Women's Chest Pain: What Once Was "Benign" Could Now Spell "Trouble"

By:
Karen Pallarito

Does this sound familiar? You're rushing to catch a plane, and suddenly, a wave of seething pain stretches across your chest. It may be fleeting or long-acting. You may have previously experienced this kind of discomfort while at rest. But here's the kicker: On examination, your coronary arteries show no signs of blockage.

Doctors used to brush off these reports of chest pain in women, suggesting that it was all in their head. When stress tests detected abnormalities, the findings were considered false positives. The condition was dubbed "cardiac syndrome X," and it was believed to be benign.

"[This type of chest pain in women has] been sort of dismissed for many, many years because we did not study women," says C. Noel Bairey Merz, MD, director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles.

But recent research into women's heart health has revealed that these reported bouts of angina are very real. Thanks to the Women's Ischemia Syndrome Evaluation (WISE) study, a long-term multicenter investigation sponsored by the National Heart, Lung, and Blood Institute, a clearer picture of this mysterious condition is beginning to emerge.

The latest WISE study findings make it clear that among women with chest pain and no evidence of blocked coronary arteries, there is often a high prevalence of microvascular dysfunction, a condition in which the tiny blood vessels that nourish the heart either don't dilate sufficiently or constrict inappropriately. When that happens, the heart is starved of blood and oxygen, causing chest pain.

In addition, these women with chest pain often experience a diffuse sort of plaque accumulation not readily detected by a traditional angiogram.

 

Researchers don't yet know whether there is a causal relationship between microvascular dysfunction and the kind of plaque accumulation that spreads evenly throughout the artery wall, although that is a leading hypothesis.

"The two travel together," explains Dr, Bairey Merz, who chairs the WISE study. "We think there may be as many as 2 to 3 million women in the U.S. with this condition."

As reports of WISE findings begin to circulate, Dr. Bairey Merz is encouraged to see patients taking action. "Women are going in now to their physicians' offices and saying, 'Look at this article!'"

At least with proper diagnosis, there is hope of receiving appropriate treatment. Women who have atherosclerotic plaque may require preventive therapies, such as baby aspirin and cholesterol-lowering statins. Patients with microvascular dysfunction are often treated with angiotensin-converting enzyme (ACE) inhibitors. Some small studies also suggest that supplementation with over-the-counter L-arginine, an amino acid that improves blood flow in the coronary arteries, can be an effective treatment.

"I would say that in about 60 to 70 percent of patients in my personal experience that I put on L-arginine get a benefit from it," says Oscar C. Marroquin, MD, assistant professor of medicine and assistant director of the Ladies Hospital Aid Society Women's Heart Center at the University of Pittsburgh Medical Center.

Still, researchers haven't identified the exact factors that might make a woman prone to experiencing problems with the small heart vessels. Microvascular dysfunction has been observed among women with traditional risk factors for heart disease, such as advanced age, cigarette smoking, hypertension and high cholesterol. But it is also seen in women without those risk factors.

 

"There's no particular pattern," Dr. Marroquin observes.

So while a diagnosis of microvascular dysfunction may explain a patient's chest pain today, it doesn't provide any useful information about her future cardiovascular risks, he says. It is of no value in determining whether or not she is likely to have a stroke or heart attack tomorrow.

That's why Dr. Marroquin tells patients, "The most important thing to remember is that most women die of garden-variety heart attacks." To prevent a heart attack, he stresses how important it is to know your cholesterol levels and blood pressure, stay active and stop smoking.

On the Web

For more information on the WISE study findings, visit the National Institutes of Health.

SOURCES: C. Noel Bairey Merz, MD, FACC, medical director, Women's Health Program, Preventive and Rehabilitative Cardiac Center, Cedars-Sinai Medical Center, and professor of medicine, David Geffen School of Medicine, University of California, Los Angeles; Oscar C. Marroquin, MD, assistant professor of medicine and assistant director of the Ladies Hospital Aid Society Women's Heart Center at the University of Pittsburgh Medical Center; Feb. 7, 2006, news release, Cedars-Sinai Medical Center