Differences in Women’s Heart Health
Women and men experience heart conditions differently—it’s time to start paying closer attention to those differences.
Heart disease continues to be the leading cause of death for women in the United States. Even so, there seems to remain some confusion about it among the general public as well as a lag in how geriatricians and primary care physicians approach heart disease in their female patients. But research has shown that gender should be a consideration in how heart health is approached.
Ongoing Lack of Awareness
The fact that heart disease is still the number one killer of women is a critically important starting point as far as opportunities to make meaningful changes,” says cardiologist Stacey E. Rosen, MD, FACC, FACP, FAHAH, of Northwell Health in New York. “Around 80% of the risk factors are preventable so there are many opportunities to make better choices.”
For many years, Rosen says, there was a male model for understanding heart disease, and it was just assumed that women should be treated the same as men. But ongoing research has proven that is not the case. Sex is a biological factor that needs to be considered. Although that model is evolving, some say that old beliefs persist among some.
Rosen has seen things shift during her career—but there’s still room for change.
“Historically, heart disease was thought of as a man’s disease, but the science has proven otherwise,” she says. “Mortality rates show heart disease kills more women than do all forms of cancer combined.”
Everything from the way that heart disease presents to risk factors and diagnosis considerations can be different for women.
In terms of heart attack presentation, Nieca Goldberg, MD, a clinical associate professor of medicine at New York University School of Medicine and medical director of Atria New York City, says chest discomfort tends to be a symptom that does overlap in men and women. That pain can radiate to the arm, neck, or jaw, and can be associated with shortness of breath.
“But women will often have lesser-known symptoms like nausea and fatigue, which men don’t report as frequently,” Goldberg says. “We sometimes hear women express that they have abdominal discomfort or pain that is lower in the chest. And sometimes people with diabetes do not experience the typical symptoms at all.”
The latter is quite significant, as recent research has revealed women with diabetes are at increased relative risk of heart failure compared with men. More specifically, research published in Frontiers in Cardiovascular Medicine found that women with diabetes, particularly those with type 1, experienced a greater increase in risk for heart failure compared with men with diabetes.
Looking at Disparities
Goldberg says it should be alarming to physicians that women have been shown to less frequently receive potentially life-saving treatments than men. And a study published in 2017 in the Journal of the American Heart Association, found that timely access to care could be a factor associated with the excess risk of early mortality of women with ST-segment-elevation myocardial infarction, the most deadly type of heart attack. Researchers concluded that women appear to be more vulnerable to prolonged untreated ischemia than men.
Goldberg also points to some misunderstandings around aspirin—which is commonly recommended in the primary care office for heart concerns. Research has shown that aspirin does not appear to be helpful in the primary prevention of heart attacks in healthy women. In fact, the Women’s Health Study (a large trial looking at whether women with no history of heart disease could benefit from a low dose of aspirin) found that aspirin did not reduce the risk of heart attacks, but it did increase the risk of bleeding.
“I think there needs to be more caution in just recommending aspirin,” Goldberg adds. “Even though it is over-the-counter, it is not entirely risk-free.”
According to Noel Bairey Merz, MD, director of the Barbara Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai, the research shows that women are commonly undertreated. They are less likely to receive statins for dyslipidemia and less likely to receive anticoagulation for atrial fibrillation.
The female-pattern presentation being different from the male-pattern presentation is one potential reason why clinicians can miss certain factors—or ultimately undertreat, Bairey Merz adds.
“But there are a number of sex and gender differences in heart health and disease that can come into play and should be considered,” she continues. “We have recently published on Takotsubo syndrome, a stress-related heart disease that is 90% female, and little is known about how to manage and prevent recurrence.
The research, published in the Journal of the American Heart Association in October 2021, found that cases of this rare form of heart disease—which has been known to be triggered by intense emotional or physical stress—have gone up 10 times faster among middle-aged women and older women than younger women and men over the last decade.
Bairey Merz says there is a need for continued and ongoing research, adding that some of the disparities in women’s heart health go back to the way research is conducted. Currently, roughly 30% of participants in clinical trials of heart disease are women, as opposed to a 50/50 split or proportionate to prevalence.
A New Finding: Women’s Blood Vessels Age Faster
Key to the research was data representing nearly 145,000 blood pressure measurements collected over a 43-year period. Researchers looked for clues and patterns regarding how blood pressure starts to rise—and then compared data from women with women and men with men (as opposed to comparing men and women with each other as has traditionally been done).
“There were two main takeaways from this research,” says Susan Cheng, MD, MPH, MMSc, senior author of the study and director of public health research at the Smidt Heart Institute. “First, women start out in life with a lower range of blood pressure than men. This is a sign of differences between females and males in anatomy as well as physiology of the blood vessels. Just as females and males tend to have different ranges of height, weight, heart size, and shoe size, now we are more clearly seeing that there are baseline differences in the range of what we might call normal blood pressure.”
A second key takeaway, Cheng says, was pertinent to those patients who develop hypertension. The blood pressure rise in the women patients compared with the men is likely to have happened faster.
“In other words, if you have two patients in the clinic of the same age and with the same degree of high blood pressure—and one patient is a woman and the other is a man—the woman’s blood pressure began at a lower starting point and had to travel up faster to get to the same level as the man’s,” she explains.
Cheng says that this means physicians should be thinking about the same degree of blood pressure elevation differently in a woman vs a man.
“In a woman, the same level of high blood pressure is likely farther away from what her ‘normal’ blood pressure range is,” she adds. “Her blood vessels may well be managing a relatively greater amount of hemodynamic stress.” These findings, Cheng says, should alternate the way that geriatricians and primary care physicians look at risk factors. Her team recently published a compendium of articles in the journal Circulation Research that summarized the evidence of how cardiovascular risk is different in females and males.
“Beyond blood pressure, there are other measures of risk that should be considered differently in women and men,” Cheng continues. “For instance, diabetes in a woman tends to promote a greater amount of cardiovascular risk compared with when diabetes is present in a man. The same goes for smoking. There are also commonly used blood tests that measure cardiovascular risk profiles, such as NT-proBNP and troponin, that tend to have different levels of risk association when they are elevated in men compared with women. We are still at the beginning stages of understanding how to consider these differences in clinical practice.”
Key Takeaways for Practice
Keeping up with all of the latest research can be daunting but turning to organizations such as the American Heart Association for summaries of key findings can be helpful. Goldberg points out that in late 2021, new guidelines for the evaluation and diagnosis of chest pain were released from the American Heart Association as well as the American College of Cardiology. The result is a “clinical practice guideline for the evaluation and diagnosis of chest pain that provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.”
This is the first symptom-based guideline ever to be released by the American College of Cardiology and American Heart Association. It acknowledges that “chest pain” is a comprehensive descriptor that could include discomfort extending to other areas, including the arms, neck, shoulders, back, upper abdomen, and even jaw. Goldberg suggests that primary care physicians and geriatricians take the time to read these guidelines.
Changes at the clinician level are important. But the message also needs to continually reach the general public.
Rosen says the fact that many women are reluctant to put their needs first can contribute to some of the disparities discussed in this article. She says it’s important that clinicians continue to encourage women to advocate for themselves and speak up when something doesn’t feel right.
“I have heard from a number of female patients that they did not have tell-tale chest pain but just didn’t feel right—they couldn’t exactly put their finger on what was wrong,” Rosen adds. “We want to empower women to speak up and talk to a clinician about this. And we want clinicians to know that, in addition to chest pain, women can have some of these other symptoms that should not be ignored.”
Cheng says that a very important take-home message from the emerging research is that females and males have some similarities but also some important differences when it comes to cardiac and vascular anatomy and physiology—both in health as well as disease.
“This is the reason why we have charts in the echo lab for how to consider measurements of heart size and structure differently in women and men, while also accounting for body size, when we’re looking at and measuring ultrasound images of the heart—even in perfectly healthy people,” she says. “I think it’s important to reemphasize how different we are in health, because these differences set the stage for how women and men age differently and then go on to present different types of cardiovascular disease in older age. Sex differences in cardiac structure and function, existing at the outset, are likely one reason why older women tend to present more often than older men with HFpEF [heart failure with preserved ejection fraction], for instance.”
Rosen sums up that the data demonstrating that women are becoming less aware of their cardiovascular disease risk should be a wake-up call.
“It should be a call to action that this is an important time not to lose ground with fighting back against cardiovascular disease,” she says. “We know that the past two years of being focused on the COVID-19 pandemic have likely taken some of the attention away from these other illnesses. But as the life expectancy plateaus and we’re seeing an uptick in heart disease, this is the time to be diligent.”
— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.