What happens long before the cath lab
On Monday 1 September, Dr Rajan Rehan spoke at the North Shore Private Hospital Women’s Health GP Dinner. His talk — Women’s Heart Health: What happens long before the cath lab — made an argument that is easy to agree with and harder to act on: by the time a woman reaches the catheter laboratory, the opportunities that mattered most have usually already passed.
Those opportunities sit in general practice. In a pregnancy history taken twenty years earlier. In a menopause consultation. In a set of symptoms that gets written down as “atypical”.
Same risk factors, different weight
Dr Rehan opened with the observation that the standard cardiovascular risk factors do not behave identically in men and women. Diabetes confers a substantially greater relative excess risk of coronary heart disease in women. Hypertension is more prevalent among women presenting with myocardial infarction, and a given systolic pressure carries a greater relative risk of infarction than it does in men. Smoking disproportionately raises risk in women, and remains strikingly common in the under-55 acute coronary syndrome group.
Then there is a second list — the one the Australian CVD Risk Calculator cannot see. Pre-eclampsia. Gestational hypertension. Gestational diabetes. Premature or surgical menopause. These are recognised risk enhancers, and they are rarely in the problem list. They are usually in a scanned obstetric letter, if they are anywhere at all.
His practical point: code them. A pre-eclamptic pregnancy that lives in the problem list changes the conversation at every subsequent visit. One that lives in a PDF does not.
Retiring the word “atypical”
The talk devoted real time to language. Chest pain is the most common presenting symptom of acute coronary syndrome in women, as it is in men. Calling a woman’s chest pain “atypical” is both inaccurate and consequential — the label makes the clinician reading it less likely to act.
Women do more often report additional symptoms alongside chest pain, and are more likely to present later. But “additional symptoms” is a different claim from “atypical presentation”, and only one of those two framings leads to a troponin.
A normal angiogram is a finding, not a discharge
The section of the evening closest to Dr Rehan’s own research concerned what happens when the angiogram comes back clean.
Around half of women referred for coronary angiography with suspected ischaemia have no obstructive coronary disease — and, as he put it, they are not a low-risk group. The mechanisms behind their symptoms have names: coronary microvascular dysfunction, coronary artery spasm, plaque erosion, and spontaneous coronary artery dissection. Together these sit under the headings ANOCA (angina with non-obstructive coronary arteries) and MINOCA (myocardial infarction with non-obstructive coronary arteries).
They are also diagnosable. Coronary function testing — acetylcholine provocation for vasospasm, and pressure-wire assessment of coronary flow reserve and the index of microcirculatory resistance for the microcirculation — converts “nothing found” into a mechanism. And a mechanism gives a treatment: calcium channel blockers and nitrates for spasm, a different approach again for microvascular disease.
This is territory Dr Rehan has published in. In a prospective Sydney series of 110 patients with suspected ANOCA undergoing functional coronary angiography at Royal Prince Alfred and Concord hospitals, 82% were found to have a coronary vasomotor disorder — microvascular angina, vasospastic angina, or both. He is also a co-author of the Cardiac Society of Australia and New Zealand’s standardised protocol for functional coronary angiography, written to make the test more consistently available across Australian and New Zealand catheter laboratories.
The message for referrers was simple: if she still has symptoms after a “clean” angiogram, send her back.
Menopause as a prompt
On menopausal hormone therapy, Dr Rehan was clear on both halves of the question. MHT is the most effective treatment for bothersome vasomotor symptoms, and that is its indication. It is not indicated for cardiovascular prevention, primary or secondary — no major society recommends it for that purpose, and patients who have heard otherwise deserve a straight answer.
The point he suggested is most often missed is a different one. Menopause is itself the trigger to do the cardiovascular assessment. Blood pressure, lipids, HbA1c and weight — while she is in the room.
Five things for Monday morning
The talk closed with five actions:
- Ask the four questions — then code pre-eclampsia, gestational hypertension and gestational diabetes into the problem list, not the scanned letter.
- Use the Heart Health Check, but don’t let a “low” score end the conversation in a woman with risk enhancers the calculator cannot see.
- Delete “atypical”.
- Treat a normal angiogram in a symptomatic woman as a diagnosis to pursue.
- Refer to cardiac rehabilitation — and ask at the next visit whether she went.
How we can help
Dr Rehan consults at One Heart Centre and is an interventional cardiologist with a particular interest in chest pain and microvascular dysfunction. One Heart Centre offers:
- Chest pain and women’s cardiovascular risk assessment — including risk-enhancer histories that the standard calculator does not capture
- Investigation of the symptomatic patient with unobstructed coronary arteries — assessment for ANOCA, MINOCA, coronary spasm and microvascular dysfunction, with referral for coronary function testing where indicated
- CT coronary angiography and coronary artery calcium scoring, including inflammation-based risk assessment
- Cardiac MRI for MINOCA, myocarditis and cardiomyopathy
- Echocardiography and general cardiology
Referrals and appointments:
02 9114 5151
referrals@oneheartcentre.com.au
LG02, 71 Walker Street, North Sydney NSW 2060
For referring GPs
We run education evenings and lunch-and-learn sessions for local practices through the year. If you would like your practice included, or would like to suggest a topic, email practice@oneheartcentre.com.au and we will add you to the list.