Artery Heart Disease is Different in Women

There is no better example of the disconnect between what we know and what we do than in the case of women with heart artery disease.

By William H. Bestermann, Jr., MD | Published 6/7/2021 0

The specific research around the ways heart artery disease is different in women has been done. It is landmark research that has life or death implications. There are dozens of scientific articles1 that address this topic.

Differing Symptom Patterns

In all American medicine, there is no better example of the disconnect between what we know and what we do than in the case of women with heart artery disease.  While the different symptom patterns in women with abnormal heart arteries are receiving more attention, a failure to translate those best-practice treatments makes their lives more dangerous and expensive.  The woman who is seen in the emergency room for chest pain or other symptoms suggestive of coronary disease will be evaluated under an outdated scientific paradigm aimed at finding blocked arteries.  She will have a stress test done and /or cardiac catheterization.  If these tests are normal, the patient will be told that the symptoms are not related to her heart.  I saw patients who had repeated chest pain and had been told that the problem was her esophagus or worse depression.  She was told in effect: “Go home, take your Valium and Prozac, you will be fine!”  What she has been told is wrong-too often dead wrong!

The American taxpayer has already paid for a specific study looking at the unique nature of coronary artery disease in women.  The findings of the NIH-sponsored WISE study2 (women’s ischemic syndrome evaluation) study are extremely important and have very practical implications. 

Gender Differences

Coronary artery disease in women is different from coronary disease in men.  This illness in men produces local arterial blockages that cause chest pain with exercise that is relieved by rest.  Many women produce cholesterol deposits that are distributed evenly throughout the arterial system producing arteries that are small and with less localized blockage.  Still, these deposits can rupture and produce clots.  Most heart attacks are clotting events, which explains why the clot preventer aspirin prevents heart attack and clot-busters will stop a heart attack already in progress.  When a clot blocks the artery, that kills the heart muscle downstream and produces a heart attack.

Related Content: Heart Attacks: When Will We Finally Do What Needs to be Done?

Not only are cholesterol deposits in women widespread, but they push3 the artery wall outward and may therefore be very large before producing any blockage.  These soft, inflamed, dangerous deposits explain why women with repeated chest pain in the WISE study still had a high risk4 of heart attack and sudden death, even with a normal heart catheterization.   What these women really need is optimal medical therapy for their vascular risk which has been shown to have a powerful effect on stabilizing cholesterol deposits, relieving symptoms, and preventing heart attack. Optimal medical therapy consists of aspirin, blood pressure control, cholesterol management, and smoking cessation.  Diabetic and prediabetic patients should be on metformin.  Female patients who already have chest pain may benefit from beta-blockers, nitroglycerin, and new medications like Ranexa.5  70% of these women can have their chest pain completely relieved within a year when they are on the best medical treatment.

A Diagnostic Error?

Our current medical system continues to operate under the fixed blockage model in coronary artery disease.  If a patient does not have a fixed blockage, they are told that the problem is not related to the heart.  What are the consequences of this diagnostic error?

These women do not have their real problem effectively addressed.  A year after their catheterization only about 10% of these women were on any treatment for their blood pressure and cholesterol problems.  Many women with repeated chest pain continue to have unnecessary pain and suffering.  Many of them have heart attacks and too many of them die.  The personal costs are devastating.  Because the real problems are not addressed, these women frequently return to the emergency room, have repeated tests and hospitalizations, and seek second opinions.  The lifetime cost 6of care for the woman with repeated chest pain and no heart artery blockage approaches $800,000. These women need optimal medical treatment, and they respond very well to it. I have treated about 25 women like this and they were some of the most grateful patients I ever assisted. Medication treatment relieved their pain and made them safer.

Calculate Your Heart Attack Risk

If you are a woman aged 69 or older your risk of a heart attack is elevated, and you should take a statin even if your cholesterol is not elevated and you have no other risk factors. Use the link just above to calculate your heart attack risk and if it is over 7.5% then you need optimal medical treatment for heart artery disease. Age is the most potent cardiac risk factor. Roughly half of the deaths due to heart artery disease occur suddenly7 and without warning. These women don’t get another chance to protect themselves. If you know a woman with a family history of heart attack, or a woman 69 or older, or a woman with repeated chest pain, please recommend this post to them.  It is time to get much more serious about addressing the unique needs of female patients with heart artery disease.  When will we step up and protect our mothers, wives, and neighbors?

These pictures represent heart arteries that have been cut across like a garden hose or a soda straw. Begin at the top of the picture. That is a normal artery. The next picture down has a darker gray cholesterol deposit extending from about 1 o’clock to 6 o’clock. Below that is a much larger deposit that is soft, inflamed, and prone to rupture but is still not blocking the artery at all. That is why women with no blockage can have a heart attack.

On the left side, you can see what happens in patients that do not receive optimal medical treatment. The cholesterol deposit can rupture as in the first image. That causes the clot you see in the second image, and then that leads to scar tissue formation and blockage as you see in the third image.

On the right side, you see the results of optimal medical treatment (OMT). The cholesterol deposit stabilizes, becomes less inflamed, and it is much less likely to rupture and cause a clot leading to a heart attack. These changes give you more protection within days. As you can see, these soft, dangerous deposits can be reduced with medical treatment and the artery becomes more normal. Our understanding of heart artery disease is much better now and there are very targeted, precise treatments available to protect you. This image is from The South Beach Heart Health Revolution and I have used it with Dr. Agatston’s permission.

This is new information and I know that some of you must have questions which I am very happy to answer if you place them in a comment. I am convinced this information will save lives and I hope you will tell your friends about it.


  1. This Women’s Ischemia Syndrome Evaluation, National Institute of Health.  
  2. WISE Study of Women and Heart Disease Yields Important Findings on Frequently Undiagnosed Coronary Syndrome. National Institue of Health.  News Release, Jan 2006.
  3. Matheen A. Khuddus, M.D., Carl J. Pepine, M.D., Eileen M. Handberg, Ph.D., et al, An Intravascular Ultrasound Analysis in Women Experiencing Chest Pain in the Absence of Obstructive Coronary Artery Disease
  4. B. Delia Johnson1, Leslee J. Shaw, Carl J. Pepine , Steven E. Reis et al,  Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women’s Ischaemia Syndrome Evaluation (WISE) study. European Heart Journal 2006.
  5. S. Ndegwa, Ranolazine (Ranexa) for chronic stable angina, National Library of Medicine, Issues Emerg Health Technol. 2007 Jun; (99): 1-6.
  6. Leslee J. Shaw, PhD; C. Noel Bairey Merz, MD; Carl J. Pepine, MD; et al,  The Economic Burden of Angina in Women With Suspected Ischemic Heart Disease< National Institue of Health. DOI: 10.1161/CIRCULATIONAHA.105.609990
  7. Puja K. Mehta, MDB. Delia Johnson, PhDTanya S. Kenkre, PhD, et al, Sudden Cardiac Death in Women With Suspected Ischemic Heart Disease,
    Journal of the American Heart AssociationVolume 6Issue 821 August 2017

William H. Bestermann, Jr., MD

William H. Bestermann Jr., MD is a board-certified internist who has practiced preventive cardiology for more than 20 years. His core expertise is consistently producing optimal medical therapy (OMT) for cardiovascular and related conditions. He does this by using evidence-based care processes consistent with best practices.

He looks at OMT as a product. He understands how health care organizations can combine new systems, new science, and new payment models to produce that product much more consistently. That combination can be standardized, scaled, and industrialized. These new systems combine teams, protocols, population health tools, clinical/financial analytics, and provider training. Certain clinical interventions reduce clinical events more than they impact the target risk factor.

Dr. Bestermann has developed integrated protocols that combine those interventions which maximize impact on weight reduction, minimize drug interactions, and reduce side effects. When these systematic interventions are combined, they dramatically reduce the cost of care, prolong life, and delay cardiovascular events.

Dr. Bestermann wrote the first article on a systematic, integrated approach to the metabolic syndrome. He collaborated later with multiple academics and community leaders in a more detailed article on metabolic syndrome science and treatment. He proposed a new mechanism of action for metformin explaining its impact on cardiovascular, events, cancer, and aging.

He supervised an advanced medical home team within Holston Medical Group for cardiometabolic conditions that contained an ambulatory care residency for PharmDs. The team managed high-risk diabetic and hypertensive employees of Eastman Chemical Company.

He is also a senior clinical advisor for the Quality Blue Primary Care initiative at BCBS of Louisiana. That effort reduced hospital admissions, length of stay, and specialty referrals while lowering per member per month costs. He has personal experience producing OMT in multiple medical settings.

He has become convinced that only evidence, data, and transparency can deliver us from the low-value healthcare that prevails across the United States. There are many vendors making claims regarding their clinical and financial success. Most of those claims are not valid. Almost no one is consistently applying optimal medical therapy to patients with cardiovascular and related conditions in a way that prolongs life, delays cardiovascular events and reduces costs. Dr. Bestermann submitted his approach to the Validation Institute and received their stamp of approval.

In addition to being a contributing author for The Doctor Weighs In, Dr. Besterman also serves on the TDWI Editorial Board, where he medically reviews articles submitted for publication.

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