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RENEE MONTAGNE, host:

This is MORNING EDITION from NPR News. I'm Renee Montagne.

STEVE INSKEEP, host:

And I'm Steve Inskeep.

Good morning. Next we're going to report on women's hearts, how they're different from men's, and what that means for your health. For one thing, women's hearts are smaller and so are the arteries. Most women who have heart disease, have blockages in their major arties caused by plaque, just like men, but researchers are finding evidence that heart disease in women may look a lot different from heart disease in men.

NPR's Patricia Neighmond reports.

PATRICIA NEIGHMOND reporting:

Diane Asdourian was just 50 years old when she started having symptoms of heart disease.

Ms. DIANE ASDOURIAN (Heart Disease Victim): I woke up, I had chest pains, a little dizzy, and pain down my left arm.

NEIGHMOND: Alarmed, Asdourian went to a hospital ER, where she had a number of tests. Doctors found nothing wrong and sent her home. One year later she suffered another attack and went to the hospital again. But when she had an angiogram, the classic diagnostic tool for blocked arteries, doctors again told her there was no problem.

MS. ASDOURIAN: After the angiogram and the resident came in to tell me that I could go home, I started crying. And he says, what's wrong? And I said, I feel worse now than I did when I came in, because I feel like there's an elephant sitting on my chest. I can't breathe.

NEIGHMOND: Not very far away, at Los Angeles' Cedars-Sinai Medical Center, Dr. Noel Bairey Merz was studying women just like Asdourian, women who complained of symptoms of heart disease.

Dr. NOEL BAIREY MERZ: Women would have what we'd call signs, so they would either have chest pain, shortness of breath, often with exertion - we call that angina. And then we would do a stress test, and they would do poorly on stress tests. They would look, for all the world, like we needed to take them upstairs for a cath - a cath or coronary angiogram - and probably do something like an angioplasty or send them even to bypass surgery.

NEIGHMOND: And for men, that would typically be the case.

Dr. BAIREY MERZ: And if you do that sequence in men, yeah, that's what they have; they have plugged up arteries. But in at least 50 percent of the women, they go up and the arteries are open.

NEIGHMOND: And that was the mystery Barry Merz was trying to solve. These were women with obvious symptoms of heart disease, but on angiogram testing, their arteries showed no clogging. In fact, their arteries appeared clear and open.

So Bairey Merz and colleagues were trying to figure out reasons why these women might be having symptoms like chest pain and dizziness, symptoms that continued to plaque Diane Asdourian.

Ms. ASDOURIAN: I was at work one day, probably about seven or eight months later, and I got the chest pains again. And it went all the way down to my arm, and it just kept getting worse. Usually, if I stood up and moved around, it would go away enough that I could just deal with it. This one didn't. It kept getting worse and worse and worse. I honestly have never had anything hurt as badly as that did.

NEIGHMOND: And once again, hospital tests showed Asdourian had not suffered a heart attack and that she appeared to be okay.

Ms. ASDOURIAN: I followed up with my internal medicine doctor, two days later, and she said that the cardiologist had called her and asked her if I had ever been referred to pain therapy or a psychiatrist because maybe it was just in my head. They couldn't find anything.

NEIGHMOND: Fortunately, cardiologist Bairey Merz was making discoveries. She was finding that women did have blockages in their major arteries. It was that it didn't look the same as it did in men. The plaque was there, but it was spread out smoothly and evenly against the arterial wall. It didn't clump up like it did for men.

A man's angiogram would show bumps and lumps in the blood flow, whereas women's angiograms looked smooth. And the reason, says Bairey Merz, fat - men and women store it differently.

Dr. BAIREY MERZ: Women tend to get fat everywhere. They get fat in their face, they get fat in their upper arms, they get fat in their buttocks and thighs, they even might get fat ankles. So it's very diffuse fat. How do men get fat? In their belly. That's the classic beer belly, and their faces typically remain lean, their upper arms, their ankles, their calves - still look lean. So it may have to do with some basic gender differences in metabolism, storage of fat -and then in the coronary arteries, storage of garbage, cholesterol garbage.

NEIGHMOND: And perhaps, even more dramatic, Bairey Merz was finding evidence of heart disease in other areas of the coronary system - not only in the major arteries that feed blood to the heart, but also in the small arteries that feed blood to the major ones.

(Soundbite of doctor performing angiogram)

Unidentified Doctor: Are you okay, Ruth?

RUTH (Patient): Yes, I'm okay.

Unidentified Doctor: Okay. (Unintelligible) putting the catheter in the space. Okay?

NEIGHMOND: This patient is having a specialized angiogram, one that looks specifically at those small arteries.

(Soundbite of doctor performing angiogram)

Unidentified Doctor: Injected.

RUTH: Okay.

NEIGHMOND: In this procedure, extremely tiny catheters are inserted into the small arteries of the heart.

(Soundbite of doctor performing angiogram)

Unidentified Doctor: Are we ready for the (unintelligible) injection?

NEIGHMOND: Four different medications are then injected. Each one designed to produce a reaction that will tell doctors how well the woman's small arteries are working, and whether they're delivering appropriate amounts of blood to the large arteries, and ultimately, to the heart.

If the arteries aren't flexible and in good working condition, they won't dilate properly, and that means blood flow may be disrupted. The condition is called small artery dysfunction. It turns out that that's what more than half the women in Bairey Merz's study had.

And so did Diane Asdourian, who is now a patient of Dr. Bairey Merz.

Ms. ASDOURIAN: When she told me what was wrong, it was like, I felt better. Because at least I knew that there was something wrong.

NEIGHMOND: And more importantly, that there was something that could be done.

Dr. BAIREY MERZ: All right. Diane, how are you?

Ms. ASDOURIAN: I'm feeling better. A lot better.

Dr. BAIREY MERZ: Are you better? All right. Well...

NEIGHMOND: For the past four months, Asdourian and Dr. Bairey Merz, have been trying to turn her condition around.

Dr. BAIREY MERZ: Big breaths. Good.

NEIGHMOND: Asdourian is now on blood pressure medication and cholesterol lowering drugs. She takes a baby aspirin once a day, and exercises - a brisk walk every day for an hour and a half.

Barry Morse says a daily exercise regimen is crucial to fix arteries that have been damaged. Exercise stimulates cells to make nitric oxide, which is a chemical that helps the arteries dilate.

Dr. BAIREY MERZ: And I've had ladies that get dramatically better, you know, are really good for a year - they get a cold or the flu, or they go on a cruise vacation, and they stop exercising for two weeks - and they're right back where they started. They're, like, can't walk again. So we have to start all over again. So the regimen is just incredibly important.

NEIGHMOND: As is diet, and that was a particular challenge for Asdourian.

Ms. ASDOURIAN: I love French fries. I can't have French fries anymore. I have totally cut out salt, and I was a tremendous salt eater. I salted watermelon before I would eat it. I don't use salt anymore. We don't have it in the house.

NEIGHMOND: And with changes in diet, lifestyle, and medication, Bairey Merz says arteries can be retrained, and small artery disease turned around. When that happens, symptoms diminish. That's already happened for Asdourian, who couldn't be more grateful she found her way to Bairey Merz.

Ms. ASDOURIAN: I think, without her, the big one would have come. I really do. I think I would have had a heart attack.

NEIGHMOND: It's estimated as many as three million women in this country suffer from small artery dysfunction. Unfortunately, many doctors still aren't attuned to the problem. Around the country, women are still being sent home and told everything is okay, despite recurring symptoms. And right now, only centers of excellence - major hospitals in major cities - offer the special tests that are needed to diagnose the condition.

Patricia Neighmond, NPR News.

INSKEEP: And you can test your cardiac risk in an online calculator at npr.org/yourhealth.

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