Unique Aspects in Women's Heart Health

Talking with Malissa J. Wood, MD, FACC

Managing editor Rebecca Kapur talks with Malissa J. Wood, MD, FACC, about the current state of women's heart health care and her American Heart Association Scientific Sessions presentation on identifying and treating acute coronary syndromes in women (transcript available below video).

The transcript below has been lightly edited for clarity.

I’m Melissa Wood and I'm the co-director of the Corrigan Women's Heart Health Program at Massachusetts General Hospital. I'm also the chair of the Board of Governors of the American College of Cardiology.

Can you tell us about the Corrigan Women's Heart Health program?

Dr. Wood: Corrigan Women's Heart Health Program was launched in 2007, and it was really designed to be a source of education, clinical care, and a nidus for research for all things related to cardiovascular disease in women. And our program has really grown over the years and now we have a number of separate subprograms, including the fact that we are part of the cardiovascular disease and pregnancy service. We have a team that is devoted to caring for patients with SCAD, or spontaneous coronary artery dissection. We have a menopause program, and we are in the process of actually launching cardiovascular care for non-binary and transgender individuals clinic as well. It has really been wonderful to see our program grow over time and see individuals with different expertise and research training join our program so that we can continue to evolve the area of cardiovascular disease and look at sex differences in cardiovascular disease.

Has research into women's heart health become a more central focus in cardiology?

Dr. Wood: I certainly would say that 10 years ago in the larger cardiovascular space I think we did exist in a vacuum and when we would give presentations we were preaching to the converted. The people that would attend and participate largely were individuals who were already interested in and already doing this kind of work. But I think we have really been so fortunate because there has been such an emphasis on health equity and addressing disparities in care over the past five to eight years that the area of cardiovascular disease in women has really reached the forefront.

Being part of the Cardiovascular Disease in Women Committee with the American College of Cardiology (ACC) as well as part of the American Heart Association’s (AHA’s) different committees, currently there has been a lot of attention focused on this area at our national meetings so that we really try to incorporate data pertaining to sex differences in presentations when they're given. There has been much more emphasis in getting equal distribution of men and women on the podiums so that really we don't get the perception that there is some inequality in the way that we're looking at data or presenting the data. Do I think it's ideal and perfect yet? No, but I think the ground that we have covered in the past decade has really been phenomenal and I'm excited to see that shifting.

We now recognize that the studies that were done, the data that was collected, and the guidelines that were written early on didn't necessarily have relevance or were not highly predictive of outcomes in women, and now that we are really pushing to incorporate more women into clinical studies and to have more women leading clinical studies. We are beginning to see emergence of new data sets that are very, very valuable.

At the American Heart Association Scientific Sessions, you spoke on managing acute coronary syndromes (ACS) in women, and why and when a unique approach is required. What did you discuss?

Dr. Wood: What I talked about was a few things. The first was the different pathophysiology of acute coronary syndromes in women. Women are much more likely, when they have an acute coronary syndrome, than men to be found to have normal coronaries or non obstructive coronary disease. And I think years ago when I was training, if a woman presented with chest pain — I mean, this was before we had high sensitivity troponins — she might not have been found to have had myocardial infarction. But when women had chest pain and a coronary angiogram did not reveal obstructive disease it was thought that she either had a very rare case of myocarditis or in fact that her symptoms were not due to coronary ischemia. We have learned so much over the past years that we now recognize that just because the arteries are open doesn't mean that there isn't ischemia.

I talked about the differences between plaque erosion and plaque rupture, and talked about the importance of thinking about conditions such as MINOCA, which is myocardial infarction and non obstructive coronary disease. I reviewed the evaluation of patients that have MINOCA. Those patients are much more likely to be female than male. That evaluation of course includes a coronary assessment, but if the coronaries look to be normal, then intracoronary imaging with either intravascular ultrasound or optical coherence tomography, OCT, can demonstrate things like plaque disruption. And then, certainly, incorporating other tests like echocardiograms and MRI to look for areas of involvement that would suggest unique coronary pathology.

And then I also talked about other reasons that women are more likely to have ACS than men, including takotsubo or stress cardiomyopathy, or SCAD, spontaneous coronary artery dissection, which is much more common in women than men.

And then, finally, I talked about pregnancy-associated myocardial infarction, because as we know, there has been a great deal of emphasis over the past couple years on the increasing maternal mortality in the United States, and particularly mortality in black women. We know that part of the reason for that mortality is related. The largest cause probably is a cardiac event, whether that's heart failure or acute coronary syndromes. I think it's important to develop an approach to managing coronary syndromes in women who are either pregnant or who have just had a baby, and to really develop comfort in evaluating pregnant women or postpartum women, and then really understanding the best ways to identify coronary disease and treat it appropriately in the peripartum patient.

Can you talk more about how MINOCA patients are identified and treated?

Dr. Wood: There are two kinds of conditions. There's MINOCA, which is a myocardial infarction and non obstructive disease, and so those patients come to the cath lab or come to medical attention because they meet criteria for a myocardial infarction. That means that they've had cardiac symptoms which usually would be chest pain, and they either have electrocardiographic abnormalities and/or evidence of a troponin elevation and some type of a cardiac symptom. By definition, they have met the criteria for myocardial infarction, thus leading to the coronary angiogram. And if the coronary angiogram does not reveal evidence of local or significant obstruction with a greater than 50% lesion in a coronary, then they are found to have what's called MINOCA, non obstructive coronary disease in the setting of an MI.

There is also a subset of different patients called INOCA, which is ischemia and non-obstructive coronary disease. Those are patients that have symptoms of chest discomfort and evidence of ischemia perhaps on a stress test, but not a myocardial infarction.

We certainly don't recommend stress testing patients who've just had a heart attack. In those patients who have had a heart attack, we really want to do more specific imaging to try to identify the reason for their troponin elevation. And that's where we do things like intracoronary imaging and complementary imaging such as MRI, CT, or echocardiogram, to look for localized areas of decreased blood flow to the heart muscle.

These patients do tend to be overwhelmingly female?

Dr. Wood: They do. I reviewed some of the data from a number of different studies and it looks like in general, in most studies of patients with heart attacks, women are about 80% to 85% obstructive disease and 10% to 15% MINOCA. Men have less, maybe 5% to 7% of men with an MI will have MINOCA, so about twice as many women as men in most of the big studies have MINOCA. Men can still have it, but it is less common.

Does working with pregnant and postpartum patients involve a lot of collaboration?

Dr. Wood: It does, and that's really the beauty of cardio obstetrics or the multidisciplinary team. What's amazing is for years our MFM, our maternal fetal medicine colleagues, have really been doing this on their own. Really only when the patient had an extreme situation did a cardiologist get involved and bring them to the cath lab. But now, because there has been so much interest and enthusiasm in this area, most large centers have collaborative, multidisciplinary programs that incorporate high risk OB or maternal fetal medicine, cardio obstetrics specialists, cardiologists with interest in obstetrics, anesthesia colleagues, interventional colleagues, and rarely our surgical colleagues are involved when these patients need things like extracorporeal membrane oxygenation (ECMO), valve surgery, or rarely, heart transplantation.

Any final message?

Dr. Wood: The only thing that I would say is that it's very important for cardiologists to recognize that in this era of concern about maternal health, we all must understand the risks when we counsel patients who have underlying heart disease who want to become pregnant, that there are conditions. There are risk-stratifying algorithms that we can use, like the World Health Organization Risk Stratification. There's the ZAHARA risk stratification algorithm. These types of algorithms are very helpful so that we can counsel patients before they become pregnant. The CARPREG II is very helpful.

These are so important, because we don't, especially in this day of concerns about reproductive health and in the post Dobbs era, we don't want to have to make difficult decisions when a mom's life is in jeopardy. It's much better to be proactive, and assessing risk and counseling women about safe forms of contraception if they do have conditions that would be putting them at prohibitive risk of subsequent pregnancy. It is so important for us to share with our young women who have heart disease that they need to be seen and evaluated before they become pregnant, so that we can offer them the healthiest approach to pregnancy, should it be something that we feel is safe for them to undertake.