Do women need different treatment of coronary artery disease?

by Carolyn Thomas    @HeartSisters

Cardiologist Dr. William Bestermann, in reviewing his own 40+ year career as a physician, now concludes that, in all of medicine, “there is no better example of the disconnect between what we know and what we do than in the case of women with coronary artery disease.” I’m a woman who has survived a widowmaker heart attack, and now lives with coronary microvascular disease, and I’ve only been writing about such sentiment for eight years. As Dr. B. explains bluntly:

Every other week, I see a woman who has had symptoms of coronary artery disease and has been told that the problem is her esophagus – or worse – depression or anxiety.  She is told in effect: ‘Go home, take your anti-anxiety drugs, you will be fine!’  What she has been told is often wrong – too often, dead wrong!”

“The woman who is seen in the Emergency Room for chest pain or other symptoms suggestive of coronary disease will be evaluated under an outdated scientific paradigm aimed at finding blocked arteries.  She will have a treadmill stress test done and/or a cardiac catheterization.  If these tests are ‘normal’, the patient will be told that the symptoms are not related to her heart.”

In evidence of this statement, he cites the NIH-sponsored WISE study (Women’s Ischemic Syndrome Evaluation).

”   This study looked at the unique nature of coronary artery disease in women.  The findings are extremely important and have very practical implications.   Coronary artery disease in women is very different from coronary disease in men. 

“This illness in men generally produces focal obstructions of the artery that cause chest pain with exercise that is relieved by rest. But many women produce diffuse cholesterol plaque that is distributed evenly throughout the arteries, producing arteries that are small and with less obstruction. Still, these plaques can rupture and produce clots. 

“Most heart attacks are clotting events, which explains why the anticoagulant aspirin may prevent a heart attack, and clot-busting drugs may stop a heart attack already in progress.  When a clot blocks the artery, that produces a heart attack.

“Not only is the plaque deposition in women diffuse, but it remodels the artery outward, and plaques may therefore be very large before producing any obstruction.  This diffuse, vulnerable plaque in women explains why women with repeated chest pain in the WISE study still had a high risk of heart attack and other cardiovascular events, even with a ‘normal’ heart catheterization.”   See also: Misdiagnosed: women’s coronary microvascular and spasm pain

Dr. Bestermann reminds his medical colleagues that what these women really need is what is called optimal medical therapy – aspirin, blood pressure control, cholesterol management, and smoking cessation. Each of these has shown a powerful effect on stabilizing plaque, helping to relieve symptoms and preventing cardiac events. He also cites research suggesting that up to 70% of women can have their chest pain relieved within a year when they are appropriately treated with medications like beta blockers, nitroglycerin, and angina medications like Ranexa. Other studies suggest that drugs known as ACE inhibitors, along with regular exercise, can also improve symptoms.

But according to Dr. Bestermann, our current medical system continues to operate under the fixed blockage paradigm in coronary artery disease.  If a woman does not have a fixed blockage, he says, she is told that the problem is not related to her heart.

Not only that, but as one of my blog readers discovered to her horror, some physicians are unaware that non-obstructive coronary artery disease is even real. When she wondered if her two years of persistent angina symptoms (yet “normal” test results) might be due to coronary microvascular disease, her physician replied:

“I don’t believe in microvascular disease.”

The consequences of this diagnostic error are that some women do not have their real problems effectively addressed. Women with repeated angina may continue to have unnecessary pain and suffering. Because the real problems are not being addressed, these women frequently return to the Emergency Room, have more expensive tests and re-admissions to hospitals, and seek second opinions.

But the issue may go far beyond issues unique to women.

While the gap between what we know and what we do may be most pronounced in women with coronary artery disease, this issue is just the best example of glaring problems in cardiac care.

“We identify patients with chest pain, do a catheterization, and then relieve any blockages with coronary stents or bypass surgery.  Most patients and physicians believe opening obstructed arteries protects these patients from having a heart attack for 10-15 years.  But the landmark COURAGE trial conclusively showed that in stable angina, adding a stent to optimal medical therapy provided no additional benefit.”

Several studies have confirmed that result, including the controversial ORBITA study published in the UK medical journal, The Lancet.(1)    In ORBITA, heart patients living with the chest pain of stable angina who received placebo treatment (a sham stent), showed no difference in later symptoms and/or function compared to those who had a real stent implanted. (CAROLYN’S NOTE: the ORBITA study included just 200 patients, none of whom were suffering heart attacks or had multiple blockages; only 27% of the participants studied were women;  research follow-up was just six weeks).

Dr. Bestermann adds these questions:

”     Is it time to get much more serious about addressing the unique needs of female patients with coronary artery disease? When will we step up and protect our mothers, wives, and neighbors?”

  1. Al-Lamee, Rasha et al. “Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial”. 02 November 2017.

Q:  What will it take to improve diagnosis/treatment of women’s coronary artery disease?

NOTE FROM CAROLYN:   I wrote much more about why women are not just small men in my book, A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use the JHUPress code HTWN to save 30% off the list price).

See also:

Could you wait 10 years for a cardiac diagnosis?    (Bobbi-Jo Green’s shocking story)

Is coronary microvascular disease serious? Is the Pope Catholic?

Coronary Microvascular Disease: a “trash basket diagnosis”?

No blockages: Living with non-obstructive heart disease

Meeting of Minds conference speaker videos:  the 2019 INOCA International medical conference on Ischemia with Non-Obstructed Coronary Arteries held in London, England (with over 50 videos available, podcasts, a quarterly newsletter you can subscribe to, and regular posts, updates and video clips)


9 thoughts on “Do women need different treatment of coronary artery disease?

  1. I have been going through symptoms of MVD for the past two years. I was diagnosed with MVD down in Emory University in Atlanta, by a female cardiologist who actually listened and believed what I was saying and took it very seriously. The two male cardiologists that I went to prior could not care less about me or my symptoms. I was never treated with such disregard in my 65 years..

    Bottom line ladies: Do your own research and find a female cardiologist who has done at least some research in this field. Otherwise, you will be given a host of drugs that may not even help or you can expect to be dismissed or ignored.

    Another lesson I learned: As Dr. Samady states in his video they ‘do not know the cause of MVD.’ My cholesterol levels are very low and my arteries are clean so I have serious reservations that it is diffused cholesterol. Bottom line: With the research that has been done they just DO NOT KNOW what the cause is. The more I speak to cardiologists, the more I realize they are literally fumbling for answers. So we have to accept that and move on.

    So ladies, I suggest we move past all the ‘theoretical causes’ and how deplorable male doctors treat women and try to move forward and help ourselves.

    Can we use this blog to discuss our symptoms and our prognosis? What drugs actually help us and which ones don’t? Is it true with these incapacitating symptoms that keep us from living a normal life, can only be a difference of 2% mortality from the norm? I seriously doubt these statistics. I believe it must be higher and we owe it to ourselves to ask the right questions to ourselves who may actually know if we can track this information ourselves. The way we can move forward is to discuss our symptoms, treatments on this blog and what actually helps.

    Just to mention: My last physical showed all excellent blood results. No diabetes, no high cholesterol, no high blood pressure. I was told that I eat better than 90% of the population, not overweight, walk as much as I can every day, never smoked, never drank, no drugs, ever. Always healthy all my life even during my pregnancies. My family history is strong in heart disease. I believe it is my DNA and I seriously doubt any other belief. It is up to women to become their own advocate and help ourselves to understand this. If you are looking for answers from docs, you won’t find it because they just DON’T KNOW.

    I would like to know how many years women have been suffering from MVD? Has it gotten worse or better and how many women have died from this and what was the timeframe? This information is pertinent and relevant, not theories and beliefs about diet and blaming it on cholesterol when there is not proof that is the case. The answers will come from us as a group of women. That is how docs to their research. Why not do it for ourselves?

    Liked by 1 person

    1. Hi Lois – you are on fire, girl! Doing our own research is great advice. And you ask some tough questions, e.g. has MVD gotten worse or better? Since it’s only relatively recently that MVD has even been identified and researched, it’s not yet possible to answer that. And sometimes, being able to accurately identify a specific cause (e.g. family history) doesn’t actually help much going forward.

      My own cardiologist is the one who immediately diagnosed my own distressing post-MI symptoms as MVD, and then referred me to our hospital’s Regional Pain Clinic (where my Pain Specialist had spent a full year doing post-grad fellowship training in Sweden studying in inoperable coronary microvascular disease). Both happen to be male physicians. The reality of course is that not all female cardiologists are experts in MVD or even women’s heart disease, and not all male cardiologists are “deplorable”.


  2. Dear Carolyn,

    What do you think of Repatha treatment to lower cholesterol?
    Have problems w sinus – a side effect. Runny nose all the time.

    Liked by 1 person

    1. Hi Dorothy – I’m not a physician so cannot comment specifically on Repatha, except to recommend an excellent (non-industry-funded) review of this new PCSK9 inhibitor drug (via The People’s Pharmacy).

      A new study published earlier this year had some cardiologists very excited about this new kind of injectable cholesterol-lowering drug, particularly for patients diagnosed with family hypercholesterolemia (FH). The drug cost can be insanely high (as much as $14,000 per year) and some of its results have been questioned, so do your homework!


  3. I don’t think it’s so much a question of providing women with “different treatment” as it is of changing physicians’ mindsets, particularly — but by no means limited to — physicians of the male persuasion.

    There’s still too much of the arrogant “I’m an MD and you, woman, are not, so you don’t know what you’re talking about” attitude, plus, in the case of male docs, a good dose of misogyny. The only way to effect such changes is by educating both physicians and women. I think the AHA needs to do a much more aggressive job of educating women about heart disease, and particularly microvascular heart disease.


  4. For the past several months I’ve been experiencing shortness of breath, chest/back pain on exertion (and sometimes without exertion), dry cough, fatigue and significant drops in O2 sats (by pulse oximeter) to levels mid-70’s and mid-80’s.

    The doctors are confounded. I was diagnosed with coronary artery disease in 2014. I’ve been on statins for ten years–and my cardiologist was unhappy that I take Zocor as I cannot tolerate Crestor or Lipitor, though my LDL is 72 on it, and my HDL is always above 80.

    It is considered mild (40% occlusion in LAD, and occlusion in surrounding smaller arteries) with heavy calcification. I’ve been tentatively diagnosed with small airways disease, though I have really no wheezing–so they call it cough variant. I just switched pulmonologists because the one I was seeing kept changing his mind about what to do next. I decided that my cardiologist should be involved in this and went in search of a new one.

    My new cardiologist is doing a left heart catheterization on me in two weeks. If she finds blockage(s), she will use balloon and/or stent angioplasty. Having read this article, I’m a bit alarmed about the stent issue, though I did know it was not considered particularly successful.

    So this very long history is all too say that your article was most timely for me. I don’t know that it helps me in the long run, but it supports my belief that women are not taken seriously enough in the diagnosis and treatment of heart disease, and are certainly not considered a unique group. I am terrified at the level of calcification I have and not reassured that the doctors are not. Thank you again for the enlightening information!

    –All the Best,
    Penny Wolf

    Liked by 1 person

    1. Hello Penny – what a long road you have been on! I’m not a physician so cannot comment on your specific case, but I can tell you that *something* is causing your distressing symptoms, and right now you really have no definitive answer to what that cause is. They may or may not be related to your heart at all, given that most people do not experience symptoms for blockages under about 70%. The overall consensus, given emerging research, is that coronary stents are very important in helping to prop open blocked coronary arteries in patients experiencing heart attack, or with multi-vessel disease. The trouble is, most of us have a bias for DOING SOMETHING, and when we’re desperate for symptom relief, we’ll try just about any procedure available – even if research suggests it may not help in the long run. You are wise to continue seeking further info on any planned procedure and alternatives. Ask your new cardiologist about the possibility of testing for coronary microvascular disease. Good luck to you…


Your opinion matters. What do you think?

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s