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Heart disease in women

Mrinalini Meesala, M.D, FACC.

Overview

Persistent chest pain without obstructive CAD

Ischemic heart disease in women

Diagnostic and prognostic tools

Case # 1

65 y/o woman with chest pain

Exertional

Substernal chest pressure

Radiation to arms, throat, ears

Aching sensation

Ongoing for 2 years

Limits her ability to exercise

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History

Past medical history:

Dyslipidemia

Total cholesterol 195

Triglycerides 65

HDL 43, LDL 139

Hypertension

History

Medications:

Pravastatin 20 mg daily

Premarin 1.25 mg daily

Omeprazole 20 mg daily

Social history:

Quit smoking 42 y ago

Family history:

No premature CAD

Physical exam

BP 132/75, HR 76, BMI 24

No JVD

Cardiac: RRR, Nl S1, S2, no murmurs, rubs or gallops

Lungs were clear

No lower extremity edema

Warm extremities, normal pulses

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Differential diagnosis

Coronary vasospasm

Microvascular angina

GERD

Musculoskeletal

Anxiety

Persistent chest Pain (PChP) without obstructive CAD

Double the rate of major CV events

Diffuse atherosclerosis

Coronary microvessel/ macrovessel dysfunction

Depression and anxiety

Refractory angina, re-cath, re-hospitalization for UA

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Cardiovascular events

Event free survival

Pathophysiology

Abnormal coronary microvascular flow reserve

Macrovascular endothelial dysfunction

Progression to obstructive CAD

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Diagnosis

Magnetic resonance spectroscopy (MRS)

Shift to anaerobic metabolism- myocardial ischemia

PCr/ATP after stress: Poor CV outcomes

Coronary flow reserve (IC adenosine)

Freedom from events at 3 yrs

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Management

PChP is a risk “marker”

Aggressive risk factor modification

Nitrates, Beta Blockers, Statins, ACEI

Exercise training

Close monitoring for CV events

Case # 2: DN

67 y/o WF with chest pain, indigestion

Hypertension, DM, dyslipidemia, smoking, + family h/o

Negative cardiac biomarkers, symptom resolution

Pharmacologic SPECT MPI- normal perfusion

Discharged home

6 days later- Recurrent chest pain, indigestion

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Acute coronary syndrome:Plaque “erosion” vs. “explosion”

Plaque rupture:

Large necrotic core

Disrupted fibrous cap

Macrophage/ lymphocytes

Plaque erosion:

Absent fibrous cap

Exposed intima

Smooth muscle/ proteoglycans

Plaque erosion

Acute coronary syndrome

Non-obstructive CAD

Diagnostic uncertainty

Greater atherosclerotic burden

Hormone mediated atherosclerotic storage

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Atherosclerotic storage

MINOCA

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Diagnostic and prognostic tools-detection of “culprit patient”

• P31 MR spectroscopy

• PET imaging

• C-IMT

• Electron beam CT

• Retinogram

• SPECT MPI

• Stress echo

• Cardiac MRI

• Hs-CRP

• IL-6

Inflammatory markers

Ventricular function/ Regional perfusion

Aerobic metabolism

Vessel wall abnormalities

Non-invasive testing

Detection of CAD

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Summary

Persistent chest pain without obstructive CAD

Ischemic heart disease in women

Diagnostic and prognostic tools

References

Insights From the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study

J Am Coll Cardiol. 2006;47(3s1):S4-S20. doi:10.1016/j.jacc.2005.01.072

J Am Coll Cardiol. 2006;47(3s1):S21-S29. doi:10.1016/j.jacc.2004.12.084

Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease

Eur Heart J (2006) 27 (12): 1408-1415

Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease

Circulation. 2004 Jun 22;109(24):2993-9. Epub 2004 Jun 14.