Women’s Heart Programs

Clinical Case Download : Download full-size image A 46-year-old female presented with a history of two acute coronary syndrome (ACS) episodes occurring over a 6-week interval, each confirmed by biomarker elevation and electrocardiogram (ECG) changes consistent with non-ST-elevation myocardial infarction (NSTEMI), and subsequent persistent intermittent chest pain, although of less severe degree than with the ACS episodes. She was perimenopausal, and experiencing significant emotional stress. A coronary angiogram at the time of the first ACS had shown nonobstructive coronary disease in the mid-left anterior descending artery (LAD); she was dismissed with reassurance, and initiation of aspirin and statin therapy, but because of persistent chest pain, and elevated troponin, a repeat angiogram was performed 6 weeks later. This showed resolution of the prior angiographic abnormality and no other abnormalities; she was started on a calcium channel blocker for suspected vasospasm and, since intermittent chest pain persisted, she was referred to the women’s heart program. She had not been referred to cardiac rehabilitation. Additional historical details included preeclampsia and preterm birth with her second of two pregnancies; she subsequently had persistent hypertension, but no other traditional cardiovascular risk factors. Medications included: aspirin 81 mg qd, metoprolol 25 mg bid, rosuvastatin 10 mg qd, amlodipine 5 mg qd, and nitroglycerin spray sublingual as needed. On physical examination, the blood pressure was 130/73 on left and 135/75 on right, heart rate 80 bpm regular, and body mass index 34 kg/m2. The only notable physical finding was of a left carotid bruit. Handheld echocardiogram showed normal left ventricle (LV) systolic function and no evidence of regional wall motion abnormality. How would you manage this patient? Abstract Specialized cardiovascular care for women, delivered in “women’s heart programs” (WHPs) focus on the cardiovascular needs of women. This chapter reviews the historical background leading to their development, their structure and specialized areas of focus including referral criteria for unique cardiovascular disease (CVD) risk factors in women, and CVD disorders resulting in acute coronary syndromes (ACS) with pathophysiologies seen exclusively, and/or more commonly in women including spontaneous coronary artery dissection (SCAD), myocardial infarction with nonobstructed coronary arteries (MINOCA), coronary microvascular dysfunction, and Takotsubo (stress) and pregnancy-related cardiomyopathies. The collaborative and multidisciplinary nature of WHPs is stressed, with key partners including those in obstetrics and gynecology, internal medicine, family medicine, maternal-fetal medicine, and cardiac rehabilitation specialists, specifically dieticians, physiotherapists, psychologists, and exercise physiologists. Finally, the roles of WHPs in education (clinical training programs and public awareness campaigns) and research in women with CVD are briefly discussed. The overarching goal of WHPs is to improve cardiovascular outcomes for women, through an enhanced awareness of sex-specific symptoms, cardiovascular risk factors, diagnoses, and treatments. Ultimately, successful achievement of reduction of glaring knowledge gaps in CVD care for women, with incorporation of evidence-based sex- and gender-specific cardiovascular guidelines into widespread and routine clinical practice, may reduce the need for these programs.