6 minute read
Heart Attacks in Young Women
Heart Attacks
in Young Women
BY MIAN A. JAN, MD, FACC, FSCAI, AND ZARA QURAISHI
— By Laura Bush
For decades heart disease has been labeled as a men’s disease. This assumption based on gender is incorrect and a truly harmful representation of heart disease patients. Forty-four million women in the United States are affected by heart disease. Every year 1 in 3 women die from heart disease.
In recent years heart disease in women has been recognized as a leading cause of death killing many more women than cancer does.
Recent studies have shown that heart disease is the leading cause of death both in men and women. The mortality of coronary disease has diminished dramatically in the USA in the past forty years due to rapid improvement, prevention, and treatment. Surprisingly one segment that has not benefited from this trend have been younger women aged less than 55 years; their deaths did not show a decline between 1995 to 2014. As a matter of fact, 5% of all myocardial infractions occur in this group. These women were less likely to undergo invasive strategy and given guidelinesbased therapy. Data from a CDC medical care survey between 2014 and 2018 showed young women and people of color with chest pain waited longer to be seen by a physician independent of their presentation and were less likely to be admitted.
Risk factors
Research has shown that the following seven risk factors are most important in younger women: 1. Hypertension 2. Diabetes 3. Family history of heart disease 4. Smoking 5. Low household income 6. High cholesterol 7. Depression
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Heart Attacks in Young Women
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In men, smoking and a family history of acute myocardial infarction (MI) were leading risk factors. Given that six out of seven risk factors are modifiable there is a lot of room for intervention. Additionally, women who have gestational pregnancy, diabetes, hypertension, or eclampsia are also at risk of certain types of MI.
Subtypes of acute MI that affect younger women
1. Spontaneous coronary artery dissection (SCAD)
SCAD is the cause of acute coronary syndrome in as many as 35% of young women and is the most common cause of MI associated with pregnancy. The mean age is 42-50 years, and for years this condition was underdiagnosed. SCAD occurs from a tear in the innermost layer of the coronary artery wall. The blood flows into torn layer interrupting blood flow and causing a heart attack.
SCAD is often missed because these women are often healthy and active and do not have many risk factors. It is commonly seen in female athletes, pregnant and new mothers. There may be associations with conditions such as extreme emotional stress, physical stress, and even drug use.
The presentation includes chest pain, lightheadedness, fainting, nausea, vomiting, and shortness of breath.
Diagnosis is accomplished by performing an angiography and the patient may also need an intravascular ultrasound (IVUS), and an optical coherence tomography (OCT).
Treatment included in the majority of cases is giving antiplatelet therapy and medications to control angina. The vessel usually heals by itself but if the flow is not reestablished the patient may need stenting.
The prognosis is usually good with mortality less than 4% but the recurrence rate is 5% and surveillance is important.
2. Myocardial infarction with non-obstructive coronary artery disease (CAD - MINOCA)
MINOCA is a MI that occurs in patients with non-obstructive CAD. It’s a heterogeneous group first reported almost 80 years ago but is not a benign condition with 1-year mortality similar to obstructive CAD. Five to fifteen percent of patients with MI have MINOCA. INOCA is a similar term denoting ischemia without obstructive coronary artery disease.
This condition is again more prevalent in women under the age of 55.
The diagnostic evaluation consists of angiography with intravascular ultrasound, and optical coherence tomography (OCT). Angiography reveals less than 50% blockages but may reveal plaque rupture, erosion, ulceration, and hemorrhage. It is important to assess coronary microvascular dysfunction by using a pressure wire, calculating coronary flow reserve, and index of microvascular resistance.
Blood tests (troponins) just like any other MI should be done.
Echocardiogram to evaluate wall motion and masses for pericardial effusion and source for embolic origin.
CT scan and MRI should also be done.
For treatment, therapy should be individualized.
Some studies have shown decreased mortality with renin angiotensin aldosterone systems, statins, ACE, and ARBs. If plaque disruption is seen dual anti-platelet therapy should be given.
Major adverse cardiac events (MACE) are comparable to obstructive MI.
Meta-analysis had shown twelve months of all-cause mortality in MACE to be 4.7%.
In conclusion, MINOCA is a heterogeneous working diagnosis that requires multiple modal approaches, and determining underlying causes is paramount.
3. Coronary artery spasm (variant or Prinzmetals angina)
A coronary artery spasm is a temporary constriction of the muscle in the wall of an artery which can result in reduced flow and even blocking flow to the heart muscle. Coronary artery spasm is more common in women and the presentation can be indistinguishable from classic angina pectoris associated with obstructive CAD.
These patients are younger and have fewer classic cardiovascular risk factors and may have vasospastic disorders such as the Raynaud phenomenon. Emotional stress, intense physical exercise, extreme cold, or drugs like cocaine can trigger spasm. Episodes also tend to occur at rest. There are three core elements establishing the diagnosis.
A. Nitrate-responsive angina B. Transient electrocardiographic changes
C. Angiographic evidence of coronary spasm with provocative testing including agents such as acetylcholine.
Treatment includes nitrates and calcium channel blockers and encouraging patients to quit smoking.
4. Stress cardiomyopathy (Takotsubo cardiomyopathy)
Stress cardiomyopathy is also known as broken heart syndrome and occurs when the heart muscle suddenly becomes stunned following severe emotional stress. The heart chamber looks like a Japanese fishing pot to catch octopus and thus the name Takotsubo. The emotional stress could be the death of loved ones, a serious accident, an intense argument, unexpected loss, or sudden illness. It affects women more than men.
The presentation is similar to MI with chest pain and shortness of breath. EKG may show evidence of MI and blood tests reveal high troponins.
Diagnosis can be confirmed by an Echocardiogram which reveals the classic shape of the heart. Coronary angiography will show no blockages. The treatment is to support hemodynamics as the heart recovers its function. The majority of patients recover completely.
In summary, we have discussed heart disease in young women and various types, their causes, pathophysiology, presentations, and treatment.
We strongly believed the famous quote by Dutch philosopher Desiderius Erasmus.
“Prevention is better than treatment.” We as healthcare providers need to do a better job of raising awareness of this devastating condition in women who are in the prime of their lives and recognizing their symptoms rather than ignoring them. Especially since pathophysiology and presentation are different from our classic teachings.
