Heart attack without blockage

Has your doctor told you have minor blockages in your coronary arteries? If you’ve had a heart catheterization for blockages your doctor determined are too minor to require a stent or bypass surgery, it’s still important not to ignore chest pain.

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In a recent study, researchers at the Veterans Administration’s Eastern Colorado Health Care System studied 38,000 patients, including those who had undergone a heart catheterization for relatively minor coronary artery blockages.

Some of these patients had what’s called non-obstructive coronary artery disease (CAD), which means they experienced chest pain despite a lack of blockages.

According to the findings, these patients were still at a significantly increased risk of having a heart attack or dying within a year compared to people who showed no signs. In fact, they had anywhere from a two-to four-fold increased risk of a heart attack or death.

This is why chest pain is a red flag symptom that should prompt a call to 9-1-1, even if you have minor blockages. You want to be sure to get prompt medical treatment.

Preventive strategies important

It’s important to work closely with your doctor to address any kind of buildup in your arteries – even if it’s just at the start of some plaque and not considered significant or obstructive.

Look at all your health numbers carefully – especially those that are borderline – and talk to your doctor about them.

Even if your cholesterol is within the healthy range, if it is on the low end, you may want to be proactive in improving it.

If you have borderline high blood pressure, you want to address it before it becomes an issue – especially with exercise and dietary changes. If you have pre-diabetes or diabetes, you want to lower all your risk factors for heart disease.

Be proactive about your heart health, and pay attention to your symptoms, even if you have minor blockages.

By: Steven Nissen, MD

Blocked arteries aren’t the only things causing heart attacks in women

By: Marrison Worthington

People commonly think a heart attack is caused from a blockage in one of the arteries of the heart, but a new study proves this may not always be the case in women.

Recently, the Circulation journal by the American Heart Association published a study indicating women can have a heart attack regardless of whether they have a blocked artery or not, unlike their male counterparts, whose primary cause is a blocked artery.

The study surveyed 340 women who reported chest pains and did not have blocked heart arteries. The women underwent a cardiac magnetic resonance imaging (MRI) procedure for the heart. The results found that eight percent of women who had chest pain and no blocked arteries did, in fact, have scars on their heart signifying they had a heart attack.

“Often, the symptoms of a heart attack in women are not the ‘classic’, crushing chest pain everyone envisions,” says Dr. Shermeen Memon, a cardiologist with the Advocate Heart Institute at Advocate Christ Medical Center in Oak Lawn, Ill., who specializes in reading MRIs of the heart.

“In women, symptoms of heart attacks can present as chest discomfort or tightness, indigestion, back, arm, or neck pain, or fatigue, just to name a few presenting symptoms. Not all chest pain indicates a heart attack; however, chest pain should never be ignored.”

One third of the women who had scars on their heart from the study were never diagnosed with a heart attack, even though the scans illustrated damage to their heart muscle.

“It’s always important to listen to your body and take chest discomfort, shortness of breath or any new symptoms seriously,” says Dr. Memon. “It is important to determine what the causes of those symptoms are to ensure you are provided the correct treatment.”

According to Dr. Memon, these are some of the lesser-known heart conditions to which women could be susceptible:

  • Women have a higher risk of developing “broken heart syndrome”, which is caused by the sudden release of stress hormones during stressful events. This syndrome can cause acute heart failure or stunning of the heart.
  • Women are also at higher risk of developing spontaneous coronary artery dissections, which can occur during pregnancy or during extreme stress. This results in the vessel suddenly tearing due to stress on the vessel wall.
  • Chest pain in women could also be secondary to spasms of the heart arteries and often present with symptoms similar to a heart attack.

Dr. Memon adds that it is important to live a heart-healthy lifestyle which includes a balanced diet, exercise and providing your body with enough rest to help prevent any heart disease, whether it be due to a blocked artery or other cause.

Find out your risk for heart disease by taking our simple and easy Heart Risk Assessment.

Chest Pains In Women Could Be Undiagnosed Heart Attacks

When women who don’t have blocked arteries complain about chest pain, their doctors sometimes reassure them that there’s no reason to worry, says C. Noel Bairey Merz, MD, the director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles.

This line of thinking is based on the fact that blockages in the major heart arteries are a primary cause of heart attacks in men. A study published in the February 2018 issue of Circulation showed how faulty this reasoning is: Women can have a heart attack in the absence of blocked arteries.

In the study, which is part of the ongoing Women’s Ischemic Syndrome Evaluation (WISE) research project, researchers looked at 340 women who had complained of chest pain but were found not to have coronary artery blockages on angiograms. After undergoing cardiac magnetic resonance imaging (MRI), 8 percent of the women were found to have scars on their hearts, which indicates they’d had a heart attack; yet a third of these women had never been diagnosed with a heart attack.

The study revealed that these women may have microvascular dysfunction or spasm in the tiny vessels around the heart, a condition that can go undetected because the usual tests for heart attack (such as electrocardiogram, or ECG) often don’t detect these problems. Women develop coronary microvascular disease more frequently than men do, according to the American Heart Association; it can be treated with medications.

The take-home message for women: “Listen to your body, and get a second opinion from an expert if you doubt the diagnosis or management plan,” says Dr. Bairey Merz, the principal investigator of the WISE study.

RELATED: How Heart Attack Symptoms Differ in Men And Women

Heeding Heart Attack Warning Signs

Many women don’t get the appropriate tests because they’re perceived to be at low risk for a heart attack — “and they are considered low-risk because their heart disease symptoms are different than the symptoms men experience,” Bairey Merz explains.

Rather than the crushing chest pain that men often experience, women often experience the following during a heart attack, according to the American Heart Association:

  • Uncomfortable pressure, squeezing, or fullness in the center of their chest
  • Pain or discomfort in one or both arms, the neck, jaw, back or stomach
  • Shortness of breath, either with or without chest discomfort
  • Breaking out in a cold sweat, nausea, or light-headedness

Any symptom above the waist, including the chest, arms, neck, jaw, and belly button area, or overwhelming weakness or fatigue, should send you to your doctor or local emergency department pronto, Bairey Merz says. Once you’re there, if you suspect you may have had a heart attack, don’t let a physician dismiss your symptoms as nothing to worry about just because your coronary arteries aren’t blocked, she adds.

“If a woman with no obstructive coronary artery disease has ischemic symptoms such as chest discomfort or shortness of breath that isn’t going away with rest, she should be evaluated for a heart attack,” says Janet Wei, MD, a cardiologist and assistant professor of medicine at the Barbra Streisand Women’s Heart Center at Cedars-Sinai.

The evaluation starts with an ECG and a troponin test, Dr. Wei says. Troponin is a protein that is released into the blood when the heart muscle has been damaged, such as during a heart attack.

If you’re told that you haven’t had a heart attack, but episodes of chest discomfort continue, you should be evaluated for coronary vascular dysfunction, Wei adds. This can be done with specialty tests such as a cardiac MRI or cardiac PET scan or coronary reactivity testing (an angiography procedure used to examine blood vessels in the heart and how they respond to different medications), all of which are available at top medical institutions.

The bottom line: “Women with symptoms of ischemia and no obstructive CAD are not as low risk as many physicians may think,” Wei says, “and they should seek further evaluation to determine the cause of their chest discomfort.”

Persistence is important for the sake of your heart and general health.

RELATED: Will the Right Tests Keep You From Having a Heart Attack?

by Carolyn Thomas ♥ @HeartSisters

Turns out that the kind of heart attack that I had (caused by a 95% blockage in the big left anterior descending coronary artery) – the so-called widowmaker heart attack – may actually be relatively uncommon in women. You might guess that fact by its nickname. It’s not, after all, called the “widower-maker”.

While cardiologists warn that heart disease can’t be divided into male and female forms, there are some surprising differences. Cardiologist Dr. Amir Lerman at the world famous Mayo Clinic in Rochester, Minnesota, told the Los Angeles Times recently:

“When it comes to acute heart attacks and sudden death from cardiac arrest, women have these kinds of events much more often without any obstructions in their coronary arteries.”

Instead, it appears that a significant portion of women suffer from another form of heart disease altogether. It affects not the superhighway coronary arteries but rather the smaller arteries, called microvessels. These tiny arteries deliver blood directly to the heart muscle.

Ironically, I can now boast two diagnoses for the price of one – first, the widowmaker heart attack caused by a fully occluded coronary artery back in 2008, and then, after several months of puzzling, ongoing cardiac symptoms – like chest pain, shortness of breath, and crushing fatigue – a second diagnosis of inoperable coronary microvascular disease.

In 2006, research published in the journal Circulation looked at the Women’s Ischemia Syndrome Evaluation (WISE) study data on almost 1,000 women referred for cardiac testing due to their symptoms(1). Here’s what they found:

  • 62% had non-obstructive coronary artery disease – defined as blockages less than 50% of the artery
  • 17% had one coronary artery vessel significantly blocked or narrowed
  • 11% had two vessels narrowed
  • fewer than 10% had three vessels affected

Dr. Noel Bairey Merz, a cardiologist at Cedars-Sinai Medical Center in Los Angeles, headed up the WISE study, which began in 1996. The average age of her participants was 58, but a quarter were younger and pre-menopausal.

Researchers found that what’s known as ischemic heart disease (any decreased blood flow and oxygen to the heart muscle) is often caused by a blockage within one or more coronary arteries that are feeding the heart muscle, but can also be due to at least two other possibilities:

  1. dysfunction of the smallest coronary microvascular arteries
  2. coronary spasm

1. Coronary Microvascular Disease

They used a test in which doctors first measured blood flow through the heart and then injected a drug that should have made the arteries dilate and increased the flow. If the flow did not rise, the patient most likely had microvascular disease.

One third of the women in the L.A. study had low blood flow to the heart muscle caused by coronary microvascular disease. For these women, the rate of deaths or heart attacks was higher than would be expected for other women with normal angiograms.

According to the Texas Heart Institute, coronary microvascular disease most likely happens when small blood vessels in the heart tighten or constrict. This tightening reduces the blood flow to the heart muscle and causes the pain of angina pectoris (a Latin phrase that means “strangling in the chest“).

The encouraging news at first: because these vessels are so tiny, early research suggested that they may not increase the risk of a heart attack or death. But the Journal of the American Medical Association reported in 2005 that the prognosis of patients with unstable angina and non-obstructive coronary artery disease is not benign and includes a 2% risk of death or heart attack at 30 days of follow-up(2). (JAMA. 2005;293(4):477-484. doi: 10.1001/jama.293.4.477)

Problematically, coronary microvascular arteries are too small to detect with the standard cardiac tests that cardiologists would normally use to see larger vessels, so women in particular are often dismissed and sent home with a misdiagnosis in spite of severe and distressing cardiac symptoms.

For example, in typical patients with coronary artery disease, coronary angiography – considered the ‘gold standard’ of cardiac diagnostics – usually shows a clearly blocked artery that slows blood flow to the heart muscle.

But in patients with coronary microvascular disease, these test results are normal – even though symptoms may be as debilitating as those experienced during a heart attack.

Dr. Noel Bairey Merz adds that angiograms that would clearly spot blockages in major heart arteries can miss coronary microvascular disease altogether. As a result, many women who have gone to their doctors with chest pain have gone home with a clean bill of heath – and most likely feeling very embarrassed for having made a fuss over nothing. She says:

“Historically, women have been told that it was in their head.”

According to the Harvard Heart Letter, the preferred diagnostic tool for correctly identifying coronary microvascular disease is coronary reactivity testing.

“Coronary reactivity testing is an angiogram-like test lasting 60 to 90 minutes; it allows doctors to see how very small vessels supplying the heart respond to different ‘challenges’ from medications. “

Texas Heart Institute experts tell us that up until recently, the only treatment for coronary microvascular disease (also sometimes known as Cardiac Syndrome X, a name that’s generally hated by those of us diagnosed with MVD because of its implication that this disorder somehow doesn’t exist!) has been with these medications:

  • Nitroglycerin (nitro) can widen or dilate the arteries and improve blood flow to your heart. Nitro can be given through a skin patch, pills, an ointment, or a spray. See more on nitroglycerin.
  • Beta blockers “block” the chemical or hormonal messages sent to your heart. When you are under physical or emotional stress, your body sends signals to your heart to work harder. Beta-blockers block the effect these signals have on your heart, so they reduce the demands on your heart.
  • Calcium channel blockers can help to keep your arteries open and reduce your blood pressure by relaxing the smooth muscle that surrounds the arteries in your body. The oxygen demand of the heart is also reduced by these medicines.

Physical exercise has also been shown to be helpful in managing MVD symptoms. A Swedish study reported in the Journal of the American College of Cardiology in 2000 suggested that being out-of-shape is a “prominent feature” in patients diagnosed with MVD. Researchers found that a 30-minute workout on an exercise bike three times a week resulted in increased exercise capacity with lesser chest pain for the MVD patients they studied.

As more physicians become educated about the widespread incidence of coronary microvascular disease, particularly in women patients, more treatments are becoming available, including my own particular current treatment for microvascular disease: wearing a portable TENS machine all day long to help increase blood flow to the heart muscle and thus reduce chest pain symptoms. Read more on this underused, non-drug, non-invasive cardiac treatment in “My Love-Hate Relationship With My Little Black Box”.

And emerging research has shown significant success using TENS neuromodulation to treat the chest pain of angina. In fact, the U.K. National Refractory Angina Group now recommends TENS therapy for the debilitating chest pain of angina:

“Neuromodulation owes its origins to Melzack and Wall’s gate theory of pain that predicted that stimulation of vibratory afferent nerves would reduce or gate the transmission of pain traffic relaying through the spinal cord at the same point.

“Transcutaneous electrical nerve stimulation (TENS) was specifically designed to make use of this predicted effect and was used to treat a variety of pain conditions before it was shown to be effective in angina.

“TENS neuromodulation should be offered as part of a multidisciplinary angina management programme based on the current guidelines.“

2. Coronary Spasm Disorders

Another example of non-obstructive heart disease often seen in women is called Prinzmetal’s Variant Angina, chest pain caused by a spasm of a coronary artery. While Prinzmetal’s is not thought to cause a heart attack, chances of a cardiac event are higher in those with underlying heart conditions.

We don’t yet know exactly what causes coronary spasms like Prinzmetal’s.

One theory lies within the thin lining of the blood vessels called the endothelium. Usually this artery lining produces a chemical (nitric oxide) that helps to widen the blood vessel, allowing blood to flow through with ease.

But if the artery lining is damaged or isn’t working properly, the blood vessel may narrow and cause a coronary spasm. Levels of the artery-widening chemical are higher when estrogen levels are also high at certain stages of the menstrual cycle. A 2001 study published in the journal, Annals of Internal Medicine, suggested that during times when estrogen levels are high, women have fewer chest pain symptoms(3). In addition, smokers tend to have lower levels of nitric oxide in their blood vessels than non-smokers, and smoking is a major risk factor for coronary spasm.

Symptoms of angina can also occur in the absence of any coronary artery disease. Up to 30% of people with a heart valve problem called aortic stenosis, which can cause decreased blood flow to the coronary arteries from the heart, can have angina. People with severe anemia may have angina because their blood doesn’t carry enough oxygen. People with thickened heart muscles need more oxygen and can have angina when they don’t get enough.

We do know that cardiovascular disease kills more women than any other cause, about six times more women each year than breast cancer does, and in fact, more than all forms of cancer combined. Each year since 1984, more women than men have died of cardiovascular disease. Men tend to develop heart disease on average 10 years earlier than women do.

Anatomically, male and female hearts look about the same. When healthy, both should be about the size of a fist (a man’s heart is the size of a man’s fist, and a woman’s heart is smaller because it’s about the size of a woman’s fist). If you’re a woman, yours weighs about the same as a green pepper and, also like a green pepper, has hollow chambers inside.

Both men and women have three main coronary arteries surrounding their hearts. These are the large blood vessels that wrap around the outside of the heart, supplying blood, oxygen and nutrients to heart muscle to keep each heart pumping properly – and thus the arteries most susceptible to life-threatening cardiac events through obstructive – or non-obstructive – heart conditions.

But women who have a heart attack fare worse right after the event and also suffer a poorer quality of life.

Learn more about coronary microvascular disease:

  • in this LA Times feature
  • on this 22-minute video about identifying hard-to-catch diagnoses in female patients via medical imaging called Diagnosing Cardiovascular Disease in Women with cardiologists Drs. Redberg, Shaw and Bateman
  • in this 5-minute video about my heart sister Joan Jahnke of South Carolina, who went to Emory Heart & Vascular Center to have her coronary microvascular disease appropriately diagnosed and treated
  • on these websites from Mayo Clinic and the Texas Heart Institute .

NOTE from CAROLYN: Please do NOT leave a comment here describing your current symptoms. I’m not a physician and cannot diagnose you online (nor can anybody else). If you are experiencing distressing symptoms, seek a medical opinion from your physician.

See also:

  • Misdiagnosed: Women’s Coronary Microvascular and Spasm Pain
  • No Blockages: Living with Non-Obstructive Heart Disease
  • “I Rang the Bell Again. No One Came.”
  • Coronary Microvascular Disease: a “trash basket diagnosis”?
  • His and Hers Heart Attacks
  • When Your Artery Tears: Spontaneous Coronary Artery Dissection
  • The New Country Called Heart Disease
1. Shaw L, “The Economic Burden of Angina in Women With Suspected Ischemic Heart Disease”. Circulation. 2006;114:894-904.
2. Bugiardini R, Bairey Merz CN. “Angina with ‘normal’ coronary arteries: a changing philosophy”. JAMA. 2005;293(4):477-484.
3. Kawano H, Motoyama T, Ohgushi M, Kugiyama K, Ogawa H, Yasue H. “Menstrual Cyclic Variation of Myocardial Ischemia in Premenopausal Women with Variant Angina”. Ann Intern Med. 2001;135(11):977-981.

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