Statement helps tailor care for women with suspected ischemic heart disease

Clinicians diagnosing and treating coronary heart disease in women have a new set of tools in their arsenal, thanks to gender-specific research. In a consensus statement published online June 16 in Circulation, researchers provided suggestions on how to use diagnostic testing to best review, categorize and assess disease risks in women.

While women are more likely to present symptoms due to emotional or mental stress and less through physical exertion, results of physical stress tests should not be overlooked. The writing committee restated that the symptoms of cardiac ischemia in women tend to be reported as “epigastric discomfort and associated nausea; radiation of discomfort to the arms, neck, and interscapular areas; and dyspnea and fatigue,” as opposed to the classically considered clutching chest pain.

“For decades, doctors used the male model of coronary heart disease testing to identify the disease in women, automatically focusing on the detection of obstructive coronary artery disease,” said co-chair Jennifer H. Mieres, MD, of North Shore-Long Island Jewish Health System in Hempstead, N.Y., in a press release. “As a result, symptomatic women who did not have classic obstructive coronary disease were not diagnosed with ischemic heart disease, and did not receive appropriate treatment, thereby increasing their risk for heart attack.”

Using the Women’s Ischemia Syndrome Evaluation (WISE) registry developed by the National Heart, Lung, and Blood Institute, a scale was developed to class symptoms both at rest and under stress.

By developing the diagnostic key to evaluating female patients, Mieres et al created a means of classifying risk and providing clinicians a tool to determine when particular techniques are more appropriate for their female patients. It also provided a launching point for discussions with patients about their risks and the risks and benefits of testing. Less invasive techniques are important to long-term health as they present fewer risks of exposure to radiation.

Plotting where a woman lies on the risk charts and utilizing the right tests at the right time is key to ensuring all patients are receiving the best and timely care. For example, women with nonobstructive cardiovascular disease and stress test abnormalities according to this tool, should be classified as abnormal with having an elevated ischemic heart disease risk instead of marking them as having a “false positive” test. Added parameters for exercise capacity, heart rate recovery, chronotropic and blood pressure response, among others, can improve how effective exercise treadmill testing is in female patients.

In a video, Mieres further stressed that the consensus statement is meant to encourage clinicians to appreciate a broad spectrum of possible symptoms present in women with ischemic heart disease, provide a resource for tests in diagnosis and treatment options across all levels of the disease presentation in women and to give clinicians a better means of discussing the same with their patients. Mieres said, “The statement reminds clinicians and physicians that women with coronary disease and with disease of the endothelium are also at risk for heart attack or heart failure and that microvascular disease or nonobstructive disease or diseases of the coronary endothelium no longer carries a benign prognosis.”

Members of the American Heart Association Cardiac Imaging Committee, Council on Clinical Cardiology and the Cardiovascular Imaging and Intervention Committee of the Council on Cardiovascular Radiology and Intervention contributed to the statement.