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MELISSA BLOCK, host:

Many women may have heat disease that standard tests won't detect, which means they may be sent home by their doctors with a clean bill of health, only to have a serious heart attack. Researchers found a kind of hidden heart disease among women where fatty deposits in coronary arteries do not show up as obvious blockages on angiograms.

Dr. Noel Bairey Merz is scientific chair of the Women's Ischemia Syndrome Evaluation Study and she joins us from Los Angeles. Dr. Merz, thanks for being with us.

Dr. BAIREY MERZ (Cedars-Sinai Medical Center): Thanks for having me.

BLOCK: Explain to us if you could what's happening with the arteries in women that makes this buildup harder to detect.

Dr. MERZ: From our intravascular studies it appears that women are better at depositing plaque very diffusely, such that it's hidden from a traditional angiogram, particularly in their middle years, probably before their menopause.

BLOCK: So the plaque is there, it's just more spread out?

Dr. MERZ: It seems to be more spread out and they tend to have smaller arteries and they, we believe, are doing more of what we call this, negative remodeling, in response to the injury from the cholesterol. The arteries are actually getting smaller, even though they are preserving the lumen and making them smooth.

BLOCK: And it doesn't show up on an angiogram that way?

Dr. MERZ: It's hard to see on an angiogram, although, if you carefully review angiograms in our WISE women, we'll typically see scalloping, or irregularities. Everything that cardiologists were taught previously in their training, told them that if there wasn't a large obstructive blockage, something that really anyone could see, you could pretty much ignore it because it wasn't doing anything.

What this research has discovered is, you can't ignore it. If the woman has evidence of damage to her heart muscle or if she has an abnormal stress test, it's probably an indication that these smaller arteries are involved and their ability to dilate is inadequate.

And when you say wise women, these may be women who are very wise, but you're talking about the WISE study, the Women's Ischemia Syndrome Evaluation study.

Dr. MERZ: Correct.

BLOCK: What are the implications for women who may being having symptoms, an angiogram shows that they seem to be fine - what do you tell the women and their doctors about what tests should be done?

Dr. MERZ: I think the implications are number one, they should seek out care at a center that can evaluate them for this small vessel disease, and number two, if they have evidence of plaquing, they should be treated for that, and that's pretty standard guidelines of care: aspirin, potentially a beta blocker if they're having symptoms and an ace inhibitor to help improve the arterial dilation.

BLOCK: Do women typically present with different symptoms of experiencing a heart attack than men do?

Dr. MERZ: Yes, indeed. This is another gender difference. Two-thirds of men will have what we call a classic Hollywood heart attack, clutching of the chest, chest pain, shortness of breath, perhaps even collapsing and becoming sweaty.

Conversely, only one-third of women will present with these classic symptoms. Two-thirds of women will have atypical symptoms such as severe fatigue, isolated shortness of breath or even stomach upset.

BLOCK: And would this difference in how the arteries build up plaque, would that account for why women may experience different symptoms?

Dr. MERZ: Indeed, this is one of the hypotheses that we are investigating. Women, when they have heart attacks, are much more likely to have the heart attack occur from what we call plaque erosion, and the symptoms often even will come and go. Men, on the other hand, are more likely to have what we call plaque explosions. The collagen cap will frankly rupture and spew the contents into the artery itself. It's pretty easy to see a man having a heart attack, and it can be more subtle in a woman because of this underlying difference in the plaque.

BLOCK: Would it be a pretty common thing for a woman to come in presenting some symptoms, but an angiogram shows she's fine and for her to be told it must be, it must be in your head? Go home. You seem to be fine.

Dr. MERZ: Well, indeed, in our research subjects again, the WISE women, many of them with the persistent chest pain had quite severe what we call psycho social variables, depression, anxiety, they had been prescribed sedatives, hypnotics, things like Valium. We also are concerned that this false reassurance really misguides women about what the true etiology is, and they really start to think, well, there must be something wrong in my head. Why am I having all this chest pain? The doctor keeps telling me I'm fine.

BLOCK: And that would say, they may not be fine.

Dr. MERZ: Oh, they're not fine. Not every woman has this condition, but women that have this condition, when they get to a physician that says, I'm pretty sure I know what you have. I'm pretty sure I can help you, they often just dissolve in tears of happiness.

BLOCK: Dr. Merz, thanks very much.

Dr. MERZ: Thanks for having me.

BLOCK: Dr. Noel Bairey Merz is medical director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles.

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