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.