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Created: March 25, 2003
Latest Update: March 25, 2003
jeannecurran@habermas.org
takata@uwp.edu
Backup of Health MattersSPECIAL REPORT: ENCOREHealth Matters: Though doctors may balk, stress tests are vital for women
By TARA PARKER-POPE
Staff Reporter of THE WALL STREET JOURNALWhen a man calls with chest pain, a doctor typically wastes little time: Come in for a treadmill stress test.
But when a woman calls with similar complaints, the doctor is far less likely to bring her in for the test.
And that difference can be a death sentence for the woman.
The failure of doctors to refer women for exercise stress testing is yet another symptom of the medical community's blind spot when it comes to women and heart disease. Heart disease is the No. 1 killer of women, and heart attacks are far more deadly in women than in men -- 38% of women will die within one year of having a heart attack, compared with 25% of men.
Even so, doctors rarely even think of the heart when a woman complains of health problems, let alone refer her for a stress test.
For years, Valerie Bales of Appleton, Wis., told her doctor about pain in her right rib cage. "My doctor said, 'You're just getting older,'" says Ms. Bales, now 50. "He said, 'You've been complaining for eight years and it hasn't killed you yet.'"
But when she finally consulted another doctor, he decided to order a stress test. The results were abnormal, prompting further testing. A week later, Ms. Bales was in the hospital undergoing bypass surgery to correct three 95% blockages.
In hindsight, Ms Bales regrets that she didn't insist on an exercise stress test when she first noticed her symptoms. "It never occurred to me to ask to have this test done," she says.
Problem of Perception?
No one knows for sure how often women are referred for stress testing, but studies have shown that they are less likely to be given the test than men. One indicator is the fact that women are far less likely to receive the types of treatments that normally follow a stress test. For instance, although more women than men die of heart disease each year, only 33% of angioplasties, stents and bypass surgeries are performed on women -- meaning that far fewer women than men are getting the benefit of early diagnosis.
Part of the problem is a perception among many doctors that exercise stress testing isn't useful in women. In a typical stress test, a person walks on a treadmill while an electrocardiogram, or EKG, monitors the heart. The test is more useful than an EKG alone, because often the early signs of heart disease show up only under exertion.
While the traditional test may be as much as 90% accurate in men, it may produce a false positive result in women as often as 50% of the time, says Nieca Goldberg, chief of the women's heart program at Lenox Hill Hospital in New York and author of "Women Are Not Small Men," a book on women and heart disease.
Why so many false positives? One theory is that menstrual hormones or estrogen therapy can interfere with the testing.
But women with heart symptoms should insist on a stress test anyway, even if their doctor tells them it wouldn't be reliable. That's because a negative test often can rule out an immediate heart problem. And if the test is positive, additional, more-accurate testing can be done to give doctors a clearer picture of a patient's heart health.
Although "there's some uncertainty, even a standard stress test can be incredibly useful," says Sharonne Hayes, director of the women's heart clinic at the Mayo Clinic, Rochester, Minn.
Seeing Isn't Believing
Getting a stress test is only the first hurdle for a woman; next, she has to get her doctor to believe the results.
Marie Warshauer, 45, an Indianapolis mother of three, had been complaining of tingling in her left hand for six months. Her doctor suggested an anti-inflammatory drug. The doctor "never considered it had anything to do with the heart," she says.
Then, in August 2001, she developed chest pain, which her doctor chalked up to anxiety about an impending trip to Europe. The pain continued when she returned, but her doctor assured her that since she had no risk factors -- her cholesterol and blood pressure were low, she wasn't overweight and appeared to be in good health -- there was no reason to think there was any kind of a problem. An EKG was normal.
But the following week, Ms. Warshauer continued to have chest pain and shortness of breath. Her doctor assured her nothing was wrong, but when Ms. Warshauer persisted, the doctor relented.
Ms. Warshauer underwent a nuclear-imaging stress test. During the test, a liquid tracer is injected into the blood stream and eventually flows to the heart. After exercising on a bike or treadmill to boost the heart rate, the patient lies on a table while a camera moves over the chest and scans the heart. The images can show damage to the heart muscle and blood-flow problems.
Ms. Warshauer's test was positive, but her doctor was still dubious. Even though the test is more reliable than a standard stress test, breast tissue sometimes can interfere with the camera's functioning, triggering a false positive. So, her doctor sent Ms. Warshauer for another type of test -- a stress echocardiogram.
Rushed to the Hospital
During the test, often called a "stress echo," a woman walks on a treadmill to boost her heart rate, then lies on a table as an ultrasound transducer is moved around her chest, giving detailed information about the heart muscle, valves, chambers and blood vessels. Some clinics offer stress echo bicycle testing, during which the woman lies down on a table and peddles a stationary bike while a technician collects ultrasound images.
When the result of the stress echo was again positive, the doctor took action. Ms. Warshauer wasn't permitted to leave and was rushed to a cardiologist, who three hours later performed an angiogram, inserting a catheter to her heart through her leg to get a direct look at her arteries. He found a 99% blockage; Ms. Warshauer had been at risk for a potentially devastating heart attack at any time.
"The thing that frustrates me the most is that I have a family history of heart disease," says Ms. Warshauer. "My grandfather died at 43. My father had a heart attack at 52. I had a real strong line of history and a lot of real classic symptoms. Still, my doctor said, 'Gosh, you were the surprise of the year.'"
Even so, Ms. Warshauer still sees the same doctor, who she believes now has a better understanding of women and heart disease.
To be sure, stress testing has its limits. While the test can help find severe blockages, it doesn't always pick up on mild and medium blockages. "It picks out the people who are the sickest," says Harmony Reynolds, cardiology fellow at Bellevue Medical Center in New York and the lead investigator on a study attempting to find the best way to diagnose heart disease in women. "What it's very good for is to try to figure out who is going to get sick in the next couple years, are the blockages critical and do they need to be opened right now. But a normal stress test is not a clean bill of health."
'I'm Tired, Too'
That's what Sunny Seitz, 60, of Omaha, Neb., learned. Ms. Seitz had been experiencing shoulder pain, so her doctor referred her to eight weeks of physical therapy. When it didn't improve, it was written off to degenerative disk disease. When she complained of fatigue and shortness of breath to another doctor, she was told, "Yeah, I'm tired, too. Getting old isn't fun."
As it happened, Ms. Seitz worked in a cardiology practice. Doctors there, checking out a new heart-scan machine, asked her to be a guinea pig. To everyone's amazement, the test detected a high level of plaque buildup in her arteries. Though the test can be an indicator of heart disease, it's not normally used to diagnose specific problems.
As a result, Ms. Seitz was referred for a stress echo, in hopes of determining whether she was in imminent danger. After working up a sweat on the treadmill, she was told her result was normal. But Ms. Seitz knew how poorly she felt, and asked that the doctor do an angiogram. During that test, a 90% blockage was discovered and later repaired.
While Ms. Seitz's story illustrates the limits of even the most sophisticated medical tests, it also shows how important it is for women to listen to their bodies and their instincts. When her doctor dismissed her concerns, "I should have said, 'I'm serious here. This fatigue level is incredible,'" Ms. Seitz says. "I'm not blaming any of these physicians. I'm not angry at anybody but myself for not taking full responsibility for my health."
Indeed, cardiologists now believe that the only way to change the way doctors think about women and heart disease is to get the word out to women themselves. The National Coalition for Women with Heart Disease has developed an online brochure (www.womenheart.org1) that explains the tests that are available. The group says women with symptoms who aren't being given the tests should ask their doctors why.
"I didn't know what my options were," says Ms. Warshauer. "You've got to pursue it. If you're not comfortable with the doctor's response, you've got to keep pushing."
-- Ms. Parker-Pope is a staff reporter in The Wall Street Journal's New York bureau.
Hyperlinks in this Article: http://www.womenheart.org
Updated March 24, 2003
Site Copyright: Jeanne Curran and Susan R. Takata and Individual Authors, March 2003.
"Fair use" encouraged.