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seen in the Emergency Room for chest pain or other symptoms suggestive of coronary disease will be evaluated under an outdated scientific paradigm aimed at finding blocked arteries.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 tests and hospitalizations, and seek second opinions. Dr. Bestermann warns that the lifetime cost of care for the woman with repeated chest pain and no obstructive coronary artery disease can approach $800,000.
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 recently 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).
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?”
Al-Lamee, Rasha et al. “Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial”. 02 November 2017. http://dx.doi.org/10.1016/S0140-6736(17)32714-9
Q: What will it take to improve diagnosis/treatment of women’s coronary artery disease?
- Is coronary microvascular disease serious? Is the Pope Catholic?
- Coronary Microvascular Disease: a “trash basket diagnosis”?
- No blockages: Living with non-obstructive heart disease
- Why Your Heart Needs Work – Not Rest – After a Heart Attack
- Size Matters – But Not in Coronary Artery Blockages
- What Prevents Heart Disease “Better Than Any Drug”?
- Learning To Live With Heart Disease: The Fourth Stage of Heart Attack Recovery
- Women-Only Cardiac Rehab Curbs Depression After Heart Attack
- Why Aren’t Women Heart Attack Survivors Showing Up For Cardiac Rehab?