August 30, 2017

When it comes to heart disease, women don't follow the rules set forth by male-dominated studies. And why should we? Although our basic coronary anatomy, electrical wiring, and ventricular architecture are identical to males, the weave of our endothelial and myocardial fabric is dictated by profound differences in genetics and hormones. This makes us dramatically and fantastically unique but more vulnerable. Many of us suffer and many of us die because we are treated the same as testosterone-laden humans with a Y chromosome. Worse, some of us aren't treated at all.

Fortunately, there are cardiologists who champion the notion that the rules by which women are assessed and treated must change. Dr Noel Bairey Merz is one of them. The director of the Barbra Streisand Women's Heart Center at Cedars Sinai, she is a long-recognized leader in the field of female CV medicine. In a session on New Practice Patterns in Clinical Cardiology at the European Society of Cardiology 2017 Congress, she gave a presentation titled "A Women's Clinic for Heart Disease." Her talk outlined three distinct subclinic options where women with heart disease can seek help: The MINOCA (myocardial infarction without obstructive coronary artery disease) clinic, the HFpEF (heart failure with preserved ejection fraction) clinic, and the APO (adverse pregnancy outcomes) clinic.

The MINOCA Clinic

"For decades women have been known to have myocardial infarction without obstructive coronary artery disease," Bairey Merz said while showing a slide of a systematic review of registries from 2005.[1] She also made the point that more contemporary data demonstrate an elevated 1-year MI rate in MINOCA patients with angiographically nonobstructive coronary artery disease.[2] "There is something about having open arteries that causes physicians to withdraw therapy or to not start therapy. Often these patients are considered to be a diagnostic dilemma and are discharged from active practice," warned Bairey-Merz.

She flashed a slide of a radiographically normal coronary angiogram. A smooth patent covetable left main, LAD, and circumflex projected from the screen. Next to these innocent-appearing vessels was a distinctly sinister IVUS study from the same angiogram demonstrating plaque rupture and ulceration.[3]

"Forty-five percent of women who suffer an MI with angiographically normal vessels have pathology on intravascular imaging," she added.  "These are not false-positive troponins. Current US guidelines do not address MINOCA. We have an evidence gap," she concluded.  

The HFpEF Clinic

"We are working hard to invite physicians to send HFpEF patients our way, not because we know how to treat them but because we are studying them," Bairey Merz admitted. She described research that suggests HFpEF patients often have increased triglyceride deposition in the myocardia,[4] a hypothesis that links diabetes and dyspnea with a normal LVEF. "But there is more to come," she cautioned, indicating that the pathophysiologic milieu is not resolved but so far includes remodeling, microvascular dysfunction, and fibrosis.

"HFpEF accounts for the majority of heart-failure hospitalizations and usually occurs in older women," she said.[5] The "custodial care of HFpEF management involves diuretics and beta-blockers, but nothing works. Perhaps the ability to find optimal therapies might be impacted by female-only studies," she said.

I could relate.  There is little doubt among those of us who interface with HFpEF on a daily basis that the infiltration of the myocardia as well as the liver begat HFpEF and nonalcoholic steatohepatitis (NASH), entities that are lethal, underdiagnosed, and maltreated. Prevention would be better than our pitiful attempts at therapy; however, efficacious therapy finds would be the holy grail of cardiovascular management in women.

Adverse Pregnancy Outcomes (APO) Clinic  

Bairey Merz listed a number of adverse pregnancy outcomes that affect future CV risk. These include gestational diabetes, hypertension, preeclampsia, preterm delivery, fetal growth restriction, and macrosomia.[6,7] Compared with normotensive pregnant patients, those who develop preeclampsia have an elevated long-term risk of developing hypertension in the following 4 decades.

As an example of how little attention is paid to pregnancy-associated hypertension, especially among obstetricians, Bairey Merz talked about her 48-year-old friend and fellow physician who learned a decade after the fact that her blood pressure was elevated on numerous ob/gyn visits. She made the discovery after a brother's diagnosis of hypertension led her to fact-check her own past medical history.

"We don't have ob/gyns in our clinic but we need to encourage them to refer," Bairey Merz concluded.

What Can We Do?

Bairey Merz's enthusiasm for helping women prompted me to consider what the rest of us can do. We should soundly reject the "big-is-beautiful" campaign because obesity gravely affects the incidence of HFpEF. We should prescribe diet more often than we write prescriptions. We should champion smoke-free legislation and offer cessation therapies to every smoker. We should encourage our female patients to participate in trials. We should contact our local ob/gyn and offer our assistance for with at-risk preecclampsia and pregnancy-associated hypertension patients. We should embrace MINOCA patients, reassure them they aren't psychotic, and make sure they are on good therapy to prevent recurrent events.

When it comes to women and heart disease, experts in these fields fully admit they don't have all the answers. It should be comforting to the rest of the world, however, that some are still looking.

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