A more gender-specific approach should be used in diagnosing heart disease, according to the first set of guidelines in about a decade by the American Heart Association on women’s ischemic heart disease.

The scientific statement is the first since 2005 to update recommendations about how best to diagnose suspected ischemic heart disease in women. The guidelines include studies done in the last decade supporting changing the male-model of heart disease detection to a female-specific approach.

“For several decades, the male model of coronary disease … constituted the basis for most diagnostic and treatment strategies for both sexes,” said Jennifer H. Mieres, M.D., lead author of the statement. “As a result, many women who did not have classic obstructive coronary atherosclerosis were not diagnosed with ischemic heart disease and did not receive appropriate treatment.”

Ischemic heart disease occurs when blood flow is decreased by partial or complete blockages in coronary arteries that supply blood and nutrients to the heart muscle. The decreased blood flow reduces the heart’s oxygen supply and pumping ability, which can lead to a heart attack.

Men traditionally get obstructive coronary artery disease, where the main arteries supplying blood and nutrients to the heart become blocked.

Women might instead present with other symptoms, such as dysfunction of the endothelium, which occurs when cells lining the interior wall of blood vessels malfunction.

Or possibly with coronary microvascular disease, which affects the walls and inner lining of tiny coronary artery blood vessels that branch off from the larger coronary arteries. Damage to these inner walls of the blood vessels can lead to spasms and decrease blood flow to the heart muscle.

Standard tests that are designed to look for blockages in the larger coronary arteries don’t generally detect coronary microvascular disease.

Traditional tests, including stress testing, might result in “false positive” findings, when, in fact, the women tested might be at an increased risk for heart attack.

The new statement recommends testing that more clearly identifies heart disease in women. The statement cites evidence in the last decade that coronary computed tomography angiography and coronary magnetic resonance imaging are no longer research techniques as they were called in 2005. Today, they are proven, useful tools for detecting heart disease among certain groups of women with heart disease symptoms.

The statement also highlights research that shows women experience a broader range of heart disease symptoms than men, who typically have chest pain and pressure.

Women with ischemic heart disease report feeling jaw pain, upper back pain, widespread “indigestion,” and other symptoms not localized to the chest.

In addition, women’s symptoms seem more closely tied to emotional stress than the physical exertion which often spurs heart attacks in men.

“Evolving data support the fact that women may be more vulnerable to the effects of psychological stress on the heart. Emotional stressors – such as those provoking anger – may cause changes in the nervous system that controls heart rate and trigger a type of coronary artery dysfunction of the smaller branches that occurs more frequently in women than men,” Mieres said.

The new statement points to the continued under-treatment and under-testing of women, leading to complications from heart disease and death.

In the bigger picture of heart disease, the American Heart Association is recommending researchers consider gender and race during diagnosis.

In April 2014, Rose Marie Robertson, M.D., chief science officer of the American Heart Association, testified at a Food and Drug Administration public hearing to address gaps in research trial representation.

Robertson said only 35 percent of participants in cardiovascular disease research trials are women and 31 percent of these studies report outcomes by gender.

To reduce these gaps, the FDA should send a clear message to trial sponsors that they need to include adequate representation from women and other subgroups, including minorities and geriatrics, she said.

“Only by insisting on the availability of subgroup-specific analyses and improving the public availability of the results of this data can healthcare providers and their patients make the most informed decisions about which medical treatment will work best for them,” Robertson said.

For more information:

Symptoms of ischemic heart disease


Women and prevention