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Cardiac care under scrutiny

Roni Rabin Newsday

It seems incongruous, to say the least: Women, who survive labor pain and childrearing and still usually outlive men, are more likely to die after a heart attack.

“It’s a real paradox,” said Dr. Sharonne Hayes, director of the Mayo Clinic Women’s Heart Clinic in Rochester, Minn. “Is it because women are still not getting aggressive enough care? … I think that’s still part of it.”

But even when men and women receive the same treatments, she said, studies have found women are more likely to develop complications after an intervention — and are still more likely to die. Now, researchers are beginning to investigate whether there are underlying physiological differences between men and women that could help explain not only why women fare worse, but also why diagnostic tests often miss their coronary artery disease.

“Cardiac disease in women has slightly different presentations, and the diagnostic tests may have different value than in men,” said Dr. Nanette Wenger, professor of medicine in the division of cardiology at the Emory University School of Medicine in Atlanta. “The impact of risk factors may be different, but there may also be something else going on.”

The study of these gender-specific differences has become a promising area of investigation, drawing researchers who hope their insights will improve treatment – and increase women’s survival rates.

One theory is that women, by virtue of being smaller, tend to have narrower vessels that may be more easily obstructed and more susceptible to damage from smoking, hypertension and diabetes. They may exhibit more diffuse blockages.

Some clues may come from the relatively rare cases of young women, whose heart disease often is very aggressive. Generally, women are protected from heart disease until after menopause.

“If both a man and a woman have a heart attack at 50, the woman is going to have twice the rate of dying,” Hayes said.

No one knows why, but there are plenty of intriguing hypotheses.

“Is the difference sex-based? Or is it genetic?” Hayes asked. “Women have more migraines – do they have more vascular spasms, squeezing and narrowing the arteries? Is the inflammatory component a stronger component in younger women? Are they more prone to blood clots because of their sex hormones?

Right now, women are twice as likely as men to die from open-heart surgery. They’re also more likely to suffer complications after procedures to open blocked arteries, especially bleeding complications, and they’re more likely to suffer another cardiac event after the first.

They receive only a third of lifesaving interventional procedures, such as balloon angioplasty and stenting, and a third of open-heart surgeries. And they’re more likely than men to die within a year of a heart attack: 38 percent of women die compared with 25 percent of men.

But many leading female cardiologists reject the notion that women suffer from biases in treatment.

“There’s a tendency in this field to jump to the conclusion that we’re not doing right by our female patients,” said Dr. Alexandra J. Lansky, director of the Women’s Cardiovascular Health Initiative at the Cardiovascular Research Foundation in Manhattan. “That’s not necessarily the case.”

But doctors are being encouraged to treat women more aggressively, Lansky said, because they benefit tremendously from interventional procedures using the new generation of drug-coated stents to open blocked arteries.

Women also display different patterns of blockage in their vessels.

Men tend to have very discrete blockages at distinct focal points – making them more amenable to stenting, said Dr. Salvatore Trazzera, who runs a women’s heart program that has New York offices in Huntington and Farmingdale. Women tend to have blockages that are more diffuse and that occupy a longer segment of the vessel, he said.

These blockages still cause angina and chest pain, but their structure isn’t amenable to interventions such as surgery and stenting, so they are treated with medications instead, Trazzera said.

Since women clearly fare worse than men once they have established heart disease, however, cardiologists say it is imperative they adapt preventive behaviors and a healthy lifestyle early in life.

“We’re trying to increase awareness in women at a much younger age, when they can actually prevent disease, rather than waiting until they’re in their 60s – or even 40s and 50s,” Trazzera said.

“We’re seeing a lot of older women who have heart disease. What were they doing in the 1960s and 1970s? They were smoking. And that becomes a factor later on in life – it has a lifelong effect on one’s coronary status.”

For reasons that are not well-understood, smoking is one risk factor that takes more of a toll on women’s coronary artery systems than on men’s.

High blood pressure also takes more of a toll on women, while levels of “good” and “bad” cholesterol may have different significance for men than for women.

Of all risk factors, however, it is diabetes that seems to have a dramatically more significant effect on women, multiplying their risk.

The American Heart Association’s new guidelines for diagnosing and treating heart disease in women, issued recently, specifically addressed this heightened risk, which has serious implications for black and Hispanic women because they have higher rates than white women of diabetes and hypertension, as well as heart disease.

Part of the problem with disparate treatment outcomes may lie in the fact that women are still underrepresented in clinical trials to test devices and fine-tune procedures, despite a 1993 congressional mandate to include more women in research.

Early stenting technology was bulkier than it is today; now, smaller catheters are available, and wire mesh stents come in different sizes, some much smaller than before.

But women are often older than men when they develop heart disease, so they are more frail and more likely to have accompanying diseases that complicate treatment.

And women typically delay seeking medical attention when they are having a heart attack, often mistaking their chest pain for indigestion or heartburn. Their first symptoms are often unusual, such as inexplicable fatigue, lassitude or a decreased tolerance for physical activity.

Many younger women rely solely on a gynecologist for health care, and these physicians don’t specialize in heart disease. They can, however, screen women and make referrals when necessary, experts say.

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