Women and the `Men’s Disease’

By SHAMEEM, Raffat

CORONARY arteries supply blood containing oxygen and nutrients to the heart muscle to allow it to function efficiently as a pump.

Coronary heart disease is caused by a significant narrowing of one or more coronary arteries which leads to the clinical syndrome of angina.

This would typically present as a central chest tightness or discomfort on exertion, at times associated with shortness of breath.

Once the artery becomes totally blocked, a heart attack occurs with severe chest discomfort at rest. This can lead to a variety of complications such as heart failure, heart block and sudden cardiac death. Coronary disease continues to be a major cause of disability and death worldwide.

Coronary disease in women is common, occurring in one in nine women over the age of 45 and one in three women over the age of 65. There is an under-appreciation of the importance of coronary disease in women, both by the public and by the medical profession.

There is a longstanding myth that coronary disease is a “man’s disease”. This has been perpetuated by the fact that most clinical cardiology trials have mainly included men and there was a very poor association between chest pain and heart attacks in women.

As a result, for many years chest pain in women was thought to be not cardiac in origin and therefore not appropriately investigated. A possible reason could be the atypical nature of presentation in women. This is likely to be in the form of shortness of breath or even fatigue on exertion rather than the text book description of crushing central chest pain usually described by men.

Consequently, women tend to play down the problem as they believe, or have been led to believe, that their symptoms may be due to unfitness. The less typical presentation and later age of presentation in women compared to men contributes to a delay in the diagnosis and management of coronary disease in women.

Diagnosis in women is also fraught with difficulties. The exercise treadmill, the standard test used in men, is for some women less able to provide a firm diagnosis for a variety of reasons, such as an inability to achieve the required exercise levels to provide a firm diagnosis. Therefore, there are other more sensitive tests available including stress echocardiography or stress SESTA MIBI scans which use other imaging devices in addition to a treadmill test for a diagnosis to be reasonably confidently reached.

Stress echocardiography uses an ultra sound to image the heart function while stressed. This also allows an assessment of cardiac structure such as valve function.

SESTA MIBI scan is a nuclear scan that mainly looks at the oxygen supply to the heart under stress using radiation. In those with mobility issues and cannot walk on the treadmill, these tests also allow exercise levels to be achieved by using an intravenous medicine called Dobutamine. Therefore, inability to walk on the treadmill does not prevent diagnostic testing.

If these tests confirm coronary disease as the cause of symptoms, angiography is advised. This is an invasive test that allows imaging of the coronary arteries by injecting dye into the vessels themselves.

Depending on the extent of the disease, a recommendation can then be made for a stent procedure or cardiac bypass grafts to correct the blockage.

The main aim of early diagnosis is to prevent cardiac damage by early treatment. This is heavily dependent on an increased public awareness of warning symptoms which, as illustrated above, may not be as clear cut as we would like.

My recommendation would be to seek prompt medical review with your GP if there are persistent exertional symptoms including chest discomfort, shortness of breath or even extreme fatigue.

This is particularly important if there are other cardiac risk factors present such as high blood pressure, diabetes mellitus, high cholesterol, family history of heart disease at a younger age (under 65 years) and smoking. These factors collectively increase the risk of developing heart disease. If appropriate, a referral should be made to a cardiologist for review and stress testing.

Stress echocardiography is available through Manawatu Heartcare, Aorangi Consulting Rooms, Palmerston North. Stress SESTA MIBI scan is available through Palmerston North Hospital or Wakefield Heart Centre, Wellington.

* Raffat Shameem BSc, MBChB (UK), FRACP (NZ) is a cardiologist practicing at Manawatu Heartcare, a private cardiology center offering a wide range of cardiology services and investigations. This is based at Aorangi Consulting Rooms (Alan Street entrance). After obtaining her initial medical degree at St Andrews and Manchester Universities UK, she trained as a cardiologist through Wellington Hospital. She then went on to specialise in echocardiography at Prince Charles Hospital in Brisbane. Dr Shameem is married with a one-year-old son and has lived in Palmerston North since 2002.