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Coronary Microvascular Disease (transcript)
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(Dr. Peter Salgo) 
Welcome to Second Opinion where each week we solve a real medical mystery.  When we close this file a half an hour from now you'll not only know the outcome of this week's case but you'll be better able to take charge of your own healthcare.  And doctors will be able to listen to patients more effectively.  I'm your host, Dr. Peter Salgo, and you've already met our special guests who are joining our primary care physician, Dr. Lou Papa.  Hi Lou.

(Dr. Lou Papa) 
Hi, Peter.  How are you doing?

(Peter) 
No one on this team has seen the case and we're going to get right to work.  Lou, we're going to tell you and everyone else on the panel about Jane.  Jane is a nurse.  Jane is fifty-four years old and she's in seeing her primary care physician, Lou.

(Lou) 
Great.

(Peter) 
She's scheduled the visit because she's been having some episodes of what she called as mild chest discomfort.  That's what written in the chart.  Now you need to know a little bit more I'm sure.  She was diagnosed sometime ago with reflux disease but this pain, she says, feels different.  And she can't really say what brings it on.  Now Lou what are you thinking here?  For anyone with chronic reflux, isn't chest discomfort pretty common?

(Lou) 
It is but its always concerning when someone says it's different.  Usually it's fairly reproducible in patients that have reflux disease.  So she doesn't see any real pattern to it all. 

(Peter) 
According to the chart, she doesn't know what brings it on but the one thing she does say is it feels different.  So Lou, you want to know any more about her?

(Lou) 
Absolutely.

(Dr. Peter Salgo) 
Why am I not surprised.  I'll give you some more information.  At fifty-four she is menopausal and in addition to her reflux she suffered from asthma her entire life.  And what else would you like to know?

(Lou) 
I'd like to know if she's on any medications.

(Peter) 
Yeah. She's on an ARB for hypertension.  A thiazide diuretic, she's on a Statin, mini aspirin, folic acid, flax seed oil, magnesium.  It's a list.  Her blood pressure in the office, you should know, is 130 over 85.  Her total cholesterol is 120.  Now she weighs 179 pounds and she's 5'4".  She gives you a family history of breast cancer.  She's had aspiration of cysts in her right breast, which were seen on mammography but so far those aspirations have been negative for cancer.  And she's a former smoker.  She stopped eight years ago and her doctor has recently established that she's had the diagnosis of metabolic syndrome.  And she is taking Metformin.  Somebody listening to this is saying, but wait.  I didn't hear some of these things that I've been told about forever.  She doesn't have shooting pain down her left arm.  There's no squeezing sensation in her chest.  She's just talking about this vague discomfort.

(Dr. Noel Bairey Merz) 
That we know from the Framingham Heart Study, which was done in women fifty years ago that where these risk factors are cumulative and they're actually exponential and she has at least three that I can count up, maybe four or five if we had better information.  So she is starting to have an exponentially high risk of having coronary artery disease or plaque in her coronary arteries that could cause a heart attack or even death.

(Dr. Burg) 
Well I'd be curious about when she experiencing this chest discomfort.  In other aspects of her lifestyle, you mentioned that she's a nurse.  What kind of shift is she working?  Where in the hospital is she working?  How stressful is her job?

(Peter) 
Well I can tell you we're going to get to this later because she didn't tell her primary care physician at this time.  At this point, why don't you just say or could you just say, why don't we see if it's just your reflux?  Give her some antacids and send her home. 

(Lou) 
Because she may not come back.  Either because she doesn't want to come back because she's concerned about or she could die from it. So the big issue is, I want to address that because this maybe a window of opportunity.

(Dr. Gladys Velarde) 
I think they key is what you said earlier is that it's different.

(Peter) 
Yeah.

(Gladys) 
She's had these, you know, history of GERD and asthma, its part of her.  It's different.  I think the symptoms have different. 

(Kathy Kaston) 
And she's being an advocate for herself by telling you that she can tell this is different in a lot of woman just have different.

(Gladys) 
How different.  Why is it different?

(Peter) 
You know one thing that you have not mentioned and it has to do with a pronoun you've all been using, it's she.  I mean she is female.  She is a woman.  How does that factor into all of this?  Is it different?  What we do for a woman than for a man?   Are the symptoms different? 

(Kim Kachmann-Geltz) 
Well I think when we think of chest pain and angina we think of the classic man holding his chest with his briefcase in his other hand.  And that's not at all what I experienced when I had experienced angina in my life.

(Peter) 
So you've had angina? 

(Kim Kachmann-Geltz) 
I've had. And it definitely presents as, what she would say, differently.  It doesn't.  It didn't shoot down my left arm.  It didn't shoot up into my jaw all the time.  Sometimes it just felt like discomfort.

(Peter) 
Jane is a nurse.  They put her on nights.  She's been working a lot of overtime.  What is it about stress?

(Dr. Burg) 
We've been doing research now for a number of years looking at how stress affects people with coronary disease; it might actually contribute to the development of coronary disease.  I think what we do know pretty clearly at this point is that certain emotions do seem to contribute to the expression of disease, anger particularly being one of them.  Anxiety being another and depression in a more long term way can affect the development of disease and outcomes with disease.  What we find is that with anger we see an almost immediate affect in a patient.  Patient's sitting there in our laboratory who's going through our protocol.  We have them just talk about something that just happened in the past that made them angry and we see all kinds of changes in terms of their heart rhythm and in terms of the blood flow to the heart.

(Dr. Peter Salgo) 
For the moment, Jane is still in her primary care physician's office because the primary care physician is being careful.  He must have heard what you said, Lou, because here in the chart he writes that its time for a good physical exam, which he does.  He also got an x-ray done that was unremarkable. 

(Dr. Lou Papa) 
Okay.

(Peter) 
That same day.  And he gave her a cardiogram and it showed no change from her baseline.  Now the baseline shows borderline criteria of LVH.  Is that a shocking development?  And it's unchanged?  Does it worry you?

(Noel) 
It's not shocking but it gives her one more risk factor in the Framingham score.  And in particular left ventricular hypertrophy is associated with more of the adverse outcomes being set in cardiac death.  So it makes me very worried to evaluate her quickly.

(Peter) 
She's still in her primary care physician's office, and I'd like to tell you what her doctor does.  He's concerned.  He'd like to get some more studies, Lou, so he does.  He sends out some blood work, a lipid profile, sends her for a mammogram because she is concerned that some of this pain may be breast pain.  It's so vague she's having trouble differentiating.

(Lou) 
But there was nothing on her examination?

(Peter) 
No.  He sends her home from the office with instructions to double her proton pump inhibitor, which is her anti-reflux drug and to come back.  Is it reasonable to have done that?  I mean you're going to see an awful lot of patients in your practice, right, who are just having?

(Noel) 
You know we have to get over this.  Heart disease is the leading killer of woman.  Period.  Always has been and more woman now every year died than men of heart disease.

(Peter) 
Can you say that again.  I think that's a very important statement.

(Noel) 
Heart disease is the leading killer of women.  Always has been, we just haven't paid attention to it.  And now since 1984 more women in the U.S. die of heart disease than men.  When we don't do appropriate screening or diagnostic tests that's when patients die. 

(Peter) 
Kim, you've been in this situation.  You've been on the other side of the desk.  When you had these complaints what happened to you?  Or was your situation different?

(Kim) 
I was sent home with an antacid.  My doctor said that if you're cardiologist isn't concerned about your symptoms then neither am I.  And I was about six months pregnant at the time, so it was OB/GYN who was talking.  And the chest pain that I described was getting only worse, it wasn't getting any better.  And I was still treated as if it was not significant.

(Peter) 
How did that make you feel?

(Kim) 
Well at that point I began to wonder if it was all in my head.  I really did. 

(Kathy Kastan) 
And I can talk about some story because it happened to me as well. I was misdiagnosed and had delayed diagnosis and ended up in emergency bypass surgery at forty-two years old.  And they looked at me as an athlete, a non-smoker, somebody who didn't have high cholesterol.  So they basically poo-poo'd me and said you know its probably just pectoral from all the exercising you do.  You'll be fine.

(Dr. Peter Salgo) 
Is it unusual for women to be treated this way?

(Noel) 
Sadly it's not unusual and it's why it needs to change.  And culture, you know there's societal, cultures and perceptions and also the way that physicians have been trained, really need to look at both the old data as well as the new data because indeed Framingham did demonstrate that these risk factors are relevant to women.  At the time Framingham was really focusing on, you know who died first.  And because men won that race we really ended up focusing on men.

(Peter) 
Well let me tell you what happened because I can tell you what
happened over here.  She did go home.  She did double her antacid or her anti-acid medication and two weeks later she came back for her scheduled return visit.  Her primary care did schedule her to come back, didn't lose her to follow.  And Lou, to answer your question, she survived to come back.  But she said I'm still in pain.  At that point, the lab results were all normal or at least unchanged from her previous lab results.  The mammogram was unchanged as well.  So here she is, she's back in the office having, if not more pain certainly just as much chest pain.  Again saying it feels different than what she's used to.  What do you do now?

(Lou) 
She is at high risk.  This is different pain.  Lacking any additional history with this nondescript chest pain, I'd still be concerned about coronary artery disease.

(Gladys) 
I would do a stress this, given the fact that she doesn't have a normal ECG and she has all these risk factors I will give her an imaging test, a stress test.  That is you throw her on the treadmill, you challenge her heart rate.  You give her a stress.  Not a mental stress but a physical stress.  And then you image the blood flow or the function of the heart by echo or a nuclear study.

(Peter) 
Would you like to know what Jane's doctor did?

(Lou) 
Sure.

(Peter) 
I'll tell you.  Sent her for a stress echo.  He must have listened to Dr. Velarde.  And would you like to vote on what this stress echo is going to show?  Does anybody here think its going to be normal?  Does anybody here think its going to be abnormal? 

(Noel) 
It will be abnormal in the ways that women are typically abnormal and it has been ignored in the past. And it will be normal in the ways that the male pattern of ischemic heart disease are normal.  So it will probably be dismissed and the abnormal parts will be ignored.

(Peter) 
Gladys

(Gladys) 
I think that's exactly what worries me. I want to know if she had reproducible symptoms on this study.

(Peter) 
Oh you want to know.  On the report from the study?

(Dr. Gladys Velarde) 
She has.  Yeah.  Yeah.

(Peter) 
I can tell you Jane demonstrates low exercise tolerance.  That's one for the good guys.  She had to stop due to shortness of breath at four minutes, ten seconds.  Her heart rate was 168.  She had some chest heaviness during the test.  No more though than one millimeter depressions on her cardiogram, on the ST segments.  So her ST's.  But the rest of it. Gladys is that significant to you or do you throw this test away.  It's normal.

(Gladys) 
It's very concerning.  Her functional capacity is very low.  She had symptoms.  That's very concerning too.  It's an exertional manifestation.  Woman that present with angina have the worst outcome. 

(Dr. Peter Salgo) 
On the basis of this does she have heart disease or not?

(Dr. Noel Bairey Merz) 
Well she is.  She has a limited cardiovascular reserve.  And that's what that functional capacity is.  And too many times this is dismissed as a nothing.  It is our most strongest predictor of death.  If you can't go your age predicted values, so it shouldn't be ignored and it's particularly potent in women. 

(Peter) 
Kim you were on the other side of this too.  Did you get sent for a stress test eventually or no?

(Kim) 
I did.  I had a stress test and a nuclear test. So it was the imaging of the heart with the stress test.

(Gladys) 
You were pregnant.

(Peter) 
They gave you a nuclear test while you were pregnant?

(Gladys) 
You were pregnant.

(Kim) 
No this was afterward.  This was when I sought a second opinion. 

(Peter) 
How is Jane feeling right now?

(Kim) 
Scared.  I remember sitting in the wheelchair after the test in the hospital and seeing an eighty or ninety year old gentlemen passed me and he had sutures down his chest, so he had just had open heart surgery.  And I remember just crying my eyes out at that point, thinking wow this is real.  This is real.  This is not all in my head and I doubted myself for all those months.  I was terrified. 

(Peter) 
Noel, I know you alluded to this.  But you are.  You've been leading a study, which is looking at the different ways in which heart disease presents comparing men to women.  What do we know about that at this juncture? 

(Noel) 
National Heart, Lung, and Blood actually commissioned a big study that I chair called the WISE, Women's Ischemia Syndrome Evaluation.  And we are now in our thirteenth year and we have identified that the majority of patients with cardiac syndrome acts have Microvascular Dysfunction.  It is not a big artery problem so we don't see it on the imaging test.  It's a small artery problem.  And most importantly that it is associated with an adverse prognosis meaning cardiac death, heart attack, stroke, and development of heart failure. 

(Peter) 
But isn't the point of the WISE study and what you're beginning to see that women lay down debris in their arteries differently than men do and to some degree this may explain the way they present differently.  Is that fair?

(Kim) 
Female pattern heart disease. 

(Noel) 
Correct.  So we've described in the WISE and this is research that's ongoing.  That men and women put the fat in their arteries in some way similar to how women and men get fat in their bodies.  So if we think about how the average man gets fat we think of the beer belly because its all kind of in one place.  Skinny little ankles, you know, biceps look good.  If we think about how women.

(Dr. Peter Salgo) 
What a lovely picture you've painted of men.

(Lou) 
It's like.  I don't know. 

(Peter) 
Thank you so much. 

(Noel) 
Well it's called.  It's focal fat and women get kind of fat all over.  Right.  We get fat.  Everything. 

(Kim) 
Right.  Spread it out. 

(Noel) 
So in the arteries it seems to be a somewhat similar pattern and women are very good at putting the fat in the walls of the arteries and really keeping it hidden and there's no bulges or there are fewer bulges.  The fewer beer bellies. 

(Peter) 
So if you will, the men get the chunky peanut butter to spread and the women get the creamy peanut butter to spread all the way down.  And both of them get fat?

(Noel) 
There you go.

(Peter) 
Is that fair?

(Dr. Noel Bairey Merz) 
We all get fat.  We all get fat.

(Lou) 
I think I'll have a salad for lunch.

(Peter) 
When it comes to heart disease, not only are the symptoms sometimes different between men and women but I think its fair to say based on what we're seeing, the disease itself maybe different, which explains why the symptoms are different.  Jane is back in her PCP's office after having this stress echo.  And her doctor says he's got good news.  He says the lab work, the mammogram, the cardiogram, better be prepared to come of your seats here, I guess, the stress echo were all unremarkable.  That's what he tells her.  Does the PCP have it right?  Should I duck now or later?

(Dr. Lou Papa) 
Its semantics.  Unremarkable is probably okay but it wasn't normal.  You know, in my mind if I had somebody who was, who had undergone a provocative test like that and it didn't come back stone cold normal.  And.  And they had reproducible symptoms on it, I wouldn't just get the report from the cardio that says this is all right.  I'd be on the phone saying wait a minute, this lady's had symptoms on the phone. 

(Peter) 
Does anybody here think that Jane's going to be satisfied and stop at this point?

(Kim) 
Well I think she.  I think she's probably confused.  I think, you know, you still trust your physician, even though she's a nurse and she's trained in the healthcare field.  She's probably questioning.

(Dr. Peter Salgo) 
She simply expresses her displeasure to her primary care physician and says.

(Lou) 
Good for her.

(Peter) 
And says no I'm not relieved by your good news here.  I still say something is wrong.  I want more testing.  Her primary care doc calls up a cardiologist.  I don't know if it's the same cardiologist, as did the stress test, and says what do we do now?  And the cardiologist says let's do a cath.  But that was normal.  She had an absolutely normal cath.  There was no more than 20% narrowing in any of her coronary arteries.  So he said, provocatively, Jane should finally be feeling confident. She can rule out heart disease, right? 

(Noel) 
So you already said it and this is another misnomer.  So the cath was normal.  There was no more than a 20% blockage in any of the arteries.  It is not normal to have plaque, to have a 20% blockage. And this is another thing that the women and heart disease piece has helped us identify.

(Peter) 
Well Jane decided she wasn't happy.  She didn't like this all hypochondriac business and decided to seek more studies on her own.  She called a private cardiology clinic, took some money out of her pocket, because her insurance company did not pay.  And she had a dychoperinimal cardiac pet scan.  Now there's a mouth full for you.  First of all, what is it?  And again, is it going to help or should she just take a chill pill and take some cardiac meds and go home?

(Noel) 
So we have three ways right now of assessing what we call coronary flow reserve, which is what you can measure that the small arteries, you know, call out and would be your measure of Microvascular Disease.  A dippy, a PET.

(Peter) 
Excuse me.

(Noel) 
A dippy PET. 

(Peter) 
That's what I thought you said.

(Noel) 
Yes.  A cardiac MRI or a direct invasive coronary reactivity test.  These are all ways of assessing for coronary Microvascular Disease. 

(Peter) 
All right.  Let me tell you what the PET scan showed.  It was read out as decreased cardiac reserve.  Now what does that mean? 

(Dr. Burg) 
Its Microvasular Disease.

(Dr. Peter Salgo) 
You know it's the funny thing about doctors, you go yes something's wrong.  What does it mean?

(Noel) 
Yes because now you have diagnostic certainty and yes this is very treatable.  It's treatable.

(Peter) 
So that's a positive, it's a positive result.

(Dr. Noel Bairey Merz) 
And she's not a.  Yeah.  I love to find things that are treatable. 

(Dr. Burg) 
And now she's going to feel better too because now she knows it's not all in my head.

(Peter) 
The PET scan, the result.  If you now.  Jane says please tell me what's wrong with me?  Give a name to this.  What does she got?

(Noel) 
So she has a, well.  So we have now coined the term Microvascular Disease and it is secondary to dysfunction of the resistance arterials, which are the microvasculature coronary arteries that are embedded in the heart muscle itself.  They are not regulating flow the way they should in a normal situation.

(Peter) 
This is disease of the tiny vessels, not the great big vessels.

(Noel) 
Correct. 

(Peter) 
Harder to see.  In fact it's almost invisible on a cardiac cath, which is why it wasn't picked up.

(Noel) 
Yes.

(Peter) 
Yet still dangerous.  How dangerous is it?

(Noel) 
So these ladies, and its not all ladies, its about seventy to eighty percent ladies.  So twenty to thirty percent men face a 2.5% per year event rate of death, heart attack, stroke, heart failure.  So over ten years, one out of four of these patients.  If Lou likely has a number in his practice that he doesn't even know about.  These are the ones that have these events. 

(Dr. Peter Salgo) 
Again invisible on normal catheter. 

(Dr. Noel Bairey Merz) 
Mm hmm.

(Peter) 
Why was it left to you?  Why was it left to Jane to pursue this doggedly to come to the diagnosis?  Where did the healthcare system fail them in your view?  Or did it?

(Kim) 
Well I think it's a two way street.  I think.

(Peter) 
By again I mean you of course.

(Kim) 
I think women often put doctor's on a pedestal, it's the whole white, you know, white coat stethoscope syndrome, I think.  So we need to put doctors on the same par as that we are and be assertive in our care.  And if something continues to bother you then you need to go the doctor and look for that accurate diagnosis.  Early detection is the only thing that's really going to keep you where you want to be, which is living.

(Peter) 
I want to sum up just a little bit of what we've been talking about.  Coronary Microvascular Disease is tough to diagnose.  You've heard this.  If you are experiencing symptoms that cause concern, you don't want to ignore them.  You need to continue a dialog with your doctor until you are both satisfied.  Well let me tell you Jane does have Coronary Microvascular Disease.  I think we've established this.  So her next step was to consult with a cardiologist but this time in a women's cardiac specialty service, specifically for women.  Here's what the cardiologist did.  She changed her meds.  That is Jane's meds.  And lowered her target goals for cholesterol and blood pressure.  Now they also have a whole regiment in here of lifestyle changes, diet, exercise, of course stay off the cigarettes.  Now we're telling her to take some pills.  That probably works in terms of compliance.  Lifestyle? Gladys?

(Lou) 
Mmm. 

(Peter) 
Lifestyle is tough.  Do people actually do it?

(Kathy)  
I'll tell you if you have a loaded gun pointing to your head, you're going to make some lifestyle changes.

(Gladys) 
Not only, in situations like that you don't.  I say it takes a lot out of a good provider not to give up with the patient.  Not to give up.

(Kathy)  
And I think you have to address her psychosocial issues.  What's going on in her life.

(Gladys) 
Absolutely.

(Kathy)  
And you can't ignore that.

(Dr. Gladys Velarde) 
And attack it from multiple points. 

(Kathy)  
You aren't going to take care.  You aren't going to diet.  You aren't going to stop smoking.  You aren't going to, you know, get the exercise that all your doctors tell you that you have to do unless you deal with the psychosocial issues that are affecting that patient.  And that's really critical. 

(Peter) 
Why does it work?  I mean its just weight loss.  It's just exercise.  Come on.

(Dr. Burg) 
We don't know.  

(Peter) 
Come on, its just mumbo jumbo right?

(Kim) 
But everybody can walk.  Everybody can walk in this country and so many studies have it shown that.  Just moderate exercises feed the heart.  The heart's very hungry and just walking everyday for thirty minutes. 

(Dr. Peter Salgo) 
All right.  Let's pause again just for a minute because I want to sum up some of what we've been discussing.  We've covered a lot of material here.  If you've been diagnosed with Coronary Microvascular Disease, getting adequate blood flow to your heart is critical.  Lifestyle changes are effective treatments.  They do work.  So let me tell you a little bit more about what's going on with Jane right now.  Jane committed herself, at least at first, to a better diet and exercise.  She lost thirty pounds and her chest discomfort went away.  One last question.  What are the odds she's going to be able to stick with it?  Statistically all comers in the United States.

(Lou) 
They're not great.  Yeah.  That's.  You've being.  That's because your cardiologist

(Peter) 
What do you say twenty percent?

(Lou) 
Twenty percent, it's more like ten percent unfortunately. 

(Peter) 
Kim you've got it.  Microvascular Disease, right?

(Kim) 
Yes. 

(Peter) 
So at this point, how have you changed your life?  What are you doing about it?  How are you managing?

(Kim) 
Well it was a really big eye opener in my life.  And I have a great doctor.  I have a medical regime of medications that help keep my symptoms at bay.  I walk almost every single day and I watch what I eat.  I make sure that I'm eating really wholesome whole foods, a lot of complex carbs.  And I make sure that I manage stress, it's a really.  It's a killer for a lot of people.

(Peter) 
How do you feel?

(Kim) 
You know I feel great.  I think I feel better than I ever have in my life.

(Peter) 
Well congratulations.  Thank you so much for being here.  Guys and ladies, tremendous discussion.  We just have run out of time.  So before we leave, we've covered a lot of ground today.  Let me just sum up some of the key things to remember.  When it comes to heart disease, not only are the symptoms sometimes different for men and women but the disease itself maybe different.  Coronary Microvascular Disease is tough to diagnose.  If you're experiencing symptoms that concern you don't ignore them.  You need to continue a dialog with your doctor until you are both satisfied that you've nailed it.  If you've been diagnosed with Coronary Microvascular Disease, getting adequate blood flow to your heart is critical.  Lifestyle changes are effective treatment, don't poo-poo them.  And our final message is this.  Taking charge of your health means getting informed care, and having quality communication with your doctor.  I'm
Dr. Peter Salgo and I'll see you next time for another Second Opinion.
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