Deborah Howell (Host): Microvascular dysfunction is a heart disease affecting the inner lining of smaller blood vessels of the heart that branch off from the larger arteries. Women tend to be at a higher risk of developing this disease and can present with different symptoms, along with chest pain, and the Women's Heart Center at Memorial Care Long Beach Medical Center wants to ensure women understand the signs and symptoms of coronary artery disease early on. Today our guest, Dr. Nissi Suppogu, Medical Director, Women's Heart Center, Memorial Care Heart and Vascular Institute at Long Beach Medical Center, will talk to us about microvascular dysfunction in women.

Welcome, Dr. Suppogu.

Nissi Suppogu, M.D.: Thank you, Deborah.

Host: Glad you're here. Let's dive right in. What is microvascular dysfunction?

Nissi Suppogu, M.D.: So, microvascular dysfunction is very specific to the smaller blood vessels of the heart. Normally, when a patient presents with chest pain or when we're talking about patients having heart attacks, we're talking about the bigger blood vessels of the heart, the coronary arteries that have plaque in them and that causes a blockage and it's, they need a stent or a bypass to open it so that the blood flow, is re-established and they function normally.

However, microvascular disease, it's the smaller branches coming from these larger coronary arteries that actually comprise of about 60 to 80 percent of the blood supply to the muscle of the heart. And the smaller blood vessels need to like relax or allow for the blood flow to increase or decrease based on the needs of the muscle metabolism and whatnot.

And more often than not, women tend to have an abnormality in these smaller blood vessels of the heart that tend to cause similar symptoms as in the larger blood vessels of the heart as well.

Host: So, I'm hoping you can explain to us why microvascular dysfunction predominantly affects women.

Nissi Suppogu, M.D.: So microvascular dysfunction, yes, it predominantly affects women, but it also can affect men as well. But mainly, we think so far, based on the research, it's been probably because of the hormonal changes that we face throughout our life cycle.

And maybe that has a lot to do with how these smaller blood vessels are present. Also, a whole bunch of risk factors, like for example, if you have coronary artery disease or somebody that has a heart attack in general, maybe they have diabetes, hypertension, obesity, those symptoms, those comorbidities tend to also contribute to microvascular disease; but then they affect different sexes differently.

So some like diabetes can have a worse outcome in women for cardiac disease than in men. And also apart from these common comorbid conditions that contribute towards coronary artery disease, there are other risk factors that are identified that are more specific to women itself. For example, the stage of menopause itself, where we transition from an estrogen predominant state to a no estrogen state, where there's changes to the way the cholesterol is metabolized, you start to have more clots in our system and whatnot, and then there's conditions like, depression and anxiety. And for decades, there has been research done on stress but we know now for sure that having a significant amount of stress does affect your cardiac outcome and more number of women tend to go through this stress and anxiety just because I think we're managing multiple things on a daily basis.

Just how we are placed in the roles we play in our lives. And also like inflammatory conditions like lupus, rheumatoid arthritis, and other inflammatory conditions are more predominant in women too. And these all like specific risk factors that are more predominant in women also affect us in a different way.

So, that's why the small microvascular blood vessels of the heart tend to get affected early on. So, these symptoms can be presented by younger women, too, in their late thirties, early forties, even before menopause. And, they present with all concerning symptoms and have all the testing for you know, blockages in the blood vessels of the heart for, I mean, what was originally, invented.

We always look for blockages because we think that's the only thing that's going to kill the person or, that's the worst outcome. But there's a lot happening with the small vessels and only in the last decade and a half or so we've evolved in our ways of testing to find ways to diagnose this condition.

Host: Okay. Now, you mentioned risk factors. So, what risk factors and or symptoms can women be aware of with microvascular dysfunction?

Nissi Suppogu, M.D.: Let me talk about symptoms first, and then I'll talk about risk factors as well. So, for symptoms, I want all the women listening here, or everybody that's listening to this podcast to know that women can present with chest pain also, but the way they describe the chest pain could be different.

They could say, Oh, I feel a pressure in my chest. Or, it's like a heaviness. I have had patients specifically tell me, no, I don't feel chest pain. I just feel a discomfort in my chest, a heaviness in my chest, a pressure in my chest, or, a different sensation, like somebody's squeezing my, heart, but it's not pain, they would say. It's a different way of describing the chest pain itself. But they can also present with pain radiating to the sides of their neck into their jaw, pain or heaviness radiating into their left arm, into the back on the left side, from the front of the chest to the back, they can be associated with significant fatigue, weakness, limited in their activity that they used to do before, like shortness of breath with exertion, specifically. I think those would be most of the symptoms that they present with microvascular dysfunction.

Talking about risk factors that affect women specifically, apart from the common comorbid conditions like diabetes, hypertension, sedentary lifestyle, like history of stroke and other things, hypercholesterolemia, apart from all these conditions, there's some conditions that are more predominant in women and also mostly affect women. Those are conditions like inflammatory conditions, which is rheumatoid arthritis or lupus or a whole bunch of autoimmune disorders that are there.

Conditions that are related to stress, anxiety, and depression, those can affect women differently. Premature menopause, like early onset of menopause in their forties. Risks associated with pregnancy, like hypertension in pregnancy, preeclampsia, preterm delivery, gestational diabetes, which are specific to pregnant women. Those tend to affect women as well. I think those are some of the very specific female focused risk factors for microvascular disease.

Host: Okay, thanks. That was very clear. Now, you definitely touched on this. I just want to make sure you cover everything you want to, so I'll ask you again. How can microvascular dysfunction present differently in women?

Nissi Suppogu, M.D.: I think as women, we go through a lot of different pains through our life cycle, with us having menarche and periods every month and perimenopausal syndromes and pains and then pregnancy and labor and whatnot and then menopause, the journey, and then other things like that.

So, we go through, and we're very aware of our bodies, and we know and sense different things more clearly than men do. So when we do recognize symptoms, I want women to respect their symptoms. So if you do feel chest pain symptoms, if it's more than 15 seconds or more than 30 seconds, it keeps happening, whether it's at rest or exertion, give it some importance, like find out why are you having these pains now or if you feel a pressure like symptom. And I don't want all the women feeling every symptom in their chest to run to the doctors. No. If any symptoms present for a few seconds at a time, usually it's not cardiac.

It was just a few palpitations now and then and symptom of, oh, I felt a sharp chest pain for a few seconds and then it went away. That's not concerning, but I'm talking more about symptoms like you feel a pressure or fatigue that's more than usual. You're not able to complete your routine of workout that you were doing before, or, you're waking up in the night with some discomfort or you're going about your day and you had stop, because something was wrong.

You felt too tired that day, like a profound weakness or weakness going from your chest, into your arm. I want you to pay attention to those and get help. Get checked, go get an ekg, get an echocardiogram, see a cardiologist, and explain to them what you're feeling so that they can at least do a complete test on you to rule out, of course, the major coronary artery disease, at least, and at least to start you off by identifying any risk factors that you have and trying to refer you to a person or a place like ours, like at Long Beach Memorial Heart and Vascular Institute, we do specific testing for microvascular disease, to identify that ahead of time.

Host: Good, good. Now, what can microvascular dysfunction be an early sign of?

Nissi Suppogu, M.D.: So, microvascular dysfunction is a coronary artery equivalent, so it's a sign of heart disease. So, if you have microvascular disease, after going through diagnosis and testing, then it is a sign that you have heart disease, which means that you have to be on specific medications, you have to try to exercise regularly, you have to make all those lifestyle changes, to follow a healthy diet; because if you don't, then you will end up with worsening symptoms, more frequent symptoms and more complications with your cardiac health.

Host: Okay. So what are the long term outcomes of microvascular dysfunction if left untreated?

Nissi Suppogu, M.D.: Microvascular dysfunction not just causes all these debilitating symptoms and affecting the quality of life symptomatically itself, but it does play a significant role in various cardiac conditions. So, because these are tiny blood vessels supplying the muscle of the heart, and if they're diseased and not working well, they can lead to heart failure symptoms, like heart failure with preserved ejection fraction, where the pressures inside the heart are increased, you know,

almost forms a root cause for atherosclerosis formation. So if you don't treat it, it will eventually lead to obstructive coronary artery disease. It can cause heart attacks where you have damage of the muscle of the heart. It can cause acute coronary syndromes. It can also cause stress induced cardiomyopathy or like Takotsubo Syndrome as it was referred to in the past. It can cause spontaneous coronary artery dissection in most commonly seen in pregnant women and younger women as well. So there's a multitude of cardiac complications that it can lead to if left untreated.

Host: Okay, so then what type of testing, whether invasive or non invasive, can women do to determine a microvascular dysfunction diagnosis?

Nissi Suppogu, M.D.: So, that's what we've been working towards. So, there is non-invasive testing available and there is invasive testing available. Let's talk about the non-invasive testing first. So, among the non-invasive testing that's available, the most precise ones are cardiac stress MRIs and, PET scans.

So these two tests, the MRI and PET scans for the heart, are more specific for finding microvascular dysfunction. There is work being done to see if we can identify it through perfusion abnormality on a CT scan or on echocardiogram, but it's still not validated yet. So the non-invasive part is mainly PET and MRI.

Now, even before we get to PET and MRI, sometimes the general stress testing that we do for microvascular disease in women can present as some abnormality in a testing that's done for obstructive disease as well. And they go on to do an angiogram and find out that there's no blockage that's causing it.

So, that should also raise the red flag that, oh, this female patient had an abnormal stress test so why is the angiogram abnormal? So what else is wrong? Let's go look for it. Now coming to the invasive testing, there's a gold standard coronary functional testing that we can do.

So it is also an angiogram of the coronary arteries of the heart. So it is an invasive testing. So we look to make sure there's no blockages. And then we use some other medications like adenosine and acetylcholine, and measure some flow measurements and calculations to see what pathway of the microvascular dysfunction is abnormal.

Host: Great. Excellent. I'm glad to hear it. And how important is it to have a dedicated women's heart center to help women with their heart conditions?

Nissi Suppogu, M.D.: Well, I think it's utmost important because I'm a specialist in women's heart disease and I see various female patients coming to me from different cardiologists that they've been following that have not addressed their issues, and some that are aware of these issues and probably address it, but are also sending them over for a second opinion to me because I'm well versed in this area.

I think it's important to have a women's heart center, because not just that microvascular disease is one of the predominant condition that affect women and also in younger women, but like I said, there's so many cardiac conditions that are specific to women during their pregnancy or after the pregnancy or during the menopause.

There's so many conditions and the way women present is also different. So you need somebody that recognizes this so that they can send them for the appropriate testing at the appropriate time and treat them appropriately as well, right? And also not just that some of these cardiac conditions are so specific in women; there's so many cardiac conditions that are present both in men and women, but women tend to be given the backseat in their treatment options or in the way they're treated for their outcomes. The referrals for them to get a procedure done is always so delayed that their outcomes are also not as great as for men for CABG procedures or valve procedures.

So we need a cardiologist or a specialist in a women's heart condition that can be an advocate for them. So that they are recognized on time, treated appropriately, and prevented from having an adverse effect.

Host: It's the least we can ask being 52 percent of the population, right?

Nissi Suppogu, M.D.: Absolutely. It's time we take over.

Host: Is there anything else you'd like to add to our conversation?

Nissi Suppogu, M.D.: Well, I want to thank you for this opportunity, Deborah, it was so nice to share about women's heart health, and I know some of the terms are very technical, so for the audience that's listening, I just want you to know that women can have small vessel disease. It's called microvascular dysfunction. Women can have symptoms of chest pain that present very differently. So recognize those symptoms, identify and respect your symptoms. And when you do recognize your symptoms, then I do request you to please get yourself checked. There's no harm in, talking to your physician or asking to see a cardiologist that can evaluate you.

And if you're evaluated and you find out that you're okay, then that's a good thing, right? But if you don't evaluate and keep experiencing the same symptoms, you're delaying presenting with that symptom to the medical provider and then there's delay from the medical provider. So there's a whole trail of events that we can avoid.

And I want women to advocate for themselves. Recognize your symptoms, respect your symptoms, advocate for yourself and for your community; so that together we can change that cardiovascular disease is the number one killer in women, so that we can have healthier lifestyle, healthier outcomes for our cardiovascular health.

Host: Yes, that is the goal. This has been incredibly interesting. Thank you so much for being with us today and for all your good work, Dr. Suppogu.

Nissi Suppogu, M.D.: Thank you once again Deborah for having me.

Host: And you can learn more about heart conditions and where to get treatment by visiting MemorialCare.org/Women'sHeart or by calling 657-241-9051. And you can listen to a podcast of this show at MemorialCare.org. That's all for this time. I'm Deborah Howell. Have yourself a great day.