Nonobstructive Coronary Artery Disease: Why Doctors Miss Warning Signs Of Heart Disease in Women

Cardiologists at Yale University interviewed 30 women between the ages of 30 and 55 who had had heart attacks. Every woman interviewed said that at first she had ignored symptoms because they didn’t have the usual risk factors for coronary artery disease, and they did not realize their symptoms were those of heart attack.

American comedienne and talk show host Rosie O’Donnell had a heart attack in 2012 at the age of 50. Near death when she was brought to the hospital, she did not seek medical treatment for 24 hours because she did not realize she was having a heart attack.

Every year, 15 thousand American women aged 50 or younger die of heart attacks. In the hospital, these younger women have twice the risk of men of dying of an acute myocardial infarction. Part of the reason is that the symptoms of heart attack in most women are not as dramatic as those in most men.

No Clutching at the Chest and Falling to the Ground

The stereotypical heart attack in men is announced by the sudden onset of intense chest pain and a loss of muscle strength, often with a physical collapse. The pain radiates from the chest to the neck and left arm, and there can be intense perspiration.

Women’s heart attack symptoms can be quite different. Women may have signs of heart attack for days or even weeks before they finally seek medical treatment. A woman can have intense chest pain with a heart attack, but she may have no chest pain at all. The pain may radiate to the left leg rather than the left arm, or to the right arm instead of the left arm, or to both legs and both arms, there can be headache instead of neck pain, and flu-like symptoms such as shortness of breath, nausea, and vomiting. Some women don’t have any symptoms at all.

READ How Much Do You Know About Heart Attack?

Doctors Recommend Seeking Treatment Within Five Minutes of Onset of Symptoms

Medical experts, of course, recommend immediate treatment of symptoms. The greatest opportunities for preventing permanent damage to the heart occur in the first hour of a heart attack, not the first week or the first month. Women are urged to go to the emergency room even with “odd” symptoms that don’t match the usual understanding of a heart attack. It’s clearly better to be safe than sorry.

However, even when women present themselves to the emergency room with a full-fledged heart attack, the cardiologist may not find what would be expected in men.  The tried and true “clog in the pipes” model of coronary artery disease may not apply to most women. Even when women come in with serious pain and abnormal EKG’s that lead doctors to do diagnosis with enzymes, ultrasound, and catheterization, the coronary artery dysfunction may be something entirely different from what the doctor usually looks for.

Where Your Cardiac Interventionist May Go Wrong During Your Heart Attack

In most modern hospitals, people with symptoms of heart attack are first seen by a cardiac interventionist, also known as an interventional cardiologist. In men, there is a very well-known sequence of events. The man comes in with chest pain. The attending physician runs a blood test for an enzyme called troponin, and troponin levels come back high. As soon as a catheterization lab is open, the doctor makes a tiny incision in the femoral artery to insert a tiny pipe called a catheter, injects a fluorescent dye into the bloodstream, confirms that there is atherosclerotic damage to one or more coronary arteries, and uses the catheter to place a stent in the artery to keep it open. The patient is kept for a day, or sometimes less, and sent home with strict orders take statins for cholesterol, beta-blockers and ACE inhibitors for blood pressure, and anticoagulants to ensure that the newly placed stent is not blocked by blood clots.

Women, however, often don’t have a visible blockage in their coronary arteries (that is, the doctor cannot find a blockage of more than 20 percent in an artery outside the heart). The patient may be pronounced free of coronary artery disease. Alternatively, the doctor may find that a coronary artery is somewhere between 20 and 50 percent blocked. These blockages may be assessed as “non-obstructive,” meaning they do not interfere with the normal circulation of blood to the heart. If the arteries aren’t actually blocked, however, why does the patient come in with a heart attack?

In women, and some men, other cardiovascular issues may be the real problem:

• Endothelial dysfunction. The endothelia, or linings, of the coronary arteries normally expand when the heart needs greater blood flow. Some women (and, again, some men) have arteries that aren’t blocked, but that can’t stretch to accommodate the heart’s need for a greater blood supply during exercise or stress. In these patients, the problem may be “open artery ischemic heart disease.”
• Myocardial infarction without coronary artery dysfunction. A myocardial infarct (MI) is an area of tissue death in the heart caused by deprivation of oxygen. This can happen even if an artery is not blocked.
• Microvascular angina. Sometimes the problem is not in the arteries. It’s in the heart itself. Tiny blood vessels just won’t open enough to let blood they receive from the arteries reach the parts of the heart when it is needed, and tissue damage (MI) results.

Adding to the confusion is the fact that sometimes the problem really is a blocked artery, but angiography, the process of putting the catheter in the artery to visualize the heart, just does not pick it up. This is most common in really severe atherosclerosis, in which an inexperienced cardiologist, or sometimes an experienced cardiologist, or several cardiologists, cannot tell the difference between arteries that are nearly completely blocked and arteries that are nearly completely open.

Women should not wait to seek emergency help when they have the vague symptoms that can be heart attack. It’s not enough for the doctor to run a single troponin test and send you home. It’s not enough to take an EKG or run an ultrasound. There’s almost no way to make a definitive diagnosis without a coronary catheterization. Even with a coronary catheterization, women need to ask:

• Is there a blockage of any of my arteries?
• If there is, it is stable? And if it’s not stable, what should I be doing to make sure it doesn’t burst and cause another heart attack? (This is the real value of statin treatment in women who don’t have high cholesterol.)
• Do I need to be on nitrates to help my arteries open? And if I am put on a nitrate, such as isosorbide mononitrate, is there a risk of becoming resistant to it? Does my doctor need to vary my dosage?

READ How to survive a heart attack when you are all alone?

It’s important not to let the doctor ignore your symptoms. It can be hard to remember all the questions you need to ask when, after all, you’re having a heart attack. Don’t let the doctors send you home without a clear explanation of what happened and a clear plan to keep it from happening it again.