Women's heart centers bring forth fresh perspectives

Peer-reviewed scientific evidence increasingly supports anecdotal data that women need special cardiac care

When Barbara Kermisch suffered from an acute cardiac problem five years ago, she received excellent care at Massachusetts General Hospital. After all, she recently turned 60 and is able to work full time with an implanted titanium aortic valve.

It was during her aftercare that Kermisch realized something was missing. She searched for support groups that understood her emotional needs. She searched for physicians and nurses who would address her heart issues in the context of being a working postmenopausal woman with an active family and community life. She searched for literature that addressed women and heart disease. In all three categories, she struck out. Only when she moved to Minnesota did she find kindred spirits.

At the Mayo Women's Heart Clinic in Rochester, Kermisch found a library replete with information relating to women and heart disease. She found physicians who did not tell her to cut back on her work schedule as coordinator of auxiliary volunteers at Rochester Methodist Hospital. She also found professionals who understood when she needed to cry.

The Mayo clinic was one of the first of its kind to open in 1998, but its women-specific approach is spreading nationally. The Web site WomenHeart.org lists about 30 women's heart clinics and programs across the country. Scientific evidence justifying the separation of the sexes continues to amass.

"What we've noticed on a small scale in clinical practice regarding the differences between women and men in terms of heart disease has been echoed by some recent studies," said Dr. Sharonne Hayes, director of the Mayo Women's Heart Clinic.

For years, Hayes has seen women with chest pain who don't have significant coronary blockages to account for the ischemia seen with echo or SPECT. Recent data from the WISE trial (Women's Ischemia Syndrome Evaluation), funded by the National Institutes of Health, indicate that women may lay down plaque burden differently from men. Whereas a man's plaque may be concentrated in one area, a woman's may be diffusely spread throughout the vessel. Cardiologists tend to underappreciate women's plaque risk angiographically because the whole vessel is narrowed circumferentially, Hayes said.

The literature also indicates that premenopausal women who suffer a myocardial infarction have twice the risk of dying from that heart attack than a man who has an MI at the same age. The reason for this is unclear, Hayes said. But a subset of premenopausal women tends to have very aggressive coronary disease, leading researchers to investigate whether genes or hormones play a role.

Women's arterial vessels are smaller in diameter than men's. Consequently, they don't accommodate as much plaque, according to Dr. Tracy Stevens, codirector of the Muriel I. Kauffman Women's Heart Center, which is part of Saint Luke's Health System in Kansas City, MO. Some differences in women's responses occur from hormonal fluctuations. During menopause, women have less binding of estrogen receptors to the artery walls. The receptors atrophy, and the arteries lose their tone and flexibility, further complicating vascular disease.

Acute cardiac symptoms often differ between men and women, something Kermisch didn't find out until she moved to Minnesota. Women often do not have the classic left arm pain. Instead, they have back pain or nausea. Medics encountering a woman who is sweating and uncomfortable and has shortness of breath are likely to ask her to breath into a paper bag, suggesting she has the vapors, Kermisch said. A man in the same situation would get an immediate ECG. Such professionals are products of their education, which is why physicians and patients alike have taken their message of sex-specific cardiac care to conferences and communities with increasing success.

HEART OUTREACH

The Norton Women's Heart Center in Louisville, KY, shares space with a screening vascular lab. Both reside in the women's pavilion building, which is connected to Norton Suburban Hospital. A vascular assessment-including carotids, aorta, and lower extremities-costs $75. For $25 more, women can also have a heart risk assessment that includes the standard Framingham metrics, as well as body fat analysis and counseling on diet and exercise. The heart assessment takes about an hour.

If someone is found to be at risk, follow-up is recommended with either her primary-care physician or the center's cardiologist, who is onsite Mondays. All billing goes through the cardiologist's office except the ECG, which is done by the hospital. Additional imaging tests are often performed in the hospital.

"We can generate revenues that way," said center nurse Teresa Byrd.

While the structure and operational model of the Norton center are important, outreach is booming. Last year, the center conducted about 150 heart risk assessments. On the road, however, Byrd and another nurse performed about 2000 cholesterol screenings, 4700 blood pressure screenings, and 2500 body fat analyses at various locales including churches, schools, malls, and support groups. They had about 20 corporate speaking engagements in 2005. The two recently gave their ob/gyns, who reside in the same building, cholesterol screenings, educated them about the importance of women's heart health, and left marketing brochures, hoping to attract women who only come in for a gynecological exam.

Plans are afoot to go into area high schools and offer teenage girls free blood pressure and cholesterol screenings. And Byrd is working with her human resources personnel to set up a program to reach out to the more than 9200 employees and 1800 physicians of the four Norton hospitals.

She has started support groups for women with cardiovascular disease. She also takes her screening equipment to the local pharmacy once a week and offers a "quickie" cholesterol screening. The center's annual Celebrating Women event last year drew 500 attendees and 200 volunteers, along with famed activist Erin Brockovich as the guest speaker. The hospital helps support the center's promotional blitz, which includes ads on buses and billboards, in newspapers and women's magazine, and on TV and radio.

This type of outreach is integral to a viable women's heart center or program, Byrd said. Many such centers consider educating the community one of their top priorities. In 2002, Woman's Day magazine recognized the Muriel I. Kauffman Women's Heart Center as one of the top 10 cardiac centers for women in the country. In 2004, the same magazine awarded its inaugural Red Dress Award to the center for its leadership in women's heart health. The mission of the center is to empower women to be proactive and to take charge of their heart health through education and risk factor awareness for coronary artery disease, according to codirector Marcia McCoy, a nurse. McCoy developed a mentoring program that helps newly diagnosed patients seek comfort and solace from "veterans" of heart disease.

IMAGING DIFFERENCES

Mortality from cardiovascular disease for men has been decreasing since the 1970s, but it has not decreased for women. Epidemiologists debate the reasons for this plateau, but it's partly due to the fact that heart disease is underdiagnosed and undertreated in women, and that problem relates to noninvasive testing and invasive workup, according to Dr. Pamela Marcovitz, medical director of the Ministrelli Women's Heart Center at the William Beaumont Hospital in Royal Oak, MI. Retrospective studies have shown that women with positive stress tests are much less likely to be referred for cardiac cath than men who have positive tests.

"If you're not looking for the disease, you're not going to find it, and if you don't know it's there, you're not going to treat it," she said.

Pregnant women present challenges for clinicians that range from choosing the proper hypertension medication to knowing about a pregnancy-related weakening of the heart muscle and understanding that palpitations during pregnancy are often hormonal in origin. Physicians also should be aware of specific imaging concerns related to women such as breast attenuation problems inherent to SPECT perfusion imaging. Different ways to address this problem include postprocessing or use of other views. But many cardiologists still need to be educated, Hayes said. She receives many reports from outside facilities for second opinions on scans with breast artifacts. These reports hesitate to make the call, saying that it could be an anterior defect or ischemia or an artifact.

"When I see scans from elsewhere, I don't know if the reporting physicians can't tell what's wrong or if they're unwilling to commit," Hayes said. "The problem with this is that the patients have to see more and more care."

Sex-specific interpretation is less of an issue with echo, aside from the fact that some arterial segments of large women and large-breasted women can become nondiagnostic due to acquisition parameters, according to Hayes. In these cases, intravenous contrast helps the opacity, thereby clarifying wall motion and increasing accuracy.

The use of cardiac CT has exploded recently. While cardiologists associated with women's heart centers are taking notice, they also

await peer-reviewed data. The Mayo Women's Heart Clinic continues to use electron-beam CT on select patients, particularly for risk stratification in intermediate risk individuals. Hayes also has access to a 64-slice scanner, but she is not convinced of its utility. The higher radiation exposure compared with EBCT is an issue.

Stevens also has concerns about adopting cardiac CT before all the evidence is in. She is particularly concerned about soft plaque, which can be missed with CT angiography and can be particularly problematic for women.

"We have to be careful not to lump together recommendations for both men and women," Stevens said.

PET and PET/CT stress tests are increasingly entering the cardiac clinical scene. In postmenopausal women, diastolic function may be decreased, possibly due to loss of hormones. A PET stress test offers an accurate test for women, even those who can exercise, Stevens said. There are no breast or diaphragm artifacts, and PET is more efficient than SPECT.

BRICKS OR PAPER

Should a facility develop a women's heart program within an existing department, or should it dedicate a separate building to the enterprise? Stakeholders have to decide early on whether they want a separate entrance that says "Women's Heart Center," Marcovitz said. Research conducted at Beaumont indicated that women wanted certain things in their healthcare: a separate place, a residential setting, and testing close by.

"They didn't mind leaving an office to get their heart assessed, but they didn't want to travel somewhere else to have imaging and other tests done," Marcovitz said.

It's not enough to attach a "Women's Heart Clinic" sign to a practice that offers a feminine waiting room but little science to back it up, Hayes said. People have to answer questions about why they want to open such a clinic. Is there already a patient demand in the practice? Will the move strengthen the practice by bringing in more patients or by providing better care? Will it help strengthen market share? Is it merely because the division chair wants a clinic? In the last case, having support from above is half the battle.

It's also important to determine what, if any, barriers may exist and to figure out how to address them. What if the division chair or hospital CEO is not on board? What if there are competing clinics in the area? How will the clinic distinguish itself? Finally, a dedicated women's clinic should have dedicated cardiologists. It's not good enough to have 20 cardiologists rotating through for a half-day a month, Hayes said. The center should have a core group of physicians or at least one physician who is dedicated to it.

Cardiologists at Saint Luke's in Kansas City initially resisted the idea of a separate women's heart clinic. They felt they were delivering the necessary care in their offices, McCoy said. The difference between the physician's office and the heart center is one of prevention versus treatment.

"We spend an hour educating the women, talking about prevention, developing a plan to help them improve and maintain their heart health. They feel the warmth of our interest," McCoy said.

When Barbara Kermisch was in her forties, her doctors didn't think her heart murmur was problematic. Today, with her aortic valve intact, she continues her own volunteer outreach efforts to educate physicians and to help women become their own best advocates. She wants to ensure that all women including her 15-month-old granddaughter won't have to face the same obstacles she did.

Mr. Kaiser is news editor of Diagnostic Imaging.