Mar. 31, 1998 By Melanie Fridl Ross
ATLANTA---To the list of what makes men and women different, add a few new items in the category of heart disease. Researchers have only recently begun to debate the effects of gender, age, hormones and other factors on the affliction. Now, preliminary findings from a major national study of women with heart disease shed new light, including information on a promising new diagnostic tool for the half of the population that - despite popular perceptions -- has a death rate 10 times that of men.
"Part of the problem has to do with the perception of risk in the female population. For many years it was not really recognized that coronary disease was a major cause of morbidity and mortality in women," said Dr. Jannet Lewis, an associate professor of medicine at the University of Florida College of Medicine.
The first details to be reported from the WISE study - for "women's ischemic syndrome evaluation," are unveiling new insights, though many mysteries remain. The National Institutes of Health is funding the $7 million effort. UF has been granted $1.45 million to conduct its portion of the study.
Among the pilot data reported today (3/31) by researchers from the University of Florida and other WISE investigators: * Blockages in the coronary arteries are common causes of reduced blood flow to the heart; physicians also have known that arterial abnormalities occurring before obstructions form play a role. In men, heart disease and its risk factors are frequently associated with abnormally functioning coronary and "peripheral" arteries (such as the brachial artery, the main supplier of blood to the arm). In contrast, among women with chest pain and multiple risk factors for heart disease -- such as diabetes and high blood pressure - dysfunctional coronary arteries are common but not necessarily associated with the malfunction of these other, outlying vessels. * Older women with chest pain and multiple heart disease risk factors, meanwhile, are particularly predisposed to developing dysfunctional peripheral arteries. * A new, noninvasive test - dobutamine stress echocardiography - assesses women with chest pain believed to stem from inadequate blood flow to the heart; it looks promising. (In women, routine exercise stress testing is not always reliable, often indicating a problem when none exists.) During the test, physicians inject patients with a medication that mimics exercise by increasing heart rate and blood pressure. They then search for abnormalities that signal areas of reduced blood supply on an echocardiogram, which uses ultrasound imaging to create images of the heart.
"There is no doubt in my mind that heart disease is different in some women than in men," said Dr. Richard Kerensky, medical director of the cardiac catheterization laboratory at Shands at UF. "Although our data ispreliminary, we are all enthusiastic because we are finding abnormalities. There are a wide variety of tests being performed in this study and the results are bound to give us clues where to go next to improve diagnosis and treatment."
UF cardiologists have spent the past year testing new diagnostic procedures as part of the effort to better identify and treat women with known or suspected ischemic heart disease, caused by blocked or diseased arteries, said Dr. Carl Pepine, co-director of cardiovascular medicine at UF's College of Medicine and principal investigator for UF's portion of the study. Lewis is co-principal investigator.
The condition is noted for an insufficient blood supply to the heart, typically due to obstruction of coronary arteries and blood vessels by fatty cholesterol deposits or disease. It can lead to sudden death or heart attack and causes the chest pain known as angina.
The exact prevalence of ischemic heart disease is unknown, though the American Heart Association estimates it accounts for at least 365,000 deaths annually among women.
To date, UF researchers have enrolled 136 patients, ages 21 to 75, who have ischemic heart disease or who suspect they suffer from it because of chest pain or other related symptoms. About 1,000 women will be tracked nationally for four years at UF and three other sites: the University of Alabama at Birmingham, the University of Pittsburgh and Pittsburgh's Allegheny University of the Health Sciences. While some techniques will be conducted at all the centers, each will test its own unique procedures.
"I think over the last few years, there has been a re-education of both lay people as well as medical professionals about the impact of coronary disease in women, and also a re-direction toward performing trials to get more information that is gender-based," Lewis said.
Participants undergo detailed evaluation, including a physical exam, psychological and quality-of-life tests, detailed hormonal and estrogen receptor evaluations, tests that examine the heart's response to mental and physical stress, and invasive coronary assessments such as angiography, which lets physicians view blood vessels on X-ray films. Researchers also will conduct a series of tests to determine the adequacy of coronary function.
Other imaging tests are done to identify abnormalities of the coronary arteries that occur before the formation of obstructive lesions such as plaque. The heart's smaller vessels, part of the body's "microcirculation," also will be evaluated using a special technique that senses blood flow.
"The latter two techniques should be particularly useful for a large group of women who have severe, recurrent chest pain but no severe coronary narrowings," Pepine said. "Many times these women remain disabled by their symptoms but nobody knows how to treat them, let alone diagnose their condition."
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