There may be no more striking disconnect between new compelling science and current practice than we see in the treatment of women with chest pain. Just today, I saw a woman in her early 50s who has had recurrent chest pain for over two years. She has a family history of heart attack and she is prediabetic with high cholesterol, LDL cholesterol , and triglycerides. She has low HDL or good cholesterol. She is a high risk patient for cardiovascular disease. Her pain was not characteristic of exertional angina as we might see in a man. She had the pain that we frequently see in women that is brought on by stress or may just occur spontaneously. Her pain lasts for several minutes and it is reliably relieved by nitroglycerin. She had a normal stress test 6 months ago and another 2 years ago.
She recently had an episode of pain that alarmed her and she went to the emergency room. She was released from the emergency room with a referral to the cardiologist some days later. She was irritated because she felt that the doctor who saw her did not take her chest pain seriously. The cardiologist performed a cardiac catheterization that showed no blockage at all in her coronary arteries. The note from the cardiologist said, “I tried to reassure this lady of the non-cardiac nature of her symptoms.”
This interpretation is wrong-possibly dead wrong. While we lament the lack of studies to inform practice of the special needs of women, we ignore those studies too often when we have strong evidence that calls for a change in what we do for our female patients. 250,000 women die of coronary artery disease in the United States annually. More women die of heart artery disease than all forms of cancer combined and are roughly ten times more likely to die of a heart attack than breast cancer. It has been known since the 1970s that chest pain in women is less likely to be associated with arterial blockages that limit blood flow when compared with male patients with the same symptoms.
In fact, if a woman after menopause has repeated chest pain, she has a 20% six year risk of dying, having a heart attack, having a stroke, or developing congestive heart failure even if she does not have flow-limiting obstructions of her heart arteries. There is no test or procedure that can be done to assure her safety. The woman with repeated chest pain is high risk even if she has a stress test and catheterization that is normal. She can reduce her risk dramatically by controlling her blood pressure, cholesterol, and glucose with life style changes and carefully selected medications. In spite of the availability of these powerful, inexpensive and highly effective interventions, one year after these women without blockages had their heart catheterization, only around 10% of them were on anything for their pressure and cholesterol. They are in harm’s way.
These women are poorly served in several ways. If they have a low risk stress test they do not need a cardiac catheterization and are exposed to unnecessary cost and risk. If their arteries are not blocked, they are told that their heart is ok, they are less likely to treat the arteries effectively by lowering their pressure, sugar and cholesterol. When they are told that it is not their heart, they are falsely reassured and may not get help in a timely fashion when they are actually having a heart attack. Finally, the female chest pain patient may walk away with the implied message, “This is all in your head, go home and take your Valium and Prozac, honey. It is all going to be all right.”
Because we have not changed our systems of care to see that patients reliably receive treatment that is evidence-based and consistent with best practices, thousands of women die or become disabled needlessly. These are our wives, sisters, neighbors and friends. It is a matter of the utmost urgency that we address women with chest pain more effectively in a way that is consistent with the most current scientific knowledge.
My oldest son graduated from West Point. He taught me that tactics lag technology. Generals get their soldiers killed by fighting in ways that were appropriate for the last war. We are witnessing a failure of leadership with exactly the same implications. It may be that we need a Cardiovascular War College staffed by women to turn this thing around.
Bill Bestermann MD is a Vascularist and Director of Medical Home Quality at the Holston Medical Group in Kingsport, TN.