COMMENTARY

Beyond Go Red: The Lessons From Susan Lucci's ACS

Melissa Walton-Shirley, MD

Disclosures

February 17, 2019

As a female cardiologist, I am especially grateful for the sea of red that sweeps our nation every February. By any measure, the Go Red for Women campaign  has been a resounding success. Since the first National Wear Red Day in 2013, almost 1 million women have joined Go Red for Women; 90% of them have had their blood pressure checked, 75% checked their cholesterol levels, and 64% exercise regularly.  Death in women decreased by more than 30% in the 10 years before 2017.  

What about us physicians and providers? Have we done the recommended checks before we pronounce a female patient to be in “good  health”?

The Story Within the Susan Lucci Story

Susan Lucci, famed soap opera maven and fitness enthusiast, made headlines this month for sharing the details of her interface with cardiovascular disease.  Chest tightness, twice ignored—she mistook the first episode as the discomforts of an ill-fitting bra—eventually led to a percutaneous coronary intervention. After suffering a third episode of chest pain that left no doubt something was amiss, Lucci was hospitalized for unstable angina and had two stents placed in October 2018. In several interviews, Lucci rightly emphasized how important it is to heed warning signs and to seek medical attention. We owe her a debt of gratitude for being a spokesperson. 

However, equal in magnitude to the importance of the lesson for patients is a lesson for providers: Don't pronounce a postmenopausal woman in good health without proving it to the best of our capability and without screening for the number 1 killer of women: heart disease.

The Physical That Wasn't

According to American Heart Association News, Lucci had undergone "tests" 3 months prior to her admission that "showed she was in  excellent health." Her "checkup" from a cardiovascular perspective  included an electrocardiogram. A drill-down on her family history revealed that her father suffered a heart attack at age 49. And then there are the obvious risk factors for coronary artery disease (CAD)—she is a 71-year-old postmenopausal woman. Another point not to be missed: You can't appropriately screen for CAD with an electrocardiogram and a stethoscope.

Lucci's story should highlight to providers that no matter how beautiful, fit, or youthful in appearance, physiology is physiology. Her family history or her age should have led to a recommendation for a CT calcium score at the least. She had significant calcification in her coronaries when she presented to the emergency department and significant obstruction in her left anterior descending artery on optical coherence tomography. A CT calcium score, an inexpensive screening test that doesn't always require a physician's order, would have likely led to the addition of aspirin, a statin, and probably functional testing. Perhaps if she'd been prescribed aspirin or a statin, she could have avoided the  ACS admission altogether.

Don't Stop at  CAD

I don't know if Lucci's gestational history was assessed. According to a study in Neurology, women with a history of preeclampsiamay benefit from taking aspirin for stroke reduction.[1] Additionally, the British Medical Journal published a trial highlighting a 6.5-fold increased risk for late-onset vascular dementia in women with a history of preeclampsia.[2] There is enough evidence on the preeclampsia–morbidity link that both the American Heart Association[3] and the European Society of Cardiology[4] have included it in their cardiovascular disease (CVD) prevention guidelines. 

Yet how many of us routinely inquire about a history of preeclampsia or pregnancy-associated hypertension?  Do we recommend that women at risk purchase a blood pressure cuff for home use? Do we discuss the proper way to check blood pressure, describe the DASH diet, or give a specific definition for hypertension? Do we discuss symptoms of stroke or the importance of getting into the hospital quickly for lytic therapy?

Beyond Blockages and Calcium

MINOCA (myocardial infarction with nonobstructive coronary arteries) is alive and well. We need to pay attention to the odd symptoms of women presenting to the emergency department by offering serial troponins more often. Those women at risk with ECG changes, leaking troponins, and/or unresolved causes of chest discomfort should be considered for angiography, aspirin, statins, and monitoring.  Lifestyle changes should punctuate every discussion regarding risk reduction.    

Lucci explained the lessons from her experience: "I would like women to pay attention to the symptoms that they're feeling—to be in touch with their bodies and to act on those symptoms" and "If you think something needs medical attention, pay attention and go to the doctor." Those are admirable conclusions, but the lesson goes much deeper for us practitioners (some of these apply to men as well):

  1. Don't be fooled by appearances. Risk factors are risk factors. Postmenopausal status is among the greatest.

  2. It is appropriate to pair every initial stress test with a CT calcium score and a lipid profile. I repeat calcium scoring on a "biblical 7-year" cycle. 

  3. Ignoring a family history of CVD is perilous—your patient could be damned by your skipping that piece of information.

  4. Ask about pregnancy-associated conditions, such as systemic arterial hypertension and diabetes. Recommend close monitoring in patients with that history. Include a discussion about signs and symptoms of stroke and the specifics of timely treatment. Don't skip the DASH diet information.

  5. Ongoing unexplained symptoms deserve angiography

  6. Lifestyle changes should be discussed in detail. At a minimum, recommend 30 minutes of moderate exercise 5 days per week and the specifics of the Mediterranean diet.

  7. Consider CT coronary angiography as a possible risk-stratifying tool where appropriate and available.

  8. Respect elevated low-density lipoprotein cholesterol in patients with coronary artery calcium, especially in those with a history of events. 

  9. Respect peripheral artery disease as a CAD equivalent. Don't forget to auscultate the carotids and work up absent pulses. I'm not necessarily advocating vascular angiography at every turn, but establishing the presence of atheroma deserves medical therapy and lifestyle change. 

Susan Lucci's story is really more about how doctors and providers should never pronounce a 71-year-old patient in "good health" without appropriate cardiovascular testing. Hers is a classic case. That should have been the  headline all along.

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