Melissa Walton-Shirley


November 18, 2013

It's taken a decade, but we now know that women don't have the same presentation for ACS as men, we die more from heart disease than breast cancer, and we more readily access 911 to help others than to help ourselves. As a collective group of healthcare providers, we have overcome the first hurdle: Admitting we have a problem. It's time, though, to start acting on what we know. Dr Carl Pepine, the only male presenter of this morning's Go Red for Women session, concluded by stating, "Men are as old as their arteries, but women are as old as their microvasculature," and he used an excellent case presentation to illustrate his theory.

She is 35 years old with the little-acknowledged CV risk factors of primary ovarian failure, low HDL cholesterol, and infertility. Her LDL-C was in the 120s range and her triglycerides were normal. She is an African American physician, jogger, and wife. Her onset of pain was at the half-mile marker of her run but also "atypical," occurring when she reached up to put away the dishes. This runner, for some reason, had a pharmacologic stress test with no reversible nuclear defects to suggest ischemia. Likely because the squeaky wheel gets the grease, she was referred to Dr Pepine for help.

He wanted to "reproduce her symptoms," which oddly no one else had done.

Four minutes into her stress exam, her ST segments sagged like a swinging bridge between her QRS and her T wave, the first real hint at her pathology. Next, we saw beautiful lead-pipe vessels from her coronary angiography, the RCA cascading down the screen in shadowy gray and white imagery, both large and smooth. The left main, LAD, and circumflex were the usual beacons of normalcy in this age group, the kind that often prompt the knee-jerk reflex to pull down our masks, lean under the camera, and reassure the slumbering patient, "Great news, you're normal" . . . and if this had happened to this patient, she would have gone home with the same chest pain and no answers. Worse, she could have died because simply acknowledging gender, ethnic, economic, and educational disparities has not affected mortality rates in younger women with CVD. Because we can't stent it or bypass it, we often don't believe it exists. We go as far as our routine levels of education dictate, but "routine" is not optimal.

The IVUS of that big fat juicy RCA revealed a large hunk of plaque lurking beneath the surface. The acetylcholine challenge was then predictably abnormal. Her MRI clearly showed reversible ischemia in her entire lateral wall, which in reviewing the anatomy, could not be ascribed to a single coronary arterial distribution. So, now we arrive at the diagnosis. Next: what to do?

It's here that we are marching into the unproven. I suspect there were recommendations of aspirin, a dihydropyridine calcium-channel blocker, statins, and PRN nitro. I wonder how she's doing. I hope she has a better quality of life now, but quantity is equally as important in this age group.

We certainly should be making recommendations for women's cardiovascular care based on the hard work and data assessment mined from the first 10 years of the Go Red campaign. We should select drug-eluting stents for female obstructive coronary disease.

We need to ask the right questions in our trials and on our intake exams, like, "Do you have any discomfort anywhere above the waist?" We shouldn't prescribe hormone therapy for prevention because of increased VTE and stroke risk. We should acknowledge that aspirin doesn't work for MI prevention in patients without coronary heart disease. Antioxidants like vitamin-E, vitamin-C, beta-carotene, folic-acid, and B-vitamin supplements are a waste of precious monetary resources, and we should inform our patients accordingly. Because women also have lots of fixed obstructive disease, we should provide angiography when we think our female patients need it.

If we perform a PCI, we should consider a radial approach. We should push for surgical revascularization for diabetic women found to have multivessel disease, and before the anesthesiologist puts our patient to sleep, make sure they're going to stalk the surgeon for the rest of their natural life if they don't use an IMA graft.

Today's presentation, "Stopping the number-one killer of women in the second decade of Go Red for Women," was moderated by Dr Sunil Rao (Duke University Medical Center, Durham, NC) and Jennifer Mieres (Hofstra North Shore-LIJ School of Medicine, Hempstead, New York). It was articulated by some of the best minds in the business of caring for women with heart disease: Carl Pepine (University of Florida, Gainesville), Kathy Berra, RN (Stanford University School of Medicine, CA), Dr Nanette Wenger (Emory University School of Medicine, Atlanta, GA), Lori Mosca (Columbia University Medical Center, New York), and Monica Acevedo (University of Santiago, Chile).

Women might be "as old as our microvasculature," but we physicians are only as effective as we are inquisitive and motivated. With the first decade of Go Red for Women behind us, I can't wait to see what the next one brings.


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