Oct. 12, 2009 -- Women with heart disease may have worse outcomes than men do because treatment typically focuses on obstructive coronary artery disease -- which up to half of women may not have, according to a new review of the topic.
For many women, the problem is not obstruction in major heart blood vessels, but a reduction in blood flow, called ischemia, in very small arteries of the heart, says C. Noel Bairey Merz, MD, director of the Women's Heart Center at the Heart Institute at Cedars-Sinai Medical Center in Los Angeles. She is the lead author of a review published in the Journal of the American College of Cardiology. Bairey Merz and her colleagues reviewed numerous published studies about gender differences in heart disease before writing the review.
''Women, particularly at midlife, 45 to 65, are more likely to have abnormalities of the function of the small arteries -- you do not see those vessels on the traditional angiogram," Bairey Merz tells WebMD. "They are more likely to be falsely reassured when in fact there is a problem."
Bairey Merz and colleagues propose that the term coronary heart disease or CHD be used when the problem is obstructed major coronary vessels, but that the term ischemic heart disease or IHD be used when the problem is reduced blood flow because of small artery problems.
About 25% to 50% of women with heart disease don't fit the typical male CHD pattern and instead have ischemic heart disease, Bairey Merz estimates.
About 20 years ago, doctors and researchers began to suspect that women's heart disease is often different than men's, Bairey Merz says.
''This [review] is sort of a 'what do we know now, in 2009, going into 2010.' We have a story to tell that is starting to hang together.''
Bairey Merz is the chair for the National Institutes of Health Women's Ischemia Syndrome Evaluation (WISE) initiative. The WISE study was launched in 1996.
Heart Disease: Men vs. Women
After reviewing the published studies, Bairey Merz says, "It remains true that men and women differ, on average, in terms of symptom presentation. Men are more likely to have the Hollywood heart attack -- the chest pressure, chest pain, the typically exertional heart attack."
''Women are less likely to have that Hollywood-type heart attack pain. They are less likely to describe it as pain. It might be pressure, but they are more likely to have indigestion and shortness of breath.''
Another difference is that women tend to have more problems in the small arteries of the heart, she says.
In the cardiac catheterization lab, when doctors check the blood flow in the coronary arteries, women's arteries are often open, whereas men's are often obstructed, she says. "Men are much more likely to have fatty buildup of the large arteries," she says.
As a result, treatment strategies aren't optimized for women, Bairey Merz says, because they often don't fit the mold.
''The focus should be on ischemia and ischemic heart disease, particularly for women, and that women are not adequately served when we don't focus on that, when we just focus on the anatomy, the obstruction of [major heart] blood vessels."
Among other points discussed in the review:
- More women than men die annually in the U.S. from heart disease -- 455,000 women compared to 410,000 men.
- Women are more likely than men to die from a heart attack and are more frequently hospitalized for heart failure.
- Women have higher average levels of C-reactive protein, a marker of inflammation and predictor of heart disease.
- The Framingham Risk Score, a traditional measure of heart disease risk, classifies more than 90% of women as low risk. A newer tool, the Reynolds Risk Score, may work better for women.
''It's a really important review,'' says Nieca Goldberg, MD a cardiologist and spokeswoman for the American Heart Association, who is also director of the New York University Langone Medical Center Women's Heart Center and clinical associate professor of medicine at NYU.
"It's been a long time since someone has put together all the smaller studies in one place for doctors to get all the information," says Goldberg, who reviewed the study for WebMD and has written several books on women's heart health.
For women with heart disease symptoms, she says: "Just because your angiogram is normal doesn't mean you aren't having ischemic symptoms."
''If you think you have been misdiagnosed, seek a second opinion," Bairey Merz tells women who suspect they have heart disease.
''There are increasing numbers of medical centers that have women's heart programs," she says.