Listening to the heart of a woman reveals new data

Credit: Steve Fisch Photography

Jennifer Tremmel, MD, is the director of Women's Heart Health at Stanford, a new cardiovascular clinic.

Months after joining an exercise group, Valerie Garcia would stay red in the face, gasping for air, feeling like she was going to pass out, while the rest of her classmates jogged by. No matter how hard or how often she exercised, she was incapable of building any endurance.

'I was sure it wasn't my heart but nothing else was helping,' said Garcia, who is 48. Her asthma doctor gave up on a diagnosis and referred her to the new women's cardiovascular clinic, Women's Heart Health at Stanford Hospital & Clinics.

She underwent stress testing and was found to have a possible narrowing in a heart artery, so she had an angiogram. That showed nothing. But after additional specialized testing, which examines the function of the heart vessels, Garcia was diagnosed with 'marked endothelial dysfunction,' a form of heart disease that often goes undetected and undiagnosed in women.

It utterly caught Garcia off guard. She had never even considered heart disease.

'I could have easily been dismissed, but they're specifically interested in women,' said Garcia about her treatment at the women's clinic. 'You can feel it.'

Diagnosing and treating women who might otherwise slide under the radar screen is the goal of Stanford's quickly growing Women's Heart Health Clinic, which opened less than a year ago, said clinic director Jennifer Tremmel, MD, who is also an instructor of cardiovascular medicine at the School of Medicine. The specialized clinic operates one day a week at Stanford Hospital and twice a month at a clinic in Monterey, and has about 150 patients.

As part of a growing trend across the nation to set up cardiology programs for women, the new clinic is designed to reach out to those who for a variety of reasons - less aggressive care, differing risk factors, gaps in research - are getting missed. The clinic is also part of the Stanford Cardiovascular Institute's overarching goal to address issues of women's heart health through patient care, education and research in the areas where huge gaps in knowledge remain.

'We can find out what's wrong with these patients,' Tremmel said. In addition to treating women, she is conducting an American Heart Association-funded study on sex differences in cardiovascular disease. 'We can diagnose them, we can treat them. Most physicians are going to stop early. We keep going.'

While women are generally more likely to worry about breast cancer, the reality is that cardiovascular disease kills almost twice as many American women as all cancers put together. It's the largest single cause of mortality among women, accounting for 38 percent of all deaths among females, according to the American Heart Association.

Credit: Steve Fisch Photography

Jennifer Tremmel (right) and Mary Nejedly, a nurse practitioner, look over test results from patients at the new women's heart health clinic.

And yet, consistently, heart disease in women is misdiagnosed and under- treated.

Most disturbing, women have not had the decrease in death rates from heart disease that men have continued to experience over the past few decades. More women than men have died of cardiovascular disease in every year since 1984. Exactly why this is happening remains unclear.

'The sex gap in cardiovascular disease hit its peak in 1999 and is finally getting some attention,' Tremmel said.

Traditionally, men have garnered more attention than women when it comes to evaluating cardiovascular disease. The growth in women's heart centers is an attempt to target this apparent inequity of care, said Sharonne Hayes, MD, director of the Women's Heart Clinic at the Mayo Clinic in Minnesota and member of the advisory board of WomenHeart: the National Coalition for Women with Heart Disease.

'There are still marked disparities in care,' Hayes said. 'Women are less likely to be prescribed medication or be as intensely treated as men. Women also don't feel like they are being listened to when they discuss their symptoms with their doctors.

'Our patients tell us they have often felt dismissed or not listened to or blown off, even if they have great care,' Hayes said. 'Nobody ever sat down and adequately addressed their concerns.'

This is where a clinic specifically targeting women can step in and help, Tremmel said. As an expert on women's heart health, she keeps up to date on research, and after treating so many women in a large group, she's more attuned to their different needs.

'It's amazing how similar all these women are when you get them together in one clinic,' Tremmel said.

For example, while women and men suffer many of the same symptoms of heart disease, such as chest pain or shortness of breath, women tend to complain of additional symptoms. They may experience back, neck or arm pain as well, and they often report getting their symptoms when under emotional stress.

'When women come in and list off several symptoms, it's confusing to know what's wrong with them,' Tremmel said. 'In the past we called them atypical, but I see so many women with these symptoms, they're now typical to me.'

Women historically haven't been included in scientific studies to the extent that men have. But there has been a push within the past decade to conduct more research on women's cardiovascular disease, such as the National Institutes of Health-sponsored study called the Women's Ischemia Syndrome Evaluation. That study found that just because a woman's arteries appear clear on routine tests like an angiogram, it doesn't mean she has normal coronary arteries.

Additional testing that evaluates for microvascular disease, diffuse non-obstructive plaque or endothelial dysfunction may be revealing.

'The WISE study has been pivotal in shaping my research career,' Tremmel said. 'Up to 20 percent of patients with symptoms are found to have normal-appearing arteries in the cath lab. We tell them that they are fine, but they continue to have symptoms and we have no good explanation. It's extremely frustrating for doctors and patients.'

Tremmel is conducting a study that will expand on the WISE results, comparing rates of microvascular disease and endothelial dysfunction in men and women.

But for now, she's finding that additional vascular function testing, such as the endothelial dysfunction test that uncovered Garcia's disorder, have successfully pinpointed heart disease problems in previously undiagnosed female patients.

'We're finding it just doesn't work to treat women like men using data derived from men,' Tremmel said. 'There's enough data out there that we can start treating women like women and hopefully it will lead to an improvement in outcomes and a reduction in the gender gap.'

Garcia's endothelial dysfunction test involved administering a medication into her coronary artery at the time of her catheterization, which is a technique used to insert a catheter into the arteries. The test found that the lining of the artery was actually causing the artery to constrict during times of exercise when it should be dilating.

Garcia is 48, younger than the average female heart patient, who is usually in her 60s or older. She's thin, exercises regularly and has low blood pressure. But a smoking habit that she quit 18 years ago could have been the cause of her problems which, if left untreated, could lead to a serious heart condition.

'She didn't have a lot of risk factors,' Tremmel said. 'The routine test didn't show anything. She had normal appearing arteries. What we did that's different from the routine was the vascular function tests.'

Since her diagnosis and treatment with oral medication, a long-acting nitrate, Garcia has increased her jogging distance from half a mile to 2 miles without feeling like she's going to faint.

'They were grilling me, 'Do you have chest pain? Do you get light-headed?''

She added, 'They really listened to me.'