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Improving the Diagnosis of Heart Disease in Women

September 19, 2021

Dr. Samit Shah has seen it too often.

Women come to a hospital Emergency Department or doctor’s office complaining of chest pain, shortness of breath, nausea, lightheadedness, jaw pain, or other symptoms considered concerning for a heart problem. The women might undergo standard testing to see if they have a critical cholesterol blockage in their arteries, the hallmark of obstructive coronary artery disease.

But only 50 percent of women presenting with these symptoms show a blockage after cardiac catheterization — a procedure in which a long, thin tube is inserted through the blood vessels to the heart — and an angiogram — an x-ray of the blood vessels taken to show the blood supply to the heart muscle. If a blockage is not detected, they are often sent home without additional testing or a clear diagnosis.

“Women are suffering because of this,” said Shah, an interventional cardiologist at Yale School of Medicine. “If we tell patients they have no blockages, but don’t do further testing, they will have ongoing symptoms and probably end up in the ER again. If we take the extra steps that we are now learning to take, we can make accurate diagnoses and help patients better manage their disease.”

With this year’s Wendy U. and Thomas C. Naratil Pioneer Award from Women's Health Research at Yale, Dr. Shah is leading a team to demonstrate the effectiveness of validated, but not widely administered procedures for the many women who have reduced blood flow to the heart without blocked arteries or cholesterol build-up often associated with heart disease.

The tests are designed to detect conditions that elude the standard angiogram. One condition, known as microvascular disease, involves the smaller blood vessels that branch off the larger blood vessels to supply blood and the oxygen it carries to the heart. These smaller vessels control the amount of blood flow to the heart and can increase flow by up to four times when needed to meet increased demand while exercising.

In coronary microvascular disease — associated with high blood pressure and possibly caused by disease to the blood vessels themselves or damage from a prior heart attack — the smaller blood vessels do not open up when required, preventing the heart from receiving the blood it needs. To a patient this could feel the same way a blockage might.

A second condition, known as coronary vasospasm, causes blood vessels to clamp down when they should open up, possibly triggered by cold air, smoking, or stress. To the patient this also feels like a heart attack but involves no blockage and cannot be detected by a standard angiogram or stress test.

Dr. Shah’s team is studying 100 women over two years who get referred for coronary angiography to Yale New Haven Hospital and comparing outcomes for patients who receive the standard care with those undergoing the cutting-edge tests to detect coronary microvascular disease or vasospasm. His goal is to show the value of the new tests, already covered by insurance, so they become the standard of care for patients — mostly women — who have reduced blood flow to the heart but no obstruction.

In addition, the researchers are using structured interviews to compare the patients’ experiences, including their perception of their illness, ability to control symptoms, quality of life, lifestyle modification, and medication changes.

“We see patients coming back with the same symptoms, and we do not know what the toll is on them when they are left without answers,” Shah said. “If we can change that experience, characterize it, and give women a diagnosis, we can avoid future invasive procedures and help them to better manage their health.”

The researchers are also constructing a registry of data and procedural practice to share with other institutions, building on WHRY-funded work begun by Dr. Erica Spatz to guide future research and treatment for heart disease so that it more accurately represents the biology and experiences of women.

People with microvascular disease benefit from different medications than patients with coronary vasospasm, and sometimes when you mix them together, people do worse, Shah said. By demonstrating the effectiveness of these additional tests, he hopes to better target medical therapies to meet patients’ needs.

“One female patient said to me, ‘I’m 55 years old and active,’” Shah said. “‘Why am I on the same medication as my dad who had a quadruple bypass?’”

Current medical practice does not have the answer to her question, but Shah expects his study to help change that.

“Beyond saving lives, getting re-admitted for the same problem is a burden on the patient and the system,” he said. “We can do better.”

Submitted by Rick Harrison on September 14, 2021