, see list below) and others have minimal coronary artery disease or none at all (Class 3).
Some adults with significant coronary disease present with an acute stress that results in a lack of oxygen to the heart (Class 2a), though others have no identifiable acute stress (Class 2b). Dr. Spatz adds:
“We suspect that these distinctions are important for understanding disease mechanism, treatment response and prognosis.”
That’s an understatement!
Women presenting in Emergency with no diagnostic evidence of significant coronary artery disease tend to be sent home pretty darned fast. And as many women already know, standard cardiac diagnostic tests that are mostly meant to reveal obstructive coronary artery disease may not accurately identify non-obstructive Class 3 cases at all.
The new classification system of the VIRGO taxonomy includes:
- Class 1: plaque-mediated culprit lesion (82.5% of women; 94.9% of men)
- Class 2: obstructive coronary artery disease with supply-demand mismatch (2a: 1.4% women; 0.9% men;) and without supply-demand mismatch (2b: 2.4% women; 1.1% men)
- Class 3: non-obstructive coronary artery disease with supply-demand mismatch (3a: 4.3% women; 0.8% men) and without supply-demand mismatch (3b: 7.0% women; 1.9% men)
- Class 4: other identifiable mechanism such as spontaneous dissection, vasospasm, or embolism (1.5% women; 0.2% men)
- Class 5: undetermined classification (0.8% women; 0.2% men)
The numbers are startling, and speak for themselves.
In every classification, women outnumber men – except for the Class 1 heart attack caused by a culprit lesion blocking a coronary artery – the classic Hollywood Heart Attack that men typically have, and the type of heart attack that virtually all cardiac diagnostic tools are designed to detect in (white, middle-aged) men.
If physicians are not able or willing to correctly classify women’s heart attacks, little will change when it comes to under-diagnosing women compared to our male counterparts. According to another Yale study published last year in the Journal of the American College of Cardiology, for example, it seems that we’ve made little progress in reducing heart attacks among young women – despite national campaigns designed to increase heart disease awareness and prevention.(2)
Additionally, compared to men, women heart patients under 55:
- had longer hospital stays
- had higher risk of death during hospital stays
- were more likely to have other health conditions like diabetes and high blood pressure
Meanwhile, Dr. Spatz makes an important observation of special interest to women whose unique heart disease may often be missed using standard cardiac diagnostic tests:
“In Class 3 non-obstructive heart attacks, we suspect other mechanisms explain the myocardial infarction (MI), like microvascular disease or vasospasm that is not captured at the time of cardiac catheterization. The catheterization may also lack sensitivity for micro-dissections or spontaneous resolution of a thrombus (clot), sometimes seen, sometimes not.
“Our abilities to diagnose these other vascular causes is limited. We are evaluating women with chest pain syndromes (and MI) who have normal coronary arteries on catheterization with PET scan, assessing coronary flow reserve – an indicator of microvascular dysfunction.
“Vasospasm is very difficult to diagnose and may occasionally warrant a trial of therapy based on a physician’s educated best guess.”
For the first time, the VIRGO taxonomy represents a new way for physicians to rethink heart attack classification – especially in younger women who are more likely to be under-diagnosed compared to our male counterparts.
In my own opinion as a dull-witted heart attack survivor who was sent home from the E.R. misdiagnosed with acid reflux – despite textbook heart attack symptoms and “normal” diagnostic test results, the issue remains: how long will it take for this new way of assessing young women’s heart attacks to trickle down to other cardiologists and the E.R. gatekeepers out there in the real world?
When I asked Dr. Spatz this question, she answered that this VIRGO taxonomy was built on the scenario of women being sent to the cardiac cath lab for an angiogram when they present to hospital with suspicious cardiac symptoms. And that’s quite an assumption!
For example:
“First, we have to hope that women with typical or atypical presentations of MI are being appropriately triaged in the E.R. to catheterization. If the cath (or stress test in the case of non-MI chest pain) is ‘normal’, the reflex to diagnose as ‘non-cardiac’ needs to be revisited.
“Women who are having chest pain syndromes but with ‘normal’ coronary arteries (a scenario that we know is associated with poor health outcomes) may have other vascular disease, triggers of vascular instability and such.
“We need to be alert to these, discuss the limitations of the science on treatment to date, and work with women to diagnose and improve their symptoms – and hopefully their outcomes.
“I am hopeful that in the future, our diagnostic capability to understand mechanisms of symptoms and disease will advance.
“Meanwhile, the VIRGO taxonomy gives a way for researchers and clinicians to communicate and share insights, and to identify appropriate people for research studies.”
♥
*This study is based on data from a large study called VIRGO, or Variation in Recovery: Role of Gender Outcomes on Young AMI Patients. VIRGO is the largest prospective observational study of young and middle-aged women and men diagnosed with acute myocardial infarction (AMI, or heart attack). Researchers studied AMI patients aged 18 to 55 years of age from a large, diverse network of 103 hospitals in the United States, 24 in Spain and 3 in Australia from 2008 to 2012. Led by principal investigator Dr. Harlan M. Krumholz at Yale, researchers looked at a number of important issues in this study, including:
-
the various factors that may predispose women to a heart attack
-
women’s poor recovery after that heart attack compared to our male counterparts
-
the differences between men and women in the medical care that they receive following a heart attack
♥ Need a translator for some of these cardiology terms? Visit my Heart Sisters patient-friendly, no-jargon glossary.
NOTE: Comments in response to this post are now closed. I am not a physician so cannot offer a medical opinion on your symptoms. Please consult your physician if you have specific questions about your health.
See also:
Little social support: a big gap for younger heart patients (more from the VIRGO study)
How gender bias threatens women’s health
How can we get heart patients past the E.R. gatekeepers?
“It’s not your heart. It’s just _____” (insert misdiagnosis)
Misdiagnosis: is it what doctors think, or HOW they think?
Slow-onset heart attack: the trickster that fools us
Heart attack misdiagnosis in women
.
Heart Sisters 
This reader’s comments about symptoms have been removed because I’m not a physician so cannot offer any opinions about specific cases. Please seek medical advice if you’re experiencing serious cardiac symptoms.
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I am 18 and pregnant. I have been having sharp chest pains on my left side since I was 13 and have been to many cardiologist with no results of it being cardiovascular related. My concern is microvascular diesase, since it is common in younger women and most of the time undiagnosable. However, with my age I have been turned down by many doctors and in the E.R. been sent home even after having chest pains accompanied by unconsciousness and seizures. They would not admit me and sent me home saying it was acid reflux or anxiety attack. I am very concerned for my child and I at this point. My main worry is having a class 3 non-obstructive heart attack and doctors won’t even consider it until it’s too late. I was hoping I could get some input from other young women who may have been in a similar situation or experiencing the same symptoms and what you have been diagnosed with. Thanks. 🙂
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Hi Ann — I’m not a physician so cannot comment specifically on your symptoms. I can tell you generally that it would be highly rare for a 13-year old to have undiagnosed heart disease for years without either significant progressing or showing up on some type of diagnostic tests. Much of what you’re describing (e.g. non-epileptic seizure) can in fact be linked with psychological stress. There are few things more anxiety-producing than believing that a heart attack is imminent (even if it’s not at all). It’s important for both you and your baby to reduce this kind of stress as much as you can to be in order to be as healthy as you possibly can. Please talk to your physician about this.
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This reader’s comments about symptoms have been removed because I’m not a physician so cannot offer any opinions about specific cases. Please seek medical advice if you’re experiencing serious cardiac symptoms.
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Mine was a “Class 5 Undetermined” at the age of 34. Not knowing what caused it drives me crazy.
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Good grief – age 34! That’s so young. Did they suspect SCAD (Spontaneous Coronary Artery Dissection? (commonly seen in younger women)
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No, they never suspected that. Their guesses were a random blood clot or a plaque rupture (although my tests did not show a blockage at all, and my arteries look good). I also have never had high BP, cholesterol, don’t smoke, no diabetes, no family history. All of the tests I’ve had (which are many) come back fine, except a high Sed rate and high CRP. I was also diagnosed with mild MVP with regurgitation. I got a second opinion and they don’t know, either. Very weird.
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Weird, indeed! Family history? Pregnancy complications? Sleep apnea? Vasospasm? Sometimes, as the VIRGO taxonomy suggests, about 1% of women are slotted in this “unclassified” category. We know that high CRP is linked with cardiovascular disease (but typically atherosclerosis/plaque rupture which appears not to be the case for you). You may be one of those medical mysteries!
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No family history at all, never been pregnant, no sleep apnea. I’ve had a bunch of tests and they haven’t found anything except MVP with mild regurgitation. I do have high CRP levels but they don’t know why. Let me know if you have any input.
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I wonder if it is microvascular disease. I have brought this up to my cardiologists (I’ve been seeing two of them at two different hospitals) and they don’t think it’s the case. Is there any way to know if it is?
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I’m not a physician so cannot speculate on your specific diagnosis, but in general, it may or may not be microvascular disease (which is rarely picked up using standard cardiac diagnostic tests). Read more on this – including current tests that are most often used to identify MVD.
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This reader’s comments about symptoms have been removed because I’m not a physician so cannot offer any opinions about specific cases. Please seek medical advice if you’re experiencing serious cardiac symptoms.
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Dear Bekah – I’m sorry to hear you’re experiencing these distressing symptoms. I’m not a physician so of course cannot comment on your case. I can tell you in general, however that because of a number of factors (you are a teenager, and your symptoms seem to get worse when the painful area is pressed; also that symptoms decrease when you stand up, etc.) – your physician may be quite correct in his non-cardiac diagnosis.
Also, you mentioned at least twice that you didn’t follow your doctor’s advice (to try antacids, and then massage therapy) and you continue to have symptoms.
Only a physician can determine if any of your symptoms are heart-related or not. So much about the practice of medicine is simply trying to figure out what the problem is NOT, which is why following your doctor’s recommendations is a good idea to see if you find some relief. If not, then the two of you can move on to try to rule out the next possibility. But you need to help him help you to try to solve this mystery with your assistance. He needs your full participation and cooperation so that together you can work out if anything is physically wrong. And you are absolutely correct in guessing that the more you worry about each symptom, the worse you may actually feel. Best of luck to you…
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Thank you for bringing attention to this. As you point out in another post, women are less likely to get referred to cardiac rehab. (As a physician I am mystified by this…)
Keep up the good work!
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Thanks so much for taking the time to comment here!
I too am mystified by the failure of physicians to refer women to cardiac rehab. I just spoke at a medical conference on women and heart disease at Mayo Clinic where this topic came up during my presentation; one audience member shared that her hospital was getting 70%+ rehab referrals from a simple button that docs click on the discharge screen. Her next sentence: only about 30% of patients actually attend. My thought: we know that the #1 predictor of rehab attendance (and more importantly, completion!) is physician endorsement. Ticking a checkbox or clicking an onscreen button is not an “endorsement”. Taking 11 seconds to say out loud to the patient: “This program is proven to improve your quality of life and reduce your risk of another cardiac event, and I’d really love to see you take this!” is endorsement.
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Unfortunately, the major frantic buzz in medical circles (at least in the United States, where insurance companies control the process) is fear of OVER diagnosis and OVER treatment. Now, there are very real downsides to those, but the kind of UNDER diagnosis and UNDER treatment familiar to many who follow this blog can mean years of diminished capacity, and even death.
In this case, mainly diminished capacity and deaths of women. I’d like to see more outrage in medical circles.
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You are so right, Kathleen. For example, in this study, Dr. Spatz replies to my query: “…we have to hope that women with typical or atypical presentations of MI are being appropriately triaged in the E.R. to catheterization”. My concern is that this hope is unrealistic, given we’re talking about an invasive, expensive diagnostic procedure (and certainly not without its own risks) that is rarely ordered based on symptoms alone – even when women present with textbook MI signs like my own (central chest pain, nausea, sweating and pain down my left arm) – unless current non-invasive diagnostic tools can convince an MD that there is a clear reason for a trip to the cath lab. And Dr. Spatz also adds that conditions like microvascular disease or vasospasm are not captured at the time of catheterization.
I’m not a fan of either overdiagnosis or overtreatment – but honestly, the reality of women’s delayed diagnoses/misdiagnoses in cardiac care has swung so far to one extreme, as you say, that SOMETHING needs to be done to address that imbalance.
I do appreciate those MDs (like Mayo Clinic’s Dr. Mary O’Connor) who are outspoken and outraged by the gender gap in women’s health care. Maybe if more doctors were as outraged, that gap would shrink to equal that provided to men.
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I was also a classic Type I who was misdiagnosed in primary care. I think it is very interesting that there is an emphasis on how different women’s heart attack symptoms are and that this needs to be understood.
If I had been a man presenting with the symptoms I had, I’m sure I would have been sent to a cardiac cath lab ASAP. So, on some level, I fear it is not about the symptoms women show (classic or not), but the issue of how doctors (male or female) are trained to hear women’s stories.
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You are 100% correct, tstarstorm! It IS indeed important that women presenting with vague, atypical cardiac symptoms should not be dismissed, but for crying out loud, women like me and you who ARE showing classic symptoms are being misdiagnosed, too!
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Class 1 – culprit lesion at age 72, so definitely not a young woman! But still misdiagnosed initially by both me and my GP. My heart attack transpired, in fact, over approximately 4 days – Thursday evening to Sunday evening, whereupon it became critical. At first I thought I had flu or simply an upset stomach – nausea, sweating, no chest pain. But the next day, felt a nagging pain in my chest, so went off to the GP, who said it was probably acid reflux – sound familiar? Then nothing until Sunday evening, after dinner – suddenly I experienced chest pain that I couldn’t stand any more, whereupon I went to tell my husband that something was wrong, only to pass out at the foot of the stairs, unconscious. Panic ensued, but luckily my adult son, who’d just taken a CPR course on Friday was with us – so he began CPR and my husband called 911, who responded within 15 minutes or so. We live quite close to the major heart hospital in town.
And the rest is history – I’d experienced the classic “widow maker” MI in the LAD, and coded a couple of times on the table, while they were inserting a stent to open the blockage. It was “touch and go” for awhile, afterwards, fears about the insult to the brain, etc., but thankfully I have made a good recovery.
I worry now not only about misdiagnosis, but the lack of good tests to enable doctors to tell beforehand when a heart attack is likely. It seems we have to wait until one actually happens to really do something about it. And the threat of misdiagnosis then looms as well.
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Hi Judy – hearing a misdiagnosis like “probably acid reflux” is, sadly, all too common in women. It’s almost impossible to predict when a heart attack is likely – doctors don’t have a crystal ball. So much of medicine is just ruling out what the problem is not!
This morning, I spoke at a medical conference here at Mayo Clinic on women’s heart health, where I just heard cardiologist Dr. Harmony Reynolds of New York tell her audience: “Plaque rupture is located in a normal-looking area of coronary artery in 45% of cases.”
So it’s not unusual to see such plaque rupture (causing a dangerous clot) in an artery identified with a smaller plaque blockage that suddenly ruptures, just as patients can live with stable chronic angina symptoms for years caused by larger blockages with no plaque ruptures. In the absence of such predictive tests, meanwhile, we do what we can (Mediterranean diet, daily exercise, good sleep habits, etc) to prevent widow maker #2. Best of luck to you!
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