Heart Disease in Women: Does Your Sex Matter?
For decades, there was a false perception among both health care professionals and the lay public that heart disease was a man’s disease. Historically, clinical trials of treatment of cardiovascular disease (CVD) have enrolled primarily men and until recently, evidence-based guidelines were based on these data. “Women’s health” has traditionally focused on the “bikini zone”—the breasts and reproductive organs—despite clear evidence that heart disease is the leading cause of death in both women and men and is largely preventable.
When there is a lack of awareness about one’s personal CVD risk, women are unlikely to partner with their healthcare providers to assess their personal risk and follow the recommended lifestyle and pharmacologic strategies to improve heart health. Importantly, those who do not appreciate their CVD risk are unlikely to access emergency care when suffering symptoms of a heart attack. These misperceptions, coupled with provider bias, have contributed to the historically inferior clinical outcomes in women suffering acute CVD events.
Raising awareness
Over 20 years ago, the National Heart Lung and Blood Institute (NHLBI) launched The Heart Truth® campaign, which is dedicated to raising awareness that heart disease is the leading cause of death in both women and men. Professional societies, including the American Heart Association’s Go Red for Women®, and patient-led organizations added strength, voice, and grassroots efforts to the initiative. The first Friday in February is now widely celebrated as “Wear Red” Day. The ubiquitous red dress symbol for heart disease in women has achieved recognition as the pink ribbon symbol has done for breast cancer.!
What have we learned from our improved efforts to treat CVD in women?
Fundamental sex differences in the pathophysiology of CVD
Obstructive coronary artery disease due to atherosclerosis, or buildup of fatty plaque that becomes inflamed and ultimately ruptures, is the most common underlying cause of a heart attack
However, myocardial infarction with nonobstructive coronary arteries (known as MINOCA) can also occur and is more common in women
Sex differences in symptoms
Chest pressure (or burning, heaviness, or pain) is the most common heart attack symptom for both men and women. However, its severity ranges widely among all patients. In addition, women experience more associated symptoms, such as back pain, nausea, vomiting, shortness of breath, sweating, and weakness. It’s critical that anyone suffering these symptoms seek immediate medical attention. We have powerful emergency treatments for heart attack in progress today, but their effectiveness declines when the patient delays, owing to denial or fear. This is a 9-1-1 call!
Risk factors for heart disease
Both age and a positive family history of premature CVD increase CVD risk for both men and women,
Powerful risk factors such as elevated LDL-cholesterol levels and high blood pressure, along with physical inactivity, sleep disorders, and psychosocial stress, increase the risk of CVD in men and women. Cigarette smoking and diabetes have greater impact on women’s CVD risk
Autoimmune conditions (such as systemic lupus erythematosus and rheumatoid arthritis), which are more prevalent in women, increase CVD risk
Pregnancy complications (gestational diabetes, pregnancy-associated hypertension, and preeclampsia) are associated with a higher lifetime risk of CVD. It is critical that healthcare providers across all specialties encourage long-term follow up for women who have experienced any of these complications
Sex differences in quality of care and clinical outcomes
Broadly executed national quality efforts such as the AHA/ACC’s Get With the Guidelines are dedicated to ensuring all persons receive care that is safe, timely, effective, efficient, equitable, and patient-centered. Gaps remain in the application of guideline-based care and in CVD risk awareness, particularly relating to sex, age, socioeconomic status, and race
We have made substantial progress, but we certainly are not there yet! Heart disease is an equal opportunity killer. There is no better time to reflect on your own heart health and that of the women (and men) you love.
Further Reading and Events
https://www.goredforwomen.org/
https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-truth
https://www.facebook.com/events/1327819681129086
References
Brown RM, Tamazi S, Weinberg CR, Dwivedi A, Mieres JH. Racial disparities in cardiovascular risk and cardiovascular care in women. Curr Cardiol Rep. 2022;24(9):1197-1208.
Centers for Disease Control and Prevention, National Center for Health Statistics. About Multiple Cause of Death, 1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention; 2022. Accessed January 23, 2023. https://wonder.cdc.gov/mcd-icd10.html
Manfrini O, Yoon J, van der Schaar M, et al. Sex differences in modifiable risk factors and severity of coronary artery disease. J Am Heart Assoc. 2020;9(19):e017235.
National Wear Red Day and American Heart Month. Accessed January 23, 2023. https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-month/wear-red-day
Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019;139(18):e891-e908.
Udell JA, Fonarow GC, Maddox TM, et al. Sustained sex-based treatment differences in acute coronary syndrome care: Insights from the American Heart Association Get With The Guidelines Coronary Artery Disease Registry. Clin Cardiol. 2018;41(6):758-768.
Written by Suzanne Hughes, MSN,RN
Suzanne Hughes, a cardiovascular nurse since 1974, served as the chief learning officer for the Preventive Cardiovascular Nurses Association and worked as a scientific director for Medscape Cardiology.
She was the founding codirector of “Heart of Women’s Health,” a 2-day CME program at the American College of Cardiology’s Heart House, from 2007-2011, and she received the American Heart Association’s Healthcare Volunteer of the Year award in 2012.
Ms Hughes is a senior contributing medical writer for Artcraft Health and has led the content development for Artcraft’s work with Quest/Cleveland Heart Lab’s cardiometabolic group.