Dimi and all women, please read.

[Jack54]

Dimi, I ran across this information today. It is a(the) perfect explanation for your symptoms when an angiogram shows no blockages. Also of interest, no where can I find that the 64 slice ct scan is any better in identifying blockages. However, the new MRI coronary scan is recommended for women with CAD symptoms when nothing found during an angiogram.

I have a mess of information here. It is odd that I could not find the actual WISE ending trial document. Instead just bits and pieces. Hope you and all the women here can make something of all of this untidy post.

I predict that in the future, there will be cardiologist that specialize in women's heart disease. In fact if I were a woman, I would find a cardiologist, maybe female, that is already highly knowledgeable about the results of the WISE study. That would be the first question that I would ask.......

I will have to break this up due to the length of the entire post. I see a message that tells me this message exceeds the 8k limit :)

------------------------------------------------------------------------------------------------------------------------------------------------
EMBARGOED FOR RELEASE
Tuesday, January 31, 2006
10:00 a.m. Eastern CONTACT:
NHLBI Communications Office
[phone]
E-mail: nhlbi_news***@****
NIH News


WISE Study of Women and Heart Disease Yields Important Findings On Frequently Undiagnosed Coronary Syndrome

In as many as 3 million U.S. women with coronary heart disease, cholesterol plaque may not build up into major blockages, but instead spreads evenly throughout the artery wall. As a result, diagnostic coronary angiography reveals that these women have “clear” arteries—no blockages—incorrectly indicating low risk. Despite this, many of these women have a high risk for heart attack, according to newly published research from the National Institutes of Health.

In women with this condition, called coronary microvascular syndrome, plaque accumulates in very small arteries of the heart, causing narrowing, reduced oxygen flow to the heart, and pain that can be similar to that of people with blocked arteries, but the plaque does not show up when physicians use standard tests. As a result, many women go undiagnosed, according to findings from the National Heart, Lung, and Blood Institute’s (NHLBI) Women’s Ischemia Syndrome Evaluation (WISE) study. Insights from the study are published in a special supplement to the February 6 issue of the Journal of the American College of Cardiology, available online January 31.

“When a diagnosis of this condition is missed, women are not treated for their angina and high cholesterol and they remain at high risk for having a heart attack,” said NHLBI Director Elizabeth G. Nabel, M.D. “This study and the high prevalence of coronary microvascular dysfunction demonstrate that we must think out of the box when it comes to the evaluation and diagnosis of heart disease in women.”

The National Institutes of Health initiated WISE in 1996 to increase scientific knowledge about ischemic heart disease in women. WISE aimed to develop accurate diagnostic approaches for ischemic heart disease detection in women, to better understand the ways in which heart disease develops in women including the significance of ischemia without coronary blockages in women, and to evaluate the influence of hormones, on ischemic heart disease development and diagnosis.

“So much of our understanding of the underpinnings of heart disease and heart attack, and the basis for our standard methods of diagnosis and treatment are the result of research conducted on men,” said C. Noel Bairey Merz, Cedars-Sinai Medical Center and the WISE study chairperson. “Through clinical experience, many critical questions arose about how the disease may manifest differently in women, and how diagnostic techniques may need to be used differently in order to prevent more heart attacks and save lives.”

WISE investigators found that the majority of women with “clear” angiography who are not diagnosed will continue to have symptoms, a declining quality of life, and repeated hospitalizations and tests.
“Through WISE, we have made tremendous progress toward better understanding of heart disease in women. Too often women are tested again and again, go untreated, and still have high risk for heart attacks, “ said George Sopko, MD, NHLBI project officer for WISE. “As clinicians we must systematically examine women for evidence of any blockages and initiate intensive treatment for their risk factors.”

Authors of six review papers providing insight on WISE conclude that the study has provided the groundwork for additional controlled clinical studies of diagnostic tools and treatments in women with ischemic heart disease.

Additional study conclusions from WISE appear in the same JACC edition:

Identifying Candidates for Exercise Stress Testing: Using the evaluative tool Duke Activity Status Index (DASI) in women with heart disease symptoms prior to stress testing can help determine who would be eligible for an exercise stress test versus a stress test using intravenous medications to increase the heart load instead of exercise. Current guidelines offer physicians little guidance on how to identify women who would not be able to sufficiently complete the exercise test. The DASI has been previously validated as a useful tool for determining functional capacity.
Low Coronary Flow and Scores on Function Test Indicate Poor Outcomes: Women who have low DASI scores also have lower coronary flow velocity, a combination which may explain the poor outcomes seen for women with heart disease but no blocked arteries.
Role of Pre-menopausal Hypertension in Disease Risk: Women who have high blood pressure before menopause, especially high systolic blood pressure, should be considered at a higher risk and treated accordingly

6. Stress echocardiography.
Using dobutamine stress echocardiography (DSE), the overall sensitivity and specificity was 40% and 80.6% respectively in the WISE population (Lewis). Notably, a significant proportion (15%) of the women had indeterminate tests due to inability to achieve an adequate peak heart rate before developing intolerable symptoms or cardiovascular side effects. Of these, a third had severe coronary artery stenosis (> 50% stenosis), as compared to 27% of the overall study population. Sensitivity improved to 50% when excluding women with indeterminate DSE and to 81.8% for two- or three-vessel stenosis. Thus, reliably detecting multivessel stenosis, DSE is usually negative in women with single-vessel disease. The results demonstrate the need for improved diagnostic accuracy in women with single-vessel disease.

7. Stress Radionuclide Perfusion and MR perfusion imaging.
Preliminary studies using magnetic resonance and nuclear perfusion imaging to detect coronary disease in women show promise. The WISE protocol comparatively studied cardiac MRI perfusion with intravenous gadoteridol as well as rest and intravenous dipyridamole nuclear SPECT imaging. MRI improved accuracy (sensitivity and specificity of 88% and 77%) for identification of obstructive coronary disease (>50% stenosis in at least one epicardial coronary artery) compared to Tc-99m sestamibi at rest and at peak exercise (75% sensitivity and 83% specificity)(Doyle abstract). Although these results are more promising than those of exercise stress ECG and stress echocardiography, they underscore the need for the development of a diagnostic algorithm for obstructive coronary disease in women.

[Eliese]

Wild! We got to get this info out there! I am a 57yr old lady of no profession. Was a doctor's daughter back in the '60s and was a clinical science drop-out in the '70s. Just had a myocardial perfusion test that was picture perfect, but have this feeling, because of not managing my diet due to lack of energy during the day, that there is a indescribable tension in the chest going into the back. Like there is something shaking when lying down.Blood pressure always seems at highest 130/70.  Anyway, THANKS for helping us learn more about the way our bodies really work!

[tumbleweed1999]

Thank you, from another woman (of 65 yrs) with "undiagnosed problems".  I am copying this into my wordpad so that I have it handy.

I had an ECG Friday (27th) and hope to hear tomorrow. If they say that it is clear then I am definitely going to ask them about this WISE study.  My Cardio is the head Dr. of the Heart Center here, but I guess that doesn't always mean everything.

He told me last Monday, before ordering the ECG, that he feels that I may have an AVNT (?) problem.  Something to do with the "electrical"  portion of the right side of the heart. However, I am on 50mg Coreg which has a Beta Blocker, and 10mg Altace, for my BP and he said as long as that keeps me from having "events" we aren't going to do anything "invasive".  Also, I have had "Angina" for years.

The main reason that he ordered the ECG, tho', was my having an episode a couple of weeks ago that sent me to ER.  He said that because I have AIH with Primary Biliary Cirrohsis overlap, and am on 30mg of Prednisone, the Prednisone is keeping my bp raised, but the liver problelm and the med. could be causing my heart to not get enough pressure to my lungs and causing the pain in the R/heart and lung area. ?????  

Any comments/help would be much appreciated.  

[johanni]

Thanks Jack will keep you posted.
Regards,
dimi.

[Jack54]

You are most welcome. I don't have a wealth of anything, lol. I just read a lot on the net. I also have 5 beautiful women in my life. Wife, daughters and granddaughters. Only 1 wife, lol.

I wanted women here to know that their angiograms may not be exactly correct. Angiograms were/are considered the gold standard for diagnosing CAD. Seems like they are not for some women though, according to the WISE study.

I sure hope that you can find out for sure about your coronary arteries and I am sure that you can.

If you don't have low BP, you could ask your doc to prescribe fast acting nitro. Should these symptoms come on, take a pill or spray, and see if they get better. That is always a good experiment for CAD. Talk to your doctor first!

Jack

[Jack54]

Didn't you have CABG? I could have you confused with another member. So glad you are receiving such quality care. You are special indeed.

[FLBrat]

Hmmm, makes me glad that I go to Mayo.  I fully trust my EP and Cardio.  They ask for information instead of rushing me out the door.  They know who I am, as a person as well as a patient, despite the many people in and out the door there.  The NPs answer any email, I have seen the print outs in my file of each mail I have sent AND the doctor has initialed them.  That is quality care.  By the way, my arteries are clean and clear, no blockages and very low cholesterol numbers.  Still, this "problem".

[johanni]

Thanks for posting such an informative post.You seem to be a wealth of information.It seems that yes, cad has always been considered a mans disease.Maybe I should try to get an mri done but dont know any centres in Ausrtalia where they do a dedicated one for the heart.I will do some searching and post back.
Thanks to you Sir,
Regards,
Dimi.

[Jack54]

Mayo Clinic (excerpt)

For example, we now know that just because a woman's arteries appear clear on an angiogram (a picture of the heart), it doesn't mean she's not at risk of heart disease. A study by the National Institutes of Health indicated as many as 3 million women previously diagnosed with healthy arteries could actually have an increased risk of heart attack after all.

This study, called the Women's Ischemia Syndrome Evaluation (WISE), found among other things that the gold standard test for assessing coronary artery disease — the coronary angiogram — may not spot the more diffuse buildup of plaques that often forms in the smaller coronary arteries of women's hearts.

How do heart attack symptoms differ in women and men?

The most common symptom of a heart attack in both men and women is some type of pain, pressure or discomfort in the chest. But it's not always severe or even the most prominent symptom, particularly in women. Women are more likely than men to have signs and symptoms unrelated to chest pain, such as:

Neck, shoulder, upper back or abdominal discomfort
Shortness of breath
Nausea or vomiting
Sweating
Lightheadedness or dizziness
Unusual fatigue

These signs and symptoms are more subtle than the obvious crushing chest pain often associated with heart attacks. This may be due to the smaller arteries involved or because in men, the bulky, unstable plaques tend to burst open whereas in women, plaques erode, exposing the inner layers of the artery.

Differences in symptoms may also relate to a condition called endothelial dysfunction. Endothelial dysfunction — in which the lining of the artery doesn't allow the artery to expand (dilate) properly to boost blood flow during activity — increases the risk of coronary artery spasm and sudden death.

Ultimately, women tend to show up in the emergency rooms after much heart damage has already occurred because their symptoms are not those typically associated with a heart attack. If you experience these symptoms or think you're having a heart attack, call for emergency medical help immediately. Don't drive yourself to the emergency room.

----------------------------------------------------------------
Women's heart disease: New study shows differences From MayoClinic.com
Special to CNN.com

Just because your arteries appear clear on an angiogram, it doesn't mean you're not at risk of heart disease. And the sage advice often given to men with heart disease might need a tweak or two to be useful in women.

As many as 3 million women previously diagnosed with healthy arteries could actually have an increased risk of heart attack after all, according to a study of women and heart disease by the National Institutes of Health. The study, called WISE, short for Women's Ischemia Syndrome Evaluation, found among other things that the gold standard test for assessing coronary artery disease — the coronary angiogram — may not spot the more diffuse buildup of plaques that often forms in the smaller coronary arteries of women's hearts.

"This study is very important. It's the first time we've looked at just women with chest pain," said Sharonne Hayes, M.D., a cardiologist at Mayo Clinic, Rochester, Minn., and review board member for this study.

Historically, coronary artery disease has been considered primarily a man's disease. But recent statistics have shown that the rate of heart disease has declined in men but not in women. This is, at least in part, because of gender differences in risk factors, symptoms and diagnostic accuracy. Tests and treatments for cardiovascular disease have been primarily studied in men. Researchers have now confirmed what's long been suspected, women are different.
------------------------------------------------------------------------------------------------------------------
Angiograms may miss disease signs in women

Ten women with heart disease allow a health care worker to snake a catheter through blood vessels in their upper thighs. Each tries to remain calm as dye flows through the catheter to her coronary arteries, checking for the blockages that can put her at a higher risk for a heart attack.
Each is told the angiogram showed clear arteries, meaning her heart attack risk is low.
But, for as many as four of the women, the test is wrong, according to a new national study that was partially conducted in Florida.

Those women are at high risk to have a heart attack. And without knowing their danger level, they may not take steps that might stop or postpone the heart trauma that could end their lives.
"It's not that the arteries are normal, because the arteries are not normal, but they don't have angiographic findings that correlate with the symptoms," explained Dr. Ramon Quesada, medical director of interventional cardiology at Baptist Hospital's Cardiac and Vascular Institute, in Miami. "It needs to be treated, but it needs to be treated differently."

The new information about the decades-old diagnostic, which Quesada said put into perspective things some doctors had observed in their practices, is from the Women's Ischemia Syndrome Evaluation (WISE) study by the National Heart, Lung and Blood Institute.

The study took 10 years. When the results came out in February, scientists said angiograms may fail to detect problems in as many as 3 million U.S. women with coronary heart disease. The National Coalition for Women with Heart Disease estimates about 8 million U.S. women are living with heart disease.

That means angiograms may not be reliable for 37.5 percent of women with heart disease.

Doesn't work in certain women :

WISE suggested the test doesn't work in certain women because their cholesterol plaque spreads evenly on the artery wall. Angiograms hunt for artery blockages, not thickened walls.
Women with the condition, called coronary microvascular syndrome, suffer reduced oxygen flow to the heart. Their pain can be similar to the pain people with blocked arteries suffer.
http://southflorida.bizjournals.com/southflorida/stories/2006/04/17/focus2.html?jst=s_cn_hl

----------------------------------------------------------------------