Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, I'm an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand. blood pressure, weight, cholesterol, for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station. Absolutely delighted to have Fiona Fu with me again. Today, Fiona is an interventional cardiologist based in Sydney. She works at Sydney Cardiology and Macquarie Uni. She has a particular interest in women's cardiovascular related health issues. Hey, Fiona, how are you? Hi, thank you for having me again. Look, I'm again delighted for you to give up your time and share. We've got a couple of really interesting topics that I'm keen to touch on, which are really... uh are more seen in the female population we just don't tend to see them in the male population as much and the conditions we're going to talk about are features of angina where there's not blocked arteries and this is a complicated thing to get your head around can you explain what that means to people listening so So traditionally, everyone thinks that people who have chest pain or what we call angina, particularly with exertion, they think it's due to a blockage in what we call the epicardial or the big heart arteries that you can see on an angiogram, like a CT coronary angiogram or a proper angiogram where we put dye in the heart arteries. So that's the traditional thought that people get angina or chest pain because of blockage from atherosclerosis. atherosclerotic plaque blocking up these arteries. So you're having a significant blockage in the arteries. However, there's a growing body of evidence to show that a lot of women in particular have angina or what we call, and as well as ischemia, so lack of blood flow to the heart arteries because they have but they have non-obstructive coronary artery disease. So they have non-obstructive coronary arteries. So a narrowing in the arteries, that's kind of less than 50% is what they kind of describe as non-obstructive. So there are two terms for these conditions. So one is called ANOCA, so it's angina with non-obstructive coronary arteries. So ANOCA, A-N-O-C-A, and then ENOCA, which is ischemia with non-obstructive coronary arteries. And so just to take a step back, ischemia essentially means like a lack of oxygen, like a blood flow to the myocardium. Yeah. Look, I might jump in there because there's a... a description or an analogy I often give my patients when I'm talking to them about this particular condition and it might be helpful for the people listening so they can visualize what we're talking about. To reiterate, as Fiona said, where normal coronary artery disease blockage in a big blood vessel and blood just not passing through. Really very straightforward. And what we're talking about is really problems at a cellular level, a very, very small blood vessel level, causing really the same consequence. So the way I try and describe this to my patients is imagine our cities, our roads and our transport. And if we think about... The people being transported, us, in our cars, we are the hemoglobin, if you like, and the objective is to get us to our front door so we can get inside. So getting people into their house is the objective. Now, if there's a block... or a crash on a major arterial road, it's incredibly obvious. So this is major coronary artery disease. A crash on the Sydney Harbour Bridge, nothing gets across the bridge. Major coronary artery disease. But let's think about what this non-obstructive coronary issue could be. Let's imagine that there's no blockages in the main highways. or arterial roads but let's imagine that the mbn are working in every small street in surrey hill and you live in surrey hill so you can get over the bridge you can get into surrey hill but as you go to the road where you live the mbn's got uh witch's hats and cranes and various other bits and pieces going on and you can't get up the road you can't get to your driveway you can't deliver the people in these smaller roads these smaller blood vessels to their homes. So large vessel problems, small vessel problems. Hopefully that gives people a visual to understand this a little bit better. Would that fit with what you've described, Fiona? That is awesome. So, yes. Yeah, so I think, as Warrick said, so the problem with these anoka and enoka is a problem with the microvascular. So one part of it is the microvascular. So what we call coronary microvascular dysfunction, which, you know, as you put it, the small vessels. So the small vessels you cannot see on a proper angiogram. An angiogram, for those listening, is when we put a tube up into the arteries and literally squirt, die into the arteries. It gives us beautiful pictures of the big arteries, but not down to this fine level. This is microscopic. Correct. Yeah, these very small vessels. The other aspect of Enoica is, or Enoica and Enoica, another mechanism, I suppose. So you've got this small vessel, so something called coronary microvascular dysfunction. The other aspect of it is something called spasm. So coronary artery spasm. Now, so that artery spasm can occur in the big vessels. as well, but it can also occur in the small vessels. But there's another form of angina or ischemia that you cannot see typically on just doing that angiogram. But now the good news is that you can actually diagnose it and you can do something called a functional angiogram. It's where we test the function of these small vessels and we can also do some tests to induce spasm. And I did one yesterday even. So this is, I guess, as a take-home message for your listeners. If you have recurrent chest pain and you've had like a normal angiogram, you might have one of these conditions, particularly for the females because it's a lot more common. So you might have these conditions which affect the small vessels of the heart. Or you might have one of these conditions that cause spasm. So that is just another condition. Yes, it affects females and males, but it tends to affect females more. And it's another cause of angina or chest pain that is not due to obstructive atherosclerotic cardiovascular disease. So, Fiona, this is a fascinating area. And in fact, some of the research has been driven out of Australia, leading the world, actually, which is pretty impressive, actually. We should be very proud of some of our local cardiologists who have driven this. But what I wanted to ask is what's actually, do we know what's actually occurring at this cellular level? Do we know what's actually occurring in these little side streets that is causing the blockages? It won't be the NBN in there, but what's actually happening in real humans? Is it a fibrosis thing? Could it be inflammation? Yeah, I think it's a combination of things and then even like obstruction and just the dysfunction of the vessels themselves and problems with what we call coronary flow reserve. There's a lot of physiology and actually, yeah, I'm not an expert in that and actually, you know, we work with. some of the experts, um, who have done all the studies on that, but I think it's multi, um, like, yeah, more different reasons, um, to cause like, uh, for example, a microvascular obstruction, um, and inflammation and things like that, that, that can contribute to this, but it is, it is, um, You know, there's more and more research as to this condition, but I think it's just kind of increasing awareness that this exists, you know, because you do hear stories of people who have recurrent chest pain and keep getting told that they've got normal coronary arteries. It's not their heart. But then, yeah, you do these studies, these functional coronary angiograms, and you diagnose. like coronary microvascular dysfunction or you diagnose spasm. And that's important because then they have a diagnosis and then you can change your management. So there are certain medications that are better for spasm and then there are certain medications that are better for microvascular dysfunction. Let's come back to who could be at risk of having these conditions. We touched on it being... Well, I don't know that I've actually seen a male with non-obstructive coronary ischemia. So I think it's mainly females or certainly predominantly. But other than sex, what are the other risk factors that these individuals may have? So it's actually quite similar. So sometimes there's things like... So high blood pressure, high cholesterol, obesity is one of them, as well as psychological stress as well. So they do have some shared risk factors. And that also comes down to, and that's how you also manage them as well. So you also have to manage the lifestyle and those risk factors as well as like medication. So some of these risk factors are across the board for cardiovascular disease, for heart failure. particularly that sort of heart failure where the heart doesn't relax well, the one that we call heart failure with preserved ejection fraction where it gets stiff. Is there an overlap where, you know, these people may be having non-obstructive coronary disease but are having plaque at a microscopic level where they're having features of... cardiac failure with preserved ejection fraction at a microscopic level. Are they sort of closely linked, do you think? Yes, definitely. So there's definitely evidence that there's coronary microvascular dysfunction and that heart failure with preserved ejection fraction, so that kind of that stiff heart, yeah, there's definitely that relationship. So, yeah, so that is, I don't say well-known, but that is a relationship between that. Yeah, yeah. But my own experience in this particular condition is that one of the absolute priorities is for us to recognise it. Over the years, I've seen patients, actually, now that I mention it, I have seen males with this condition far less frequently, so it's mainly females in my own experience. So I think one of the things that we really need to... to prioritize is an awareness of this condition. Because my experience over the years is I've seen patients who are incredibly frustrated, told they're absolutely fine because they've got a normal angiogram. So the large arteries look okay. The arterial arteries, the arterial highways and roads look fine, but they still have symptoms and they come very frustrated, very distressed, really quite impacted on a day-to-day living quality of life basis and an emotional basis. And I've been able to make striking difference for those individuals by running with a potential diagnosis of non-obstructive coronary ischemia and using some of these therapies and really changing them around. So there's a real need for us to make sure we keep this differential diagnosis. If it sounds like coronary artery disease and it's not, We've really got to consider this. Yeah, I agree. And I think, you know, I agree. I think, you know, we... probably did a bit of a disservice back when I was training. We hardly knew about this much at all. It was called, you may remember something like cardiac syndrome X, right? But now I think because there's been a lot more research and the availability of doing these functional angiograms as well, we are able to, people are increasing awareness of it, but also we are able to diagnose it. you know, rather than just saying, oh, you know, then just palming them off and saying, yeah, it's not your heart. You know, obviously we still need to make sure there's, you know, nothing else going on, like, you know, in the gut, for example, or, you know, other things as well. But I think, yeah, those people with recurrent chest pain. that just keep representing that, you know, it does, it significantly impairs their quality of life if they don't get a diagnosis. And unfortunately, people who actually do have this diagnosis, they do have actually have poor outcomes. Not as bad as someone with like an atherosclerotic coronary artery obstruction. So like not as bad as someone who's had like a heart attack in the big arteries. However, they still have an increased risk of like heart attacks and like a poor heart outcome when you have these conditions. So it's important to diagnose it, important from a quality of life point of view, but also important to kind of treat all the other risk factors as well. And yeah, just getting back to the man and female. Yeah, I do definitely females much more affected, but yeah, still have quite a few males that affected. Actually, I remember there was a patient who actually was a young... He was like in his 30s and he came in with chest pain. No, no, he came in with an infection and had severe chest pain, but then he had an elevated troponin, which is to show that he had had a heart attack, essentially, like that blood test was elevated. And so interestingly, I took a history from him and his mother had something called had coronary artery spasm. And so I did his angiogram and I thought, OK, well. you know, he gives a good story, you know, why did he have this troponin elevation and the chest pain? And then, you know, knowing that his mom had a coronary artery spasm. So we did this functional angiogram and we induced spasm and he had his big artery, his left anterior descending artery in the front of his heart went from being open to like 90% blocked. Wow. this provocation test that we use something called acetylcholine in that. And, you know, so now we've kind of changed his, you know, we've changed his management, but you know, that, you know, that, that's significant because you know, that in him, that spasm actually caused a heart attack. Wow. That's pretty significant, isn't it? Yeah. Well, that's non that's ischemia with non obstructive coronary arteries, which is. Fascinating area. No question about that. We were going to touch on one other particular condition, which is, again, seen in women much more than men. It's not exclusive to women, but it is seen in women much more than men. It's a syndrome or a condition called sudden coronary artery dissection. And what that means is that the inside layer, if you like, the Teflon lining of the blood vessels can shear and peel off a little and impede flow. Imagine your Teflon on your fry pan and you scratch away at it and it lifts up. Imagine that happening in your coronary arteries. That's called sudden coronary artery dissection. Tell us a little bit about that, Fiona. This is a different condition to the Inoka Minokas. but it still really falls under that. So I guess I'll just take a step back. So we've talked about ENOCA and ANOCA. So then MINOCA is that myocardial ischemia with non-obstructive coronary arteries. So it's like when someone has had what we consider a heart attack, like that patient I just mentioned, but it's not due to like sudden rupture of plaque and obstruction of the heart arteries. So that's what MINOCA is. And MINOCA is, again, more common in females. And that can be due to things like coronary artery spasm and all these other problems with the microvasculature as well. Okay. So that's, so that's Manoica. Then you've got spontaneous, it's actually spontaneous coronary artery dissection or SCAD. Oh yeah, it is too spontaneous. Yeah, so which is what you described very well. And again, it occurs in females and it occurs particularly in the younger females. And pregnancy is one of these things that people can present kind of post-pregnancy with it and that kind of that younger, less than 55, it's a big cause of heart attacks in young females. Okay. And so... I think, I guess the message is that, you know, heart attacks can occur in different ways in females. And that if you are young and older, if you feel like you're having a heart attack, don't feel like, okay, I'm a young female. This cannot be happening to me. I think we need to be aware that this is a problem. You know, I've seen, you know, several, well, many young females with like that, you know, they've had chest pain and then they've gone to a hospital. found that they've had a heart attack in the sense that their troponin, that blood test, which shows how damage is elevated. They do the angiogram and then they see this spontaneous coronary artery dissection, which you can see on an angiogram. There's different types. There's like four different types, but it's not due to a blockage in the big heart arteries. The good thing with that, I suppose, in that, I mean, it can have bad consequences, but the main management is that it actually heals. So these are conditions where it is not good to put a stent in, okay, or have bypass because you can actually cause more problems with that. dissection. But in most cases, it heals. In some cases, when patients keep having it and they're what we call very unstable, then they might need to have a stent or worst case, a bypass. But in the majority of cases, it does heal. However, the problem with SCAD is that there is an increased risk that you can have recurrence. particularly in your next pregnancy, if you've had it in pregnancy. And then the other issue is that it's often related to some other connective tissue things such as fibromuscular dysplasia. So, you know, so they always get investigated for that. But SCAD is like another, you know, you could have. Big talks about that in general, but I guess the take-home message is this is another condition that affects women much more than men, and it's a problem because it's also a condition that affects young women. Yeah. Look, I think it's a really important one to mention, and I agree, we won't take a deep dive on it. It is a complex condition, but it certainly fits in with the... cardiovascular risks or the cardiovascular problems that women may suffer far more than men. So, you know, it's obviously be very scary for these young women getting these symptoms, which are essentially a heart attack. So does there tend to be a family history with this condition, Fiona? Yes, there is. Yeah. Okay. So it might run in families. And that fibromuscular dysplasia, that may run in families as well. Correct, yeah, yep. Yeah, okay. Look, I think we've covered, again, heaps of stuff. It's been absolutely fascinating. I hope people listening have found this an interesting area of cardiology to think about. This is really talking about angina without blocked arteries in a very different way. It's been a pleasure sharing with you again, Fiona. As I keep saying, I appreciate your time. I know how busy you are. Thank you again for joining me. Thank you for having me. It's always fun. I know people will find this interesting and I hope they share it because it's good stuff. For now, I'm going to sign off. For those listening, thanks so much for tuning in. I do appreciate it. Till next time, I hope you live as well as possible for as long as possible. Take care and bye for now. Hi. Ever wondered what your risk of heart attack is? You should. It's the single biggest killer in the Western world. We're talking one death less than every 30 minutes in Australia, one death less than every 60 seconds in the United States, 9 million deaths globally per annum. Well, how do you check your risk? Well, you can go to www.virtualheartcheck.com.au. You'll find out about your risk and what can be done beyond that to be even more precise.
