I didn’t immediately ask her about the emotional turmoil she had been recently experiencing. Instead, I focused on her symptoms, EKG results, and blood work, all of which are concerning. I quickly mobilized the interventional cardiology team for a procedure to check the arteries in his heart for blockage.
On the way to the cardiac catheterization lab, she tearfully informed me of her husband’s recent death, but I didn’t think it was relevant to her care – until the end of the procedure, when we found that his arteries were open.
When emotional pain turns into a physical problem
Typically, when patients tell me they’ve had a heart attack, they’re referring to a consequence of obstructive coronary artery disease, a condition in which cholesterol-rich plaque builds up in blood vessels, ruptures and causes blockage of the arteries that bring oxygen to the heart muscle.
What this patient experienced is something different. In response to the stress, her heart literally gave out. He swelled, weakened, and his emotional pain turned into physical condition. Takotsubo cardiomyopathy, often called broken heart syndrome, is diagnosed in up to 10% of women who have a heart attack.
Triggered by intense stress, Takotsubo is largely reversible but can be dangerous. It has a mortality of about 5 percent in hospitalized patients. It’s considered rare, but I’ve seen it several times in my four short years as a doctor, and almost always in women.
In medicine, psychological symptoms are often separated from clinical symptoms. Symptoms that we struggle to explain are considered anxiety and stress and placed in the realm of psychiatry. Women, who are stereotyped as more emotional, are less likely to undergo proper testing for heart disease and more likely to die within five years of being diagnosed with heart disease than men.
Understanding the Heart of Women
Physician Martha Gulati, associate director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Heart Institute and president of the American Society for Preventive Cardiology, has dedicated her research and practice to better understanding women’s hearts.
She describes a time before conditions like Takotsubo were understood. The women often presented with chest pain, had positive initial test results, and then their symptoms were considered anxiety when it turned out that they had no blockages in their heart.
“We used to say they had false positives,” Gulati said. “But I knew that couldn’t be quite right. These patients presented again and again with the same symptoms. We were missing something. »
Today, 20 years later, the “something” we were missing is called MINOCA, which means “myocardial infarction with non-obstructive coronary arteries”. It is an umbrella term assigned to patients who show objective signs of heart damage, but without the blockages associated with traditional heart attacks.
The existence of MINOCA is an enigma for doctors. Chest pain is a vague symptom, and it’s one of the most common complaints seen in the ER. Only 15-25% of these patients have a blocked coronary artery.
Also, most tests aim to rule out obstructive coronary artery disease, which is one of the deadliest causes of chest pain. If no blockage is detected, many patients are sent home, showing up at the cardiology clinic with questions, feeling scared, turned away, and still experiencing symptoms.
When patients don’t fit the pattern
In the clinic, I often see young women with symptoms that do not fit the typical patterns of cardiac chest pain. But the tests are not without risks, so generally what I offer them is to reassure them.
But sometimes I wonder: what if something was missing? What if this patient, who may have been labeled as anxious, actually had a form of MINOCA? Would I be contributing to healthcare bias against women if I didn’t offer her more tests?
This is a question I posed to my assistant, John Blair, an interventional cardiologist. Blair specializes in physiological testing, which uses specialized equipment and medications to help categorize MINOCA. The first thing he suggests is to use non-invasive tests to assess the heart. If the heart shows signs of damage, the next step is to pursue invasive angiography. If there are no blockages, specialized physiological tests should be performed.
“Half of the patients I see in the office with chest pain and non-obstructive coronary artery disease have microvascular dysfunction or spasms,” he says. Once patients are diagnosed, he is able to start them on therapies that “have been shown to relieve symptoms and improve quality of life.”
Learn to describe your symptoms
For patients with symptoms they fear come from the heart, it can be difficult to defend themselves when the doctor is dismissive. Here are some questions that might help you.
What does your pain feel like? Chest pain from heart conditions is often pressure-like, squeezing, or heavy, usually worsens with exercise, and lasts for minutes, not seconds.
Do you have pain elsewhere in your body? Heart pain is also more likely to travel up the jaw or down the arm. In women, heart disease can cause abdominal pain.
Is the pain sharp? Sharp, pain made worse by breathing is much less likely to be due to heart disease.
At what time of the day do you feel pain? It may be helpful to determine symptom patterns. For example, coronary vasospasm, a condition in which the arteries supplying the heart literally constrict and prevent the heart muscle from getting oxygen, often occurs early in the morning.
Has your stamina changed recently? Communicating changes in exercise tolerance can also be helpful – when a patient tells me that, for example, they are no longer able to walk through parking lots or climb stairs, alarm bells go off in my head.
Finally, it is very important to manage conditions that can contribute to heart disease. Controlling blood pressure, managing diabetes, avoiding smoking, exercising regularly, following a heart-healthy diet, and monitoring cholesterol can prevent or lessen heart problems.
I am fortunate to be training at a time when there is interest in examining conditions that most often affect women. The increase in research on sex and gender disparities in cardiovascular disease has led to a significant drop in the number of women who die of heart disease.
And while there’s still a clear need for more work, I’m hopeful for a future in which women’s cardiovascular health is properly studied.
Shirlene Obuobi is a second-year cardiology fellow at the University of Chicago Medical Center. Her comics about navigating healthcare appear on her Instagram @ShirlywhirlMD. She is the author of “On Rotation”, a novel about a Ghanaian-American medical student.