I didn’t immediately ask her about the emotional turmoil she had been through recently. Instead, I focused on her symptoms, her EKG results, and her blood work, all of which are troubling. I quickly mobilized the interventional cardiology team for a procedure to check the arteries of her 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 after the procedure, when we determined her arteries were clear.
When emotional pain turns into a physical problem
Usually, when patients tell me they’ve had a heart attack, they mean as a result of obstructive coronary artery disease, a condition in which cholesterol-rich plaque builds up in the blood vessels, ruptures, and causes blockages in the arteries that supply oxygen to the heart muscle .
What this patient experienced was something different. In response to the stress, her heart literally gave up. It grew, weakened, and her emotional pain turned into a physical condition. Takotsubo cardiomyopathy, often called broken heart syndrome, is diagnosed in up to 10 percent of women who have a heart attack.
Caused by severe stress, Takotsubo is largely reversible but can be dangerous. There is a mortality rate of about 5 percent in hospitalized patients. It is considered rare, but I have seen it several times in my four short years as a doctor, and almost always in women.
In medicine, we often separate psychological symptoms from clinical ones. Symptoms we struggle to explain are written off as anxiety and stress and placed in the realm of psychiatry. Women, who are stereotyped as more emotional, are less likely to receive appropriate tests for heart disease and are more likely to die within five years of a heart disease diagnosis than men.
Understanding women’s hearts
Dr. Martha Gulati, associate director of the Barbra Streisand Center for Women’s Heart at Cedars-Sinai Heart Institute and president of the American Society of Preventive Cardiology, has dedicated her research and practice to better understanding women’s hearts.
It describes a time before conditions like Takotsubo were understood. Women often experience chest pain, have positive initial test results, and then have their symptoms dismissed as anxiety when it is determined that they do not have 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 present again and again with the same symptoms. We were missing something.”
Now, 20 years later, the “something” we were missing is called MINOCA, which stands for “myocardial infarction with non-obstructive coronary arteries.” This is a general term assigned to patients who have objective signs of damage to their heart, but without the blockages associated with traditional heart attacks.
The existence of MINOCA is a mystery to doctors. Chest pain is a vague symptom and is one of the most common complaints seen in the emergency department. Only 15 to 25 percent of these patients were found to have a blocked coronary artery.
In addition, most tests are aimed at ruling out obstructive coronary artery disease, which is one of the most life-threatening causes of chest pain. If no blockage is detected, many patients are sent home only to show up at the cardiology clinic with questions, feeling scared, rejected, and still experiencing symptoms.
When patients do not 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 testing is not without risk, so usually what I offer them is reassurance.
But sometimes I wonder – what if I’m missing something? What if this patient who may have been labeled as anxious actually has a form of MINOCA? Would I be contributing to the health care bias against women if I didn’t offer her more testing?
That’s a question I asked attending John Blair, an interventional cardiologist. Blair specializes in physiological tests that use specialized equipment and drugs to help categorize MINOCA. The first thing he suggests is to use non-invasive tests to evaluate the heart. If the heart shows signs of damage, the next step is to do invasive angiography. If there are no blockages, a specialized physiological examination should be done.
“Half of the patients I see in the office with chest pain and non-obstructive coronary artery disease have microvascular dysfunction or spasm,” he says. Once patients are diagnosed, he can start them on therapies that are “proven to relieve symptoms and improve quality of life.”
Learn to describe your symptoms
For patients suffering from symptoms they worry are coming from their hearts, it can be difficult to advocate for themselves when a doctor is dismissive. Here are some questions that might help.
How does your pain feel? Chest pain from heart disease is often pressure-like, squeezing, or severe, usually worsens with exercise, and lasts 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? Pain that is sharp and worsens with breathing is much less likely to be due to heart disease.
What time of day do you experience pain? Finding patterns in symptoms can be helpful. For example, coronary vasospasm, a condition in which the arteries feeding the heart literally spasm and prevent the heart muscle from receiving oxygen, often occurs early in the morning.
Has your stamina changed recently? Reporting changes in exercise tolerance can also be helpful – when a patient tells me that, for example, they can no longer cross parking lots or climb stairs, an alarm goes off in my head.
Finally, it is very important to manage conditions that may contribute to heart disease. Controlling blood pressure, managing diabetes, avoiding smoking, exercising regularly, eating a heart-healthy diet, and monitoring cholesterol can prevent or alleviate heart disease.
I am fortunate to practice in an era where there is interest in researching conditions that more commonly affect women. Increased research on gender and sex differences in cardiovascular disease has led to a significant reduction in the number of women dying from heart disease.
And while there is still a clear need for further work, I am hopeful for a future in which women’s cardiovascular health is properly researched.
Shirlene Obuobi is a second-year cardiology fellow at the University of Chicago Medical Center. Her health care navigation comics appear on her Instagram @ShirlywhirlMD. She is the author of On Rotation, a novel about a Ghanaian-American medical student.