Yale-led study aims to transform diagnosis of heart disease in women

Karen Lombardi, an educational coach at the school, had just pulled an unruly child out of a classroom when she felt severe chest pains. She checked into Yale New Haven Hospital, sweating profusely and hyperventilating, and was diagnosed with a heart attack. Five weeks later, she was back in the hospital with more chest pains.

It took another four months before Lombardi, 61, learned the cause of his pain, received effective treatment and returned to active exercise. She considers herself lucky because many women with heart disease never a precise diagnosis.

According to Dr. Samit Shah, interventional cardiologist at Yale New Haven Hospital. But women often have heart disease that isn’t caused by such blockages, and their symptoms may not even include chest pain, said Shah, who eventually diagnosed Lombardi.

Karen Lombardi takes her dog, Peppa, for daily walks and weekend hikes. She considers herself lucky because many women with heart disease never get an accurate diagnosis.

Shah is trying to transform the diagnosis of heart disease in women by doing tests that go beyond the usual practice of looking for blockages. It is set to embark on research with nine other hospitals across the country that will aim to standardize expanded testing. It will also track resulting diagnoses and the effects on quality of life of receiving an accurate diagnosis, believing in pain, and obtaining appropriate treatment.

“Very few hospitals do these kinds of tests,” Shah said, explaining the result is that women are often sent home without a diagnosis and told their pain isn’t real. Sometimes they are referred to different specialists because of symptoms such as stomach and jaw pain that end up being heart-related, he said.

Yale New Haven doctors presented a paper in April to the American College of Cardiology reporting a median time of more than six years from symptom onset to correct diagnosis for 64 patients without blockages they had. finally tested with the extended procedure. The patients were composed of 48 women and 16 men.

“Obviously, if left untreated, the consequences can be greater,” Shah said. Heart disease is the number one cause of death for women and men in the United States.

In 2020, one in five female deaths in the country was due to heart disease, according to the Centers for Disease Control and Prevention (CDC). It is the leading cause of death among white and black women, second only to cancer among Hispanic and Pacific Islander women, and tied with cancer among Native American and Alaska Native women, the CDC reports.

“Medicine, in general, is so biased in treating men that we overlook something that may be right in front of us,” Shah said. “Women are not raw about pain after surgery. Women who have heart attacks – it takes longer for providers to see them and longer for a heart attack to be recognized,” he said.

Shah said at least half of the women he’s treated for heart disease don’t have blockages. And, in 90% of those who aren’t blocked, the culprit is an inability of small blood vessels to pump blood back to the heart, he said. The two prevalent conditions with this problem are coronary microvascular disease and coronary vasospasm.

Shah’s tests begin with an invasive angiogram, also called catheterization, which reveals major blockages. When he can’t see them, he continues the tests by injecting drugs that help him explore the small heart vessels, which carry most of the heart’s blood supply.

Shah discovered that Lombardi’s heart disease was caused by vasospasm, which means his small vessels were closing and preventing blood flow. She said knowing the cause of her heart condition and being treated properly eliminated her chest pain and changed her life.

After his first trip to the hospital, he was prescribed nitroglycerin, blood pressure medication and blood thinner. A small blockage detected on her angiogram did not match the pain she was reporting. However, no further testing was done and she felt that she had been treated with a dismissive attitude of “this is not a major blockage. What are you complaining about,” she said.

She lived in fear of having another heart attack.

Dr. Samit Shah said that at least half of the women he has treated for heart disease have no blockages.

Following Shah’s diagnosis, the blood thinner, which was causing severe bruising, was removed, as was the prescribed blood pressure medication. Lombardi now takes a drug called amlodipine and wears a nitroglycerin patch as a preventive measure when she is particularly active. His previous prescription for nitroglycerin was taken by mouth after chest pains, which were becoming more frequent.

Now retired from the New Haven school system, Lombardi and her husband hike two to three miles a day and hike on weekends near their East Haddam home. It’s a far cry from the five-minute walks she tentatively attempted after her first diagnosis. “Anything intense, I started to feel my chest tighten and my heart racing,” she said.

Now, she says, “I feel like I can go out and do things without being scared.” She added: “I no longer consider myself a patient. I see myself as having a disease that I can manage with medication.

Carolyn Mazure, director of Women’s Health Research at Yale School of Medicine, said his center helps fund Dr. Shah’s research to raise awareness of heart disease in women and improve health outcomes. Only 56% of American women know that heart disease is the number one cause of death in the country, according to the CDC.

“We want women to be informed about this,” Mazure said. “We want the diagnostic procedures to be ready and the treatment to be ready to really treat this disorder. The essence of our work is that women have a stronger and healthier life.

The Federal Food and Drug Administration and Abbott Vascular, a medical device company, are the other funders of the research, Shah said.

Mazure pointed out that it wasn’t until the mid-1990s that the National Institutes of Health, which she called “the largest funder of biomedical research in the world,” began to demand the inclusion of women. in clinical studies. “It wasn’t until 2000 that we started seeing studies that were really designed for women” beyond reproductive health, she said.

A study published in the Journal of the American Heart Association last March concluded that greater awareness of heart disease without the presence of blockages “is urgently needed for accurate diagnosis and patient-appropriate management.” He called for the refinement and standardization of diagnostic tools, which Shah National Research seeks. And he found that when patients learn the cause of their pain and are treated for it, their quality of life is positively affected. He added that identifying microvascular disease or vasospasm prevents patients from undergoing repeated invasive testing and potentially reduces healthcare costs.

Lombardi lamented that other women were not given the opportunity to undergo expanded testing she received from Shah. When she went to the hospital with a second episode of chest pain, the cardiologist on call suggested she get Shah’s extensive testing.

“It shouldn’t be luck that determines whether women are diagnosed correctly or not,” Lombardi said. “Understanding the differences between women’s and men’s heart disease needs to be generalized.”

This story was first published on August 29, 2022 by the Connecticut Health Investigation Team.