With startling statistics about women and heart disease at my fingertips, I turned to Dr. Abraham Bornstein, an educator, Board-Certified Cardiologist and Fellow of The New York Academy of Medicine in the Division of Evidence-Based Medicine to answer my questions.
Janet Hoffman: New research published in the journal of the American Heart Association says that women are more likely to die in the year after a heart attack than a man. Are there more statistics that bring this issue into focus?
Dr. Bornstein: Cardiovascular disease continues to be the number one cause of mortality of women in the United States and worldwide. Since 1984, more women than men have died each year from heart disease and the gap continues to widen.
In that recently published study in the Journal of the American Heart Association, scientists looked at 180,368 patients from Sweden who had experienced a heart attack between January 1, 2003 and December 31, 2013. In that ten-year span, women were found to be three times more likely to die in the year after having a heart attack than men—primarily due to lack of adequate diagnostics and treatment.
In other studies, it’s been shown that women are twice as likely as men to die within the first few weeks after suffering a heart attack. Women between 40-59 years of age are up to four times more likely not to survive heart bypass surgery than men the same age. A telltale prognosis from data on heart attack survivors is that 46 percent of women compared to only 22 percent of men will be disabled with heart failure within six years after a heart event.
JH: Why are women in this situation?
Dr. B: According to statistics and research, women unnecessarily suffer from fatal heart disease primarily because of these three factors:
- 1- Medical studies have traditionally been flawed as to treatment distinctly appropriate to women because the studies were male-oriented (as if women are just long-haired men)
- 2- Treatment for women, based on these flawed studies, is therefore inadequate
- 3- Indications and symptoms of heart disease in women are different than in men and not generally understood, often because of the flawed studies
JH: IF the signs and symptoms of heart disease differ by gender, why has women’s heart disease been diagnosed and treated like men’s?
Dr. B: Traditionally, medical studies of heart disease used too many men which, in retrospect, did not address the important differences between the presentation of women’s heart disease and men’s heart disease. The studies, and resulting skewed data, were biased because the studies were never just on women. Rather, they were either of men or were of a mix of both men and women. In the latter studies, the number of women participants were a significantly lower percentage than the number of men. Perhaps this was due to an unexpressed, errant assumption that men and women’s heart health issues were the same, when, in fact, they are not. Two examples of this difference relate to
- (1) the nature of cholesterol/plaque formations, both in large and small blood vessels
- (2) the way ischemia is experienced—ischemia is a deficiency in the supply of blood to the heart due to obstruction in the large arteries (usually seem more in men) and spasm in the small arteries (usually seen more in women), often experienced as chest pains (differently in men and women).
Specifically, as to plaque formation, men’s cholesterol plaque distributes in clumps which cause significant arterial obstruction. In contrast, women’s plaque distributes evenly, without necessarily clumping, throughout the artery walls. As to ischemia, women have a higher prevalence of both anginal and atypical chest pains than do men. When women’s heart disease was tested by X-ray, CT scan, ECG or MRI, the tests were misinterpreted as normal when they were actually not normal. For example, the testing of women that did not reveal plaque clumps and obstructions (typical of men’s heart disease) were therefore misinterpreted to be normal. Another important example is that, because men with heart disease have different symptoms, the higher incidence of chest pain along with negative electrocardiogram (ECG) evidence exhibited in women were often erroneously dismissed and attributed to histrionics and/or hormones.
JH: How did all of this translate into treatment by physicians?
Dr. B: In both of these examples, the flaws often resulted in doctors under-diagnosing and under-prescribing heart disease treatments for women. Women who are eligible candidates for life-saving, clot-dissolving drugs were—and are still—less likely than men to receive them. Also, the flaws resulted in doctors under-prescribing beta blockers, ACE inhibitors and aspirin, therapies known to improve survival after a heart attack.
JH: Then what are the symptoms of a heart attack that women should be alert to?
Dr. B: First let’s look at the symptoms that may occur within one month prior to an attack as described in the journal Circulation, volume 108 in 2003:
Seventy-one percent of women experience unusual fatigue.
Forty-eight percent experience sleep disturbance.
Forty-two percent have shortness of breath.
Thirty-nine percent experience indigestion.
Thirty-six percent have symptoms of anxiety.
Twenty-seven percent note racing heart.
Twenty-five percent find they have weak/heavy arms.
According to the American Heart Association, these are the signs of having a heart attack to which women should be alert:
- 1. Uncomfortable pressure, squeezing, fullness or pain in the center of the chest that would last more than a few minutes, or go away and come back.
- 2. Pain or discomfort in one or both arms, the back, neck, jaw or stomach.
- 3. Shortness of breath—with or without chest discomfort.
- 4. Breaking out in a cold sweat and/or nausea or lightheadedness.
As with men, women’s most common heart attack symptom is chest pain or discomfort. But women are more likely than men to experience some of the symptoms listed above, particularly shortness of breath, nausea/vomiting and back or jaw pain.
Also, women often discount their symptoms because many still mistakenly believe that heart disease is a man’s disease or because they are not aware of what a woman’s symptoms are, so they may put off going to an emergency room. That can be a dangerous mistake.
JH: Aside from these flawed studies and their impact on diagnosis and treatment, are there other reasons for worse outcome of heart disease in women than in men?
Dr. B: Differences in outcome between men and women can occur because women have more risk factors for heart disease (particularly after menopause): diabetes mellitus (which results from insulin deficiency or resistance leading to high blood sugar), hyperlipidemia (abnormally high concentration of fats in the blood), metabolic syndrome (a cluster of conditions that occur together—increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels), and essential hypertension (high blood pressure due to unknown causes), as well as comorbid conditions (simultaneous presence of two chronic diseases in a patient). Outcomes can be related to the fact that women have a smaller body size with smaller arteries. Sometimes investigators have cited that gender and race bias on the part of physicians result in further disparity in clinical care and outcome. And, as mentioned earlier, women may hesitate more often than men in seeking treatment.
The cause and origin of chest pain symptoms in women is still not well understood and being further explored. There are gender-based differences in the vascular walls. Traditional diagnostic tests that focus on identifying arterial obstructive disease do not work as well in women. There are also differences by gender in the body’s response—for example women may present with more inflammation. Another contributory factor for women only is that estrogen deficiency in perimenopause, more prevalent in women with symptoms of ischemic heart disease, may be the forerunner of advanced atherosclerosis in postmenopausal women.
JH: Women under fifty years of age are said to be especially vulnerable to heart attacks. Is this accurate?
Dr. B: Women, particularly women under 50 with no other history of heart disease, are the most vulnerable population for spasm in small arteries and a rare particular type of heart attack called “spontaneous coronary artery dissection”. SCAD is a highly infrequent emergency condition that occurs when a tear forms in a blood vessel in the heart. As blood flow is slowed or blocked entirely, the result can be a heart attack, heart rhythm abnormalities, or sudden death. SCAD is chronically misdiagnosed, and not just because its symptoms are unusual; people don’t usually believe that young, healthy women can have heart attacks.
There is still a prevalent mistaken perception that Coronary Artery Disease (CAD) is a “man’s disease”. Failure to consider the differences in the distribution of risk factors by age and gender may contribute to the belief that women are at lower risk of CAD. Additionally, women are more likely to have symptoms considered atypical.
JH: You’ve given us a lot to digest. Do you want to make any concluding statements?
Dr. B: Although around 640,000 Americans seek medical help due to heart attacks each year, only 220,000 of these are women. In fact, according to the Centers for Disease Control and Prevention, heart disease takes the lives of about 25 percent of women. The British Heart Foundation has shown that women are 50 percent more likely than men to get a wrong initial diagnosis and are less likely to receive a pre-hospital electrocardiogram—an important test that is essential for rapid diagnosis.
Professor Jeremy Pearson, the Associate Medical Director at the British Heart Foundation, writes:
The findings from this research are concerning—women are dying because they are not receiving proven treatments to save lives after a heart attack. We urgently need to raise awareness of this issue as it’s something that can be easily changed. By simply ensuring more women receive the recommended treatments, we’ll be able to help more families avoid the heartbreak of losing a loved one to heart disease.
Women of all ages and ethnicities can take responsibility for their own heart health by being alert to symptoms, by consulting a physician, and by staying informed as to the reason for a recommended course of treatment or lack of one. Women can reduce their risk factors for heart disease and recurring heart disease very effectively with proper diet, exercise, and successful reduction of many risk factors such as stress, depression, hypertension, cholesterol, and atherosclerosis—which can all be reduced by practicing the Transcendental Meditation technique.
Janet Hoffman is the executive director of TM for Women Professionals in the United States