(February is American Heart Month)
When most people think of February, they think of Valentine’s Day, love, and heart-shaped gifts. February is also American Heart Month, designed to increase awareness of heart disease, the #1 killer of both men and women in the US and globally! Heart disease encompasses several cardiac conditions, but coronary artery disease, or ischemic heart disease (IHD), is most common and results from decreased blood flow within the coronary arteries feeding the heart muscle.
The most common ischemic heart event occurs when fatty, cholesterol plaques grow large enough to block one or more coronary arteries that supply oxygenated blood to the heart musculature. A textbook heart attack description involves chest pain (angina) brought on by exertion as well as shortness of breath, sweating, nausea, and sometimes vomiting. Occasionally the pain radiates to the jaw, left arm, or neck. Medical people use the phrase, “chest pain,” although some patients insist that their chest sensations are not painful, but describe them as crushing, vise-like, burning, squeezing, or like a pressure or elephant-like weight is on the chest. Chest discomfort is probably a better term to use.
While many women present with this classic anginal pattern emanating from the chest, others (including some men) may display atypical cardiac symptoms with discomfort in the neck, jaw, throat, upper stomach, or even the upper back. Some describe associated indigestion, nocturnal shortness of breath, palpitations, lightheadedness, dizziness, sudden weakness or fatigue, or extreme exhaustion. Women may have more nausea and vomiting with angina, rather than the profuse sweating found in men. While typically brought on by exertion, angina in females may also occur with significant stress or even at rest.[1]
Women who are diagnosed with heart disease often have obstruction(s) in the coronary arteries like men, and the usual tests for angina should confirm coronary artery disease. Unfortunately, stress tests (using a treadmill with electrocardiography (ECG or EKG)) are less sensitive for women, especially in pre- and peri-menopausal women who still have menstrual cycles since findings can be dependent on estrogen levels. Moreover, in up to 50% of women, coronary angiography does not exhibit significant plaque formation in the larger epicardial arteries feeding the heart.[2] While initially a relief, further specialized testing is required to evaluate for other atypical presentations of coronary artery disease: spontaneous coronary artery dissection, coronary microvascular disease, spasms of the coronary arteries, and takotsubo syndrome.
Accounting for under 5% of all heart attacks, Spontaneous Coronary Artery Dissection or SCAD produces chest “pain” when coronary artery tissue layers suddenly tear or separate, causing a structural deviation that decreases blood flow into the heart muscle. About 30% of cardiac ischemic events in pre- and peri-menopausal women are due to SCAD!
SCAD can occur in individuals of both genders who have no risk factors for heart disease and may even be very active. It is often precipitated by extreme exertion, an intense emotional response, or use of recreational drugs such as cocaine or methamphetamine. Risk factors also include pregnancy, coincidental fibromuscular dysplasia, inflammatory disease, or connective tissue disorder.
Symptoms of SCAD are the same as for angina, but an EKG may or may not show characteristic changes: however, cardiac enzyme bloodwork done in the Emergency Department typically supports an ischemic cause. In diagnosing SCAD, the key is to think of it. The diagnosis may require testing other than the usual 2-D coronary angiography such as intravascular ultrasonography which provides 3-D images.[3] Fortunately, SCAD is getting (albeit slowly) on the radar screen of emergency teams so that timely and appropriate interventions can occur.
Women, especially those undergoing the menopause transition, are more likely than men to have Coronary MicroVascular Disease (CMVD) or disease of the smaller branches from the coronary arteries. Generally exertional, this angina can have a typical or atypical presentation. Risk factors still include smoking, hypertension, diabetes, and high cholesterol, but decreased estrogen levels and coincidental inflammatory disease also figure into the mix. If the usual cardiac work-up is negative, suspicion of CMVD indicates more specific testing of coronary blood flow to evaluate the smaller arterial structure and functioning.[4] [5]
Vasospastic angina (formerly Prinzmetal angina). is regarded as uncommon and may occur slightly more often in women than men. The anginal discomfort typically lasts only 5 to 15 minutes, may occur in clusters, and typically appears at rest or wakes the individual from sleep between midnight and early morning. Coronary vasospasm can be precipitated by anything that causes blood vessel constriction—tobacco, exposure to cold, stress, medications to treat migraines, decongestants, and drugs like marijuana or cocaine. EKGs may or may not show characteristic ischemic findings if done once the anginal episode has passed. Ambulatory EKG monitoring might catch episodes, but angiography with provocatory hyperventilation or medication to stimulate vasospasm is the gold standard to make the diagnosis in troubling cases.[6] [7]
Originally described in Japan, takotsubo syndrome is an unusual cause of chest discomfort brought on by sudden, intense emotional or physical stress. Also known as “broken heart syndrome,” it can occur after the death of a loved one, during a disaster, from receiving sudden bad news or a surprise, or during an accident or traumatic event. Although takotsubo syndrome is responsible for a very small number of heart attacks, it is primarily recognized in women, particularly those who are postmenopausal. While an EKG may confirm the suspicion of heart ischemia, a coronary angiogram may be normal. An echocardiogram, however, would show the characteristic takotsubo (octopus pot) shape that the left ventricle takes when its muscle is compromised. Fortunately, this condition is usually temporary with resolution of the heart wall dysfunction within 1 to 2 months.[8]
Recognizing both the classic and atypical symptoms of cardiac ischemia can save valuable time in deciding to seek medical care. Suspicion of all types of ischemic heart disease can direct testing to find the proper diagnosis and obtain the appropriate treatment for you and/or your loved ones. To best care for your own heart, schedule regular check-ups to monitor your overall health, weight, BP, blood sugar and cholesterol. Your doctor will advise you about appropriate follow-up intervals.
If you develop exertional chest discomfort or recurrent episodes at rest, especially if it’s accompanied by shortness of breath, sweating, nausea, or vomiting, call 911. Never drive yourself to the hospital with chest discomfort to avoid causing an accident. If you have vague, intermittent symptoms that are concerning, call your doctor, especially if you haven’t had your blood pressure checked out recently. And of course, avoid tobacco products, maintain a normal weight, eat a heart-healthy diet, don’t drink alcohol to excess, exercise regularly, and keep your blood pressure, blood sugar, and cholesterol under control.
[1] Lynn Nugent, Puja K. Mehta, and C. Noel Bairey Merz, “Gender and Microvascular Angina,” Journal of Thrombosis and Thrombolysis 31, no. 1 (January 2011): 37–46, https://doi.org/10.1007/s11239-010-0477-1.
[2] Nugent, Mehta, and Merz.
[4] Nugent, Mehta, and Merz, “Gender and Microvascular Angina.”
[5] Ahmed and Creager, “Alternative Causes of Myocardial Ischemia in Women.”
[6] “Prinzmetal Angina: Causes, Symptoms & Treatment,” Cleveland Clinic, accessed February 15, 2023, https://my.clevelandclinic.org/health/diseases/21867-prinzmetal-angina.
[7] Bina Ahmed and Mark A Creager, “Alternative Causes of Myocardial Ischemia in Women: An Update on Spontaneous Coronary Artery Dissection, Vasospastic Angina and Coronary Microvascular Dysfunction,” Vascular Medicine 22, no. 2 (April 1, 2017): 146–60, https://doi.org/10.1177/1358863X16686410.
[8] Monica Li et al., “Takotsubo Syndrome: A Current Review of Presentation, Diagnosis, and Management,” Maturitas, August 19, 2022, https://doi.org/10.1016/j.maturitas.2022.08.005.
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