Women And Heart Disease--Part 2
Chester J. Zelasko, Ph.D. | March 14, 2006

In this second Newsletter about heart disease and women, I’m going to get WISE: the Women’s Ischemia Syndrome Evaluation or WISE for short. This was a major study by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The results and discussion of this project were recently published in a special issue of the Journal of the American College of Cardiology (1). The purpose of this project was to evaluate how ischemic heart disease progresses in women, examine differences between men and women, and evaluate whether diagnosing heart disease in women should be done differently. There were some very interesting results all women should know.

Ischemic Heart Disease
Ischemia means “lack of blood flow,” so ischemic heart disease (IHD) is a lack of blood flow to the heart. The heart has a very rich supply of blood vessels; some are large while others are small. The idea is to supply every heart-muscle cell with all the nutrients it needs to keep beating 24 hours a day, seven days a week, for your entire life. When vessels have fatty plaque, it can restrict or even block the flow of blood to the heart tissue, and IHD is the result.

Gender Differences in IHD
Heart disease is the leading cause of death for women of all ages, yet women have a certain degree of protection from IHD until menopause. The protection has generally been attributed to differences in hormone levels between men and women. Once a woman reaches menopause, however, the rate of IHD starts catching up to men; by the time women are in their 60s the risk is roughly equal. The question has been why the disease occurs and progresses differently in women.

One of the reasons may be a lower functional capacity. In other words, women lose fitness faster as they get older. Lower fitness levels, generally attributed to lower physical activity, leads to weight gain, insulin resistance, and hypertension--all associated with IHD. In addition, women tend to gain body fat in their abdominal area after menopause, which is also associated with IHD.

One of the interesting findings was an association between insulin resistance and depression--as insulin resistance increases, depression also increases. Why that occurs is not certain, but it may be related to a whole host of things including non-sexual hormones, lack of functional capacity, and inflammation.

Another interesting gender-related association was between IHD, inflammation, and auto-immune diseases such as lupus erythematosus and rheumatoid arthritis. One marker for inflammation is high-sensitivity C-reactive protein (hs-CRP). Levels of hs-CRP are higher in post-menopausal women, indicating the presence of inflammation. While more research is necessary, women with insulin resistance, elevated hs-CRP, and an auto-immune disorder may be at greater risk for developing IHD at earlier ages.

Symptoms of IHD in Women
Angina or chest pain is the classic symptom for IHD in both genders. However, women may not get the same degree of angina as men do because of the way the disease progresses. Instead of a severe blockage in the major arteries as is generally found in men, women may have lesser blockages in more of the smaller blood vessels that feed the heart.

Women with undiagnosed IHD complain of shortness of breath with exertion and overall fatigue--symptoms that can be attributed to other conditions such as lack of fitness or stress. When tested in the traditional manner, ischemia is not detected on EKGs and the diagnosis of IHD is missed.

Diagnosing IHD in Women
This was the most illustrative part of the report. When a man complains of chest pain--but not a heart attack--a stress test is performed. If vessel blockage is present, the EKG will reveal the lack of blood flow very clearly in something called ST-segment depression. But in women, this doesn’t seem to be the case. The question is why?

The primary reason goes back to the lack of functional capacity I mentioned earlier. Women are not able to continue to exercise until the ischemia is revealed. Simply put, their legs give out long before their hearts do. This may also be due to the way the ischemia develops in women as well.

In order to better diagnose IHD in women, the Stress-Induced Perfusion Abnormality Assessment may be used. While there are different forms of the test, it uses a radioactively labeled dye and computer-aided tomography (CAT scan) to better identify the lack of blood flow in the heart. Instead of a treadmill test, the heart can be stimulated via medication such as epinephrine to get the heart beating fast enough.

The sooner an accurate diagnosis is made, the sooner the proper action can be taken to treat the disease.

What Does This Mean for You?
The fact that IHD symptoms may be less clear in women presents a difficulty. Are you just tired or having IHD symptoms? I think the best thing to do is to note the frequency and resolution of the fatigue. Everyone gets tired, but if it happens more frequently than is normal, which will vary with each woman, keep eliminating the possibilities. If a good night’s sleep doesn’t improve the situation, or if the fatigue is suddenly worse than normal, talk to your physician about two tests: first, the hs-CRP which indicates inflammation, and second, the chemical-induced perfusion test mentioned above. It’s not a lot of fun to have things injected into your body, but if that’s what it takes to diagnosis IHD, aren’t we glad we have it available?

Bottom Line: Don’t quit seeking a diagnosis if you don’t feel right. We don’t feel the same as when we were young, but here’s the thing: in a survey of people having a heart attack, the most common symptom before onset was “I just didn’t feel right.” That may seem vague, but you know yourself--you’ve lived in that body for a long time. Assess the situation and start finding out what’s wrong. Your quality of life depends on it.

References:
  1. Challenging Existing Paradigms in Ischemic Heart Disease: The NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). Journal of the American College of Cardiology. 2006: 47(3) Supplement S.
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