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Heart of a Woman

Cardiovascular Disease and the Gender Gap

Loryn Feinberg, MD

Many of us experience a stiff neck, aching jaw or upper-back discomfort at times; at the end of a long day, for example. But you may be surprised to learn that these are among the unexpected symptoms of a heart attack for women.

While the most common heart attack symptom is chest pain for both men and women, women are more likely to experience lesser-known warning signs, such as nausea, discomfort localized to the jaw, neck, shoulder or upper back; shortness of breath, profound fatigue, marked sleep disturbance, upper abdominal discomfort, or sweating.

In fact, most women experience new symptoms a month or more before a heart attack, according to research from the National Institutes of Health (NIH). A study of more than 515 women found that 95 percent felt symptoms like unusual fatigue, sleep disturbance and shortness of breath well before the heart attack occurred. Women's symptoms are also often elicited by emotional stress or daily activities, rather than high levels of physical exertion.

As a result of the differences in presentation between men and women, women's symptoms are often attributed to another cause and there is a delay in diagnosis of heart disease, says Loryn Feinberg, MD, Medical Director of the Women's Cardiovascular Program at the CardioVascular Institute at Beth Israel Deaconess Medical Center.

This is just one of many marked differences in how cardiovascular disease affects women versus men, but these facts are more than just an interesting read. Since cardiovascular disease is the number one killer of women in the United States, this could be life-saving information for you or a woman you know.

Women Risk Deadly Delays

Women are more likely than men to delay reporting symptoms of heart attacks, a factor that contributes to more serious outcomes for females, according to a study conducted by New York-Presbyterian Hospital at Columbia University Medical Center. After examining studies conducted over a span of eight years for patterns in behavior, the researchers found several reasons why women may delay seeking treatment:

  • The symptoms are not commonly known signs of a heart attack.
  • Symptoms do not seem severe enough.
  • They mistakenly believe another illness is causing symptoms.
  • They do not believe they are at risk for a heart attack.

Because women may be unaware that their symptoms are cardiovascular-related, they can delay getting the medical attention they need, an error that can have deadly consequences.

"When women overlook these symptoms and delay seeking medical intervention during the course of a heart attack, we often find that more heart damage has occurred by the time they arrive at the emergency room," says Feinberg. "When it comes to heart attack, each minute that treatment is delayed increases the likelihood of greater damage to the heart, complications of the heart attack or even death."

Why a Woman's Age Matters

"Women tend to experience heart disease later than men, with issues arising in their 60s, versus 50s for men," explains Feinberg. "While cardiovascular disease is more common in younger men versus women, by the age of 65, it's more prevalent in women."

The timing of increased risk for women starts at about age 50 and coincides with the onset of menopause and decreasing levels of estrogen. Researchers have found that estrogen protects women against heart attack by increasing "good" cholesterol or high-density lipoprotein (HDL). HDL carries cholesterol away from the arteries and out of the body, which helps to prevent blockages in the arteries. Prior to menopause, women have much higher levels of HDL cholesterol than men of the same age. A particular subtype of LDL ("bad" cholesterol) also rises after menopause, which is believed to contribute to risk.

A decade ago, hormone replacement medications were a standard treatment for women with menopause symptoms like hot flashes. Starting in 2002, however, researchers found that hormone replacement therapy (HRT) consisting of estrogen and progesterone together actually increases the risk for stroke and blood clots, especially in older women. As a result, the American Heart Association recommends not using HRT for cardiovascular prevention, and many doctors are now far less likely to prescribe such medications.

While women seem to stay healthier longer, they are experiencing cardiovascular disease or events at an age when they may be less likely to make a robust recovery. This may partially explain why women with cardiovascular disease also have more serious issues and a higher mortality rate than men.

"The difference can be seen when tracking men and women who have suffered from heart attacks," says Feinberg. "Women who have a heart attack are twice as likely to die within the first two weeks as are men, and 38 percent of women compared with 25 percent of men will die within one year after a heart attack."

Sending Heart Health Up in Smoke

Although findings show that women experience heart disease later than men, female smokers are a major exception to that rule. Those who smoke are more likely to die from a heart attack earlier in life than men, and those who smoke and take birth control pills have a markedly higher risk of heart attack than non-smokers taking the pill.

One study of 1,784 heart attack victims showed that the mean age of female non-smokers who experienced their first heart attack was 80.7 years compared to 66.2 years for smokers - a dramatic 14.4-year difference when compared to an 8.3-year disparity found in the age of male smokers vs. non-smokers who had heart attacks.

Even after adjustments were made to account for patient risk factors and characteristics other than smoking, the age difference between female smokers and non-smokers and their first heart attack was still a troublesome 13.7 years.

Cancer Treatments can Increase Risk

Thanks to medical advancements, more women who have cancer now have a greater chance of achieving remission with the use of powerful drugs or treatments. But researchers are now investigating the long-term effects of certain cancer treatments on the heart.

One survey, which tracked nearly 4,500 women treated for breast cancer from 1954-1984, discovered that women who received radiation treatments, especially localized to the left breast, were more likely to die from heart disease decades later. This is believed to be due to the toxic effects of radiation on the heart.

In another study, a drug called Herceptin (trastuzumab) that is used to treat breast cancer was found to spur additional heart trouble in those with a history of diabetes or previous cardiovascular issues. A study that viewed women aged 70 to 92 and treated for breast cancer found that 26.7 percent of the patients developed heart problems directly attributed to the drug. Four out of the 45 patients enrolled (8.9 percent) developed symptomatic congestive heart failure, a likelihood that increased if the women had diabetes or a history of cardiac disease.

Anthracyclines, a type of chemotherapy, has also been recognized as a cause of heart damage in some individuals. The damage to heart muscles can show up right away, within a few months, or even decades after treatment.

Venus vs. Mars

There are other indications of a gender gap when it comes to cardiovascular risk.

"The fact that women have smaller coronary arteries, smaller aortas, and smaller hearts than men can make procedures like coronary bypass surgery or angioplasty technically more challenging," says Feinberg. "We find that women often have more complications after cardiac surgery, which may be due in part to the fact that they are often older and have more chronic conditions than men undergoing the same procedures."

Diabetes also increases the risk of heart disease in women more than it does in men, perhaps because women with diabetes more often have added risk factors, such as obesity, hypertension and high cholesterol. Although women usually develop heart disease later than men, diabetes erases that advantage. And, for women who've already had a heart attack, diabetes doubles the risk for a second heart attack and greatly increases the risk for heart failure.

In addition, the diagnosis of heart disease can present a greater challenge in women than in men because symptoms are harder to identify. For example, women's responses to standard exercise stress tests are somewhat different from men's, making it more difficult to interpret results. As women age, they have more physical impairments than men, which often results in a non-interpretable test result.

Research is only now beginning to uncover the biological, medical and social basis of these and other differences. The hope is that new knowledge will lead to advances in tailoring prevention and treatment for women.

Different, But the Same

When it comes to cardiovascular disease, there are still risks that hold true for both sexes, and those risks are just as vital to take note of as the factors listed above.

Risk factors that transcend gender lines include a family history of heart disease, obesity, diabetes, emotional stress, tobacco abuse, poor diet, physical inactivity and high cholesterol or blood pressure levels.

How to Beat the Odds

Now that you know the gender-specific factors and symptoms, what can be done to limit risk?

When it comes to women, researchers found that maintaining a healthy diet can be one of the keys to avoiding major cardiovascular issues, such as heart attack. In a study recently published in Hypertension: Journal of the American Heart Association, researchers found that women who regularly ate fish had healthier hearts than those who didn't.

The study's researchers surveyed 49,000 young women aged 15 to 49 about how often they consumed fish and what types of fish they ate over an eight-year time frame. Results showed that women who ate little or no fish had more frequent inpatient and outpatient hospital admissions for cardiovascular disease, and those who never ate fish at all had a risk of heart disease three times higher than women who ate fish every week.

In addition to eating a healthy diet, rich in omega-3 oil and antioxidants, women can lower their risk by reducing high blood pressure and/or cholesterol, maintaining a healthy weight, exercising regularly, and not smoking.

Read the Signs

The final lesson to take away? Follow your heart, and stay in tune with the messages that your body is sending. If you're feeling out of sorts, don't delay seeking medical attention. Be clear and specific about the symptoms you're experiencing, and don't be afraid to ask your doctor to consider other possibilities in the diagnosis stage. Paying attention to signals from your body and taking them seriously can prevent emergency room heartache and may even save your life.

Above content provided by the CardioVascular Institute at Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.

Posted February 2012

Contact Information

CardioVascular Institute at
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215