Published: Synapse, 2010 : Vol. 1
In 2004, the American Heart Association launched its Go Red for Women campaign to raise awareness of heart disease as a woman's health problem. Still, many people tend to associate heart disease and heart attacks with middle-aged men. The consequences of this bias can be dire: in fact, research shows that women often fare worse than men after a heart attack. Other important differences are emerging in how heart disease affects women versus men - differences that deserve our attention.
Heart disease, also known as coronary heart disease or coronary artery disease, occurs when the vessels that feed blood to the heart begin narrowing due to the buildup of fatty deposits called plaque. A heart attack happens when the plaque ruptures and cuts off blood supply to the heart. Without proper treatment given promptly, heart muscle dies and permanent damage sets in.
Heart disease and other forms of cardiovascular disease -- the general term for conditions affecting the heart and blood vessels -- are the leading cause of death for both American men and women, with more women now dying than men every year. Recent American Heart Association (AHA) surveys have found that women and their healthcare providers are not aware of this fact. In 2005, only 8 percent of primary care physicians and 13 percent of obstetrician/gynecologists surveyed knew that more women die of heart disease each year than men do. In a 2006 survey, 43 percent of women were unaware that heart disease is their leading cause of death. Cardiovascular diseases kill more women than the next five causes of death combined, including all forms of cancer.
Joseph Lewis, MD
Joseph Lewis, MD, an interventional cardiologist at Chester County Cardiology Associates in West Chester, points to another AHA statistic he finds alarming: Between 1979 and 2005, men's death rate from cardiovascular disease declined by more than 17 percent, women's only 2.5 percent.
"What's interesting is that when you look at the beginning point of the data, you see there were more cardiovascular deaths in American men than women," he observes. "But over the next 25 years, you can watch the death rate for men drop, but in women remain relatively flat -- so today you have more women dying than men. It's definitely an eye-opener and it supports the notion that there are gender differences when it comes to heart disease."
Donna Reed, DO
So what can be done? One answer is to make sure that women are participating in clinical research on heart disease at the same rates as men. And treatments don't necessarily work the same way in women as they do in men, notes cardiologist Donna Reed, DO, also a partner at Chester County Cardiology Associates and the director of the new Women's Heart Health Program at The Chester County Hospital.
"For years we've been using therapies that were primarily designed for men because men participated in the majority of clinical trials," says Dr. Reed. "So we simply extrapolated them for use in women. In the past few years, we've realized we need to look at this more critically."
In the meantime, education is key. Women and their healthcare providers need to be aware of the differences in how heart disease affects women versus men.
Symptoms occur when a vessel is blocked and the heart muscle does not get enough blood and oxygen. Although chest pain is the most common symptom in both men and women, women tend to experience other warning signs that they and their physicians do not automatically associate with a cardiac event.
"Women are more likely to present with atypical symptoms: profound fatigue, sleep disturbance, shortness of breath," says Dr. Reed. "Women also are more likely to have back pain, arm pain, arm weakness, or even jaw discomfort, rather than the classic chest pain. When they have chest discomfort, they often describe it differently than men do, calling it indigestion or muscular pain."
Dr. Reed and Dr. Lewis agree that atypical symptoms can lead to delays in treatment.
"There is no doubt that cases are missed," Dr. Lewis says. "Since symptoms are not always typical, women tend to ignore them and not seek medical attention. When they do seek help, doctors may not think 'heart attack' as early on as they would with men."
"The bias goes both ways -- it is both a physician issue and patient issue, and more education is needed," Dr. Reed adds.
Age of Onset
The female hormone estrogen helps protect a woman against heart disease until she reaches menopause in her early to mid 50s. That is why women generally tend to develop heart disease later in life than men -- a full 10 to 15 years later. Because they are older, they are also more likely to be dealing with other health issues, ranging from arthritis and joint problems to gastrointestinal problems to kidney disease, lung disease, and cancer.
This impacts women in two ways, notes Dr. Reed. First, when they experience symptoms of cardiovascular, women may attribute them to other health problems. Second, as women present later in life with other health problems, they are at increased risk of complications from invasive treatments such as cardiac catheterization and bypass surgery. Cardiac catheterization involves threading a slender balloon-tipped tube, or catheter, through an artery in the groin to open up the blocked vessel and sometimes implant a stent to keep it open. Bypass surgery reroutes the blood flow around clogged arteries, restoring the supply of blood and oxygen to the heart. "Just the fact of developing heart disease a decade later puts women at additional risk," says Dr. Reed. "It's more complicated because they're more likely to have other age-related illnesses."
Cardiologists can use stress tests to determine whether there is a blockage in one of the coronary arteries. They're called "stress tests" because they are done while the patient is walking on a treadmill to get the heart rate up, although in some cases medication is given to elevate the heart rate. During a stress EKG (short for electrocardiogram), patches with wires are attached to the body to measure electrical impulses given off by the heart. The impulses are recorded as waves on a monitor or printed on paper. Stress echocardiograms and stress nuclear tests are imaging tests that use different kinds of technology to create pictures of the heart as it is pumping.
Dr. Lewis points out that, for reasons not yet fully understood, the results of stress EKGs are not as accurate in women as they are in men. Adding one of the imaging tests often increases the accuracy of the diagnosis, but it also increases cost. Women should be aware of these other options and discuss them with their doctors.
Once women experience heart disease symptoms, they tend to have worse outcomes than men do. For example, a 2008 AHA-funded study of 78,000 patients found that women are twice as likely as men to die if they are hospitalized for a more severe type of heart attack called STEMI (ST-segment elevated myocardial infarction), marked by a prolonged blockage of blood supply affecting a large area of heart muscle.
Women's treatment delays and older age at onset offer some explanation as to why this may be the case. Dr. Lewis points to another possible factor: women tend to have smaller blood vessels than men, but the devices used to open blocked arteries were designed for use in larger vessels. Dr. Reed adds that there is still a lingering tendency to treat women less aggressively than men for heart disease -- a finding that came through in the 2008 AHA study, in which women experiencing heart attacks were less likely to receive appropriate treatments such as medications and cardiac catheterization within the recommended amount of time.
If you or a woman you care for experience any of the symptoms discussed earlier, see a doctor promptly or dial 911. Resist the tendency to assume that the symptoms are not heart-related. You have the power to advocate for yourself, and others, to make sure you get the right diagnosis and the proper care.
"You don't want to let these symptoms go without a good workup," says Dr. Reed. "Get a second opinion if necessary. If it is heart disease, early intervention often translates to better recovery and, ultimately, a better quality of life."
The good news for both women and men is that heart disease is a largely preventable illness. She notes that the most important risk factors for heart disease include:
- High cholesterol
- High blood pressure
- Family history of heart disease
- Sedentary lifestyle (little or no physical activity most days of the week)
"Know your risk factors, discuss them with your doctor, work on a plan for controlling the risks you can control," urges Dr. Reed.
Taking Charge of Your Heart Health
Mian Jan, MD
The news isn't all bad when it comes to women and heart disease, says Mian Jan, MD, a cardiologist at West Chester Cardiology and Chairman of the Department of Medicine at The Chester County Hospital.
"The fact that women develop heart disease 10 to 15 years later than men gives them a window of opportunity," he says -- an opportunity they can seize by taking charge of their heart health. In addition to controlling risk factors such as diet, exercise, and smoking, Dr. Jan recommends that women and men "know their numbers" related to heart health and keep them within the following general guidelines:
- HDL or "good" cholesterol (helps prevent deposits from building up in the arteries): over 50 mg/dl in women and 40 in men.
- LDL or "bad" cholesterol: less than 100 mg/dl (milligrams per deciliter) "or below 80 if one has multiple risk factors," says Dr. Jan, who is now involved in a clinical trial to look at whether reducing LDL to 70 or lower offers even greater protection.
- Triglycerides (fatty acids in the blood that can increase risk): less than 150 mg/dl.
- Waist circumference: less than 35 inches in women, 40 in men.
- Blood pressure: less than 130/85 mm/Hg, ideally less than 120/80. (mm/Hg = a unit of pressure)
- Fasting glucose (a measure of blood sugar, an indicator of diabetes risk): less than 100 mg/dl.
Dr. Jan adds that having any three of these measures out of healthy range suggests the presence of metabolic syndrome, the name given to a cluster of conditions that increase heart disease risk.
So how do you know if you need to consult with a cardiologist and perhaps undergo stress testing for heart disease? Dr. Jan recommends using the Framingham Risk Assessment Tool, which takes information about your age, cholesterol level, blood pressure, and other risk factors to figure out whether the risk of developing or dying from heart disease in the next 10 years is low (less than 10 percent), intermediate (10 to 20 percent), or high (greater than 20 percent).
The Chester County Hospital offers an online Cardiac Risk Assessment, based on the Framingham model.
By Kristine M. Conner
For matters of the heart, call 1.866.DR HEART.
The Women's Health Heart Program
If you are a woman concerned about heart health, consider taking advantage of The Chester County Hospital's new Women's Heart Health Program, an education and prevention program directed by cardiologist Donna Reed, DO. You can attend a lecture series and work with a patient navigator to make any necessary appointments for diagnostic testing and follow-up with cardiologists at Chester County Cardiology Associates or West Chester Cardiology. For more information, contact The CardioVascular Center at The Chester County Hospital at 1.866.DRHEART.