The challenge of caring for women’s hearts
Before the worst week of her life, my patient was relatively healthy. She enjoyed a robust social life and was an active participant in her church, which she and her husband attended twice weekly – until he died suddenly.
A few days later, I met her in the emergency department.
The grief, shock and financial stressors were enough to leave anyone feeling unwell, but her symptoms had become unbearable: chest pain, shortness of breath, lightheadedness. Fearing for her life, she called for an ambulance.
I didn’t immediately ask her about the emotional turmoil she had recently experienced. Instead, I focused on her symptoms, the results of her electrocardiogram and her bloodwork, all of which are concerning. I quickly mobilized the interventional cardiology team for a procedure to check the arteries of her heart for a blockage.
On the way up to the cardiac catheterization lab, she tearfully informed me of her husband’s recent death, but I didn’t think it was relevant to her care – until after the procedure, when we found that her arteries were clear.
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When emotional pain turns into a physical problem
Typically, when patients tell me they’ve had a heart attack, they’re referring to a consequence of obstructive coronary artery disease, a condition in which cholesterol-rich plaque builds up in blood vessels, ruptures and causes a blockage in the arteries that deliver oxygen to the muscle of the heart.
What this patient experienced is something different. In response to stress, her heart quite literally gave out. It ballooned, weakened, and her emotional pain turned into a physical condition. Takotsubo cardiomyopathy, often called broken heart syndrome, is diagnosed in up to 10 percent of women who present with heart attacks.
Triggered by intense stress, Takotsubo is largely reversible but can be dangerous. It has a mortality of about 5 percent in hospitalized patients. It’s considered rare, but I’ve seen it several times in my four short years as a physician, and almost always in women.
In medicine, we often separate psychological symptoms from clinical ones. Symptoms that we struggle to explain are written off as anxiety and stress and placed in the realm of psychiatry. Women, who are stereotyped as more emotional, are less likely to receive appropriate testing for heart-related conditions and more likely to die within five years after being diagnosed with heart disease than men.
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Understanding women’s hearts
Physician Martha Gulati, associate director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Heart Institute and president of the American Society for Preventive Cardiology, has dedicated her research and practice to better understanding women’s hearts.
She describes a time before conditions like Takotsubo were understood. Women would often present with chest pain, have positive initial test results and then have their symptoms dismissed as anxiety when they were found not to have blockages in their heart.
“We used to say that they had false positives,” Gulati said. “But I knew that couldn’t be quite right. These patients were showing up over and over again with the same symptoms. We were missing something.”
Now, 20 years later, the “something” we were missing is called MINOCA, which means “myocardial infarction with non-obstructive coronary arteries.” It is an umbrella term assigned to patients who have objective signs of damage to their heart, but without the blockages associated with traditional heart attacks.
The existence of MINOCA is a conundrum for physicians. Chest pain is a vague symptom, and it is one of the most common complaints seen in the emergency room. Only 15 to 25 percent of these patients are found to have a blocked coronary artery.
In addition, most testing is focused on ruling out obstructive coronary artery disease, which is one of the most life-threatening causes of chest pain. If no blockage is found, many patients are sent home, only to show up in the cardiology clinic with questions, feeling scared, dismissed and still experiencing symptoms.
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When patients don’t fit the pattern
In clinic, I often see young women with symptoms that don’t fit typical patterns of cardiac chest pain. But testing is not without risks, so usually what I offer them is reassurance.
But sometimes I ask myself – what if I’m missing something? What if this patient, who may have been labeled as anxious, actually has a form of MINOCA? Would I be contributing to health-care bias against women if I didn’t offer her more testing?
This is a question I asked my attending, John Blair, an interventional cardiologist. Blair specializes in physiologic testing, which uses specialized equipment and medications to help categorize MINOCA. The first thing he suggests is to use noninvasive tests to assess the heart. If the heart has signs of damage, the next step is to pursue invasive angiography. If there aren’t any blockages, specialized physiology testing should be performed.
“Half of the patients I see in the office with chest pain and non-obstructive coronary artery disease have microvascular dysfunction or spasm,” he says. Once patients are diagnosed, he is able to start them on therapies that “have been demonstrated to relieve symptoms and improve quality of life.”
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Learn to describe your symptoms
For patients suffering with symptoms they worry are coming from their hearts, it can be hard to advocate for themselves when the doctor is dismissive. Here are some questions that might help.
What does your pain feel like? Chest pain from cardiac conditions is often pressure-like, squeezing or heavy, typically worsens with exercise and lasts minutes, not seconds.
Do you have pain elsewhere in your body? Cardiac pain also is more likely to move up the jaw or down one’s arm. In women, heart disease can cause abdominal pain.
Is the pain sharp? Pain that is sharp and worse with breathing is much less likely to be due to a heart condition.
What time of day do you feel pain? Figuring out patterns to symptoms can be helpful. For example, coronary vasospasm, a condition in which the arteries feeding the heart quite literally spasm and prevent the heart muscle from getting oxygen, often happens early in the morning.
Has your stamina changed recently? Communicating changes in exercise tolerance can also be helpful – when a patient tells me that, for example, they are no longer able to walk across parking lots or make it up a flight of stairs, alarm bells go off in my head.
Finally, it is very important to manage conditions that can contribute to heart disease. Controlling blood pressure, managing diabetes, avoiding smoking, exercising regularly, following a heart-healthy diet and monitoring cholesterol can prevent or ease cardiac conditions.
I’m lucky to be training in an era in which there is interest in examining conditions that more commonly affect women. Increased research in sex and gender disparities in cardiovascular disease has led to significant declines in the number of women dying of heart conditions.
And while there is still a clear need for further work, I’m hopeful for a future in which women’s cardiovascular health is investigated appropriately.
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Shirlene Obuobi is a second-year cardiology fellow at the University of Chicago medical center. She is the author of “On Rotation,” a novel about a Ghanaian-American medical student.