CHEST PAIN WITH EXERCISE IN WOMEN:

IS IT HEART DISEASE?

If you’re a woman and you have chest pain when you exert yourself, does that mean you have heart disease? A new study makes the possibility more likely.

For years, doctors have understood the relationship between chest pain and heart disease. Blocked coronary arteries in the heart cause insufficient blood flow to the heart muscle, especially when the heart is pumping fast and needs more oxygen. So the poorly oxygenated heart complains by sending pain signals to the brain.

So back to our question: Does chest pain with exertion spell heart disease? Not necessarily. Many diseases can cause chest discomfort with exertion, including arthritis, stomach ulcers and blood clots in the lungs. To discern whether the pain is caused by heart disease, physicians have typically ordered tests to check for coronary blockages. The assumption has been that the no identifiable blockage means no heart disease.

Recent research suggests, however, that  this model is oversimplified, especially when applied to women.  The Woman’s Ischemia Evaluation Study (WISE), under the direction of Dr. Noel Bairey Merz at Cedars-Sinai Medical Center in L.A., has found that although some women have traditional, identifiable blockages that can be treated with stents or cardiac surgery, as many as 50 percent have no detectable disease. Yet when under exertion or stress, for some reason these women cannot deliver enough blood to their heart and thus have chest pain. 

Researchers aren’t completely sure why that is, but think that maybe a uniform, “smooth” deposition of cholesterol—one that’s hard to see on imaging studies—may be to blame. Another possibility is abnormal small blood vessels that are unable to dilate sufficiently to accommodate the extra blood flow needed with exertion.

In the past, women without detectable blockages have been assumed to have non-cardiac chest pain and have often remained untreated. They have been left to suffer with the symptoms, referred to other specialists and sometimes even sent for psychiatric testing.  With our new understanding from the WISE study, these patients can now be effectively treated with medications often used in patients with traditional coronary artery disease, such as beta blockers, statins and nitroglycerin.  These medications help increase blood flow and reduce exertional pain.

The WISE study has taught us that heart disease may not be as simple as “blockage” or “no blockage,” and it infers that men and women may have fundamental differences (who could have guessed?) in how they handle fat and cholesterol.  The WISE study is probably the tip of the iceberg in medical research as we learn that genetic factors such as gender and ethnic background need to be considered and therapy should be tailored to the individual.