Four major cardiology societies, including the American Heart Association, have endorsed an updated definition of heart attack to improve diagnosis and classification for all patients, with important implications for women.
Dr. Patricia Rodriguez-Lozano leads UVA Health’s Women’s Heart Health Care program, working to improve cardiovascular care for women. A cardiologist, clinician and researcher, she develops new therapies for microvascular dysfunction, a problem involving the heart’s small blood vessels.
Dr. Patricia Rodriguez-Lozano studies potential treatments for cardiovascular conditions with a focus on women's care. (Contributed photo)
Rodriguez-Lozano spoke with UVA Today about the changing definition and how it could lead to better healthcare for women.
Q. What has changed regarding definitions of heart attacks?
A. The new definition groups heart attacks more clearly according to three causes: a primary heart attack, caused by an acute problem in the heart’s blood vessels; a secondary heart attack, when another serious illness is affecting the heart’s oxygen supply; or a complication of a cardiac procedure.
Another important change, particularly for women, is in the (definition) of a term called MINOCA. Previously, MINOCA referred to myocardial infarction with non-obstructive coronaries, and the new document changed that definition to myocardial injury with non-obstructive coronary artery.
Let me explain in simple words why that matters. Imagine a woman comes to the hospital with chest pain, and her blood test shows that she has some kind of injury to the heart muscle, but when they look at the coronary arteries, they don’t find any major blockage. Further testing, such as a cardiac MRI, can help determine whether she had a heart attack or another cause of heart injury, such as inflammation of the heart muscle. So that change from heart attack to heart injury reinforces that MINOCA is a working diagnosis, not a final diagnosis. Finding no major blockage does not mean the evaluation is finished.
Q. When was the change made?
A. A new document was released in August called the Fifth Universal Definition of Myocardial Infarction, which is the medical term for heart attacks. The document was developed jointly by the European Society of Cardiology, the American College of Cardiology, the American Heart Association and the World Heart Federation. It gives physicians around the world a common language for diagnosing and classifying heart attacks.
The basic definition of a heart attack is the same, still referring to part of the heart muscle that has been damaged because it hasn’t received enough oxygen-rich blood. But there are different reasons it can happen, aside from a blocked artery, (such as) a problem within the artery wall, an artery spasm or a clot traveling into the heart circulation.
Q. How can heart attacks manifest differently for women than men?
A. For many women, their symptoms are different. It’s important to know that the most common symptom is chest pain or chest discomfort, but many times women also present with other symptoms like shortness of breath, nausea, unusual fatigue or discomfort in the back, both arms and jaw.
So many times, providers, and even the women, don’t necessarily recognize these symptoms are related to heart disease, and there is delay in diagnosis and then treatment. Traditional risk factors like diabetes, smoking and high cholesterol affect everyone, but women have specific risk factors, like reproductive history, (polycystic ovary syndrome) and onset of menopause.
Women are also more likely than men to have a heart attack without a major blockage in what they call the main coronary arteries, the big coronary arteries. Women are also disproportionately affected by certain conditions, such as spontaneous coronary artery dissection or scar, where a problem develops within the artery walls and interferes with blood flow.
Now, women absolutely develop cholesterol-related blockages, too, so we don’t want people to hear this and think that women only have a small vessel disease or tears or other conditions.
Another important part of the definition involves the blood test we use to detect heart injury, called troponin. The reference limit for that test is generally lower in women than in men. So, a result that doesn’t look particularly high using one cutoff may actually be abnormal for women. This updated document reinforces using reference limits that account for those biological differences.
Q. What work is your program doing to improve heart care for women?
A. We care for women across the entire spectrum of cardiovascular disease. We know 80% of heart disease is preventable. We have different clinics for all these different diseases that most of the time affect women. We have a special clinic for SCAD, the spontaneous coronary artery dissection; that is a heart attack that affects mostly young women. We have another clinic called a cardio-obstetric clinic for pregnant women with heart disease or high risk for heart disease, or people looking to get pregnant who are high risk.
