Heart Disease - Differences Between Men and Women
By Hope Ricciotti, MD
There is a widespread misconception that heart disease is a man's disease. But heart disease is also a devastating health problem for women. In fact, heart disease, which can lead to heart attack, is the leading cause of death for American women. Many women mistakenly believe that cancer is more of a threat. Nearly 500,000 women will die this year from cardiovascular disease almost double the number of deaths caused by all types of cancer including breast cancer combined. A woman is more than ten times as likely to die of cardiovascular disease as she is to die of breast cancer. This is partly due to the fact that the survival rate for breast cancer is quite high, whereas over 40% of women do not survive their first heart attack. This makes heart disease prevention a national priority.
A 1998 survey conducted by the National Center for Health Statistics showed that many women carry misconceptions about the types of disease that pose the greatest threat to their health. The results were as follows:
Percentage of women who perceive their most serious health threat as:
- Breast Cancer 46%
- Unspecified Cancer 16%
- AIDS 4%
- Heart Disease 4%
- Ovarian/Uterine Cancer 3%
What women's most serious health threats really are (incidence of disease):
- Heart Disease 36%
- Breast Cancer 4%
- Unspecified Cancer 3%
- Ovarian/Uterine Cancer 2%
- AIDS 1%
Disparity in treatment between women and men
There exists an apparent disparity in treatment for heart disease between men and women. The reason for this disparity is likely to be due to a combination of gender bias and a general lack of information about women and heart disease. Gender bias refers to cases when a woman who has the same disease as a man will receive different treatment. For example, some women appear to be treated less aggressively for heart disease than men. Until recently, women have been under represented in many studies that have set the standard for detection and treatment of heart disease. In addition, women with heart disease may have different symptoms than men, and different diagnostic tests may be less accurate in women.
Over the past several years, much attention has been directed toward a better appreciation of the influence of gender on heart disease risk and management. The good news is that the recently launched National Institutes of Health (NIH) Women's Health Initiative may provide valuable information on the unique features of heart disease in women. This initiative is an extensive 14-year study of 140,000 post menopausal women. Although it will be some time before all the results are available, the medical community now understands that heart disease in women may be different from what is seen in men, and different methods for detection and treatment may also be needed.
Women's hearts are different from men's
Women's hearts are different from men's. This area of study is fairly new, and research is underway to further examine differences in the physiology and pathophysiology of women's hearts. We do know that women have smaller hearts and smaller arteries than men. Researchers from Columbia University and New York Presbyterian Hospital believe that women also have a different intrinsic rhythmicity to the pacemaker of their hearts, which causes them to beat faster. These same researchers believe that it may take a woman's heart longer to relax after each beat. Some surgeons also hypothesize that the fact that women have a 50 % greater chance of dying during heart surgery than men could be related to some fundamental difference in women's the way women's hearts work. These differences may also account for the fact that women are more likely to die after their first heart attack.
Heart attack symptoms different in women
Women are about as likely to have a heart attack as men, but the fact that they are more likely to die after their first heart attack may be because the symptoms of heart attack are different in women. Doctors and patients often attribute chest pains in women to noncardiac causes, leading to misinterpretation of their condition. Men usually experience crushing chest pain during a heart attack. Women may have a greater tendency to have pain just under the breastbone, or complain of abdominal pain, indigestion, difficulty breathing, nausea and unexplained fatigue. Women are therefore easily misdiagnosed of indigestion, gall bladder disease, or an anxiety attack. The likelihood of misdiagnosing a heart attack in women is also increased by the fact that women tend to have heart attacks later in life, when they often have other diseases (such as arthritis or diabetes) that can mask heart attack symptoms.
Some diagnostic procedures not accurate in women
The exercise stress test, or stress ECG, may be less accurate in women. For example, in young women with a low likelihood of coronary heart disease, an exercise stress test may give a false positive result. In contrast, single-vessel heart disease, which is more common in women than in men, may not be picked up on a routine treadmill test. One way to improve the accuracy of the exercise stress test is to use it in combination with a stress echocardiogram. This involves taking an ultrasound image of the heart while the patient is exercising. This type of testing provides information both about the mechanics of the heart in terms of muscle and valve function, and also about the health of the arteries supplying the heart.
Gender bias in medicine usually happens in one of two ways: (1) a doctor assumes that women's and men's health situations and risks are similar, when in fact they are not; or (2) a doctor assumes there are differences where there are actually similarities. Despite the medical profession's best effort, gender bias may still play an insidious role in influencing physicians' decision-making. The following studies exemplify cases of gender bias in the care of women with heart disease:
- In 1996, a national survey of physicians found that more than 65 % of respondents were unaware of gender differences in the symptoms, warning signs, and tests used to diagnose heart disease. Less than 40 % had received special training in the diagnosis of heart disease in female patients. Finally, a full 50 % of respondents did not know that heart disease is the number one health risk of women after menopause.
- A 1997 article published in the Archives of Internal Medicine found that of 677 heart attack survivors over the age of 65, women underwent fewer tests and were less likely to be prescribed aspirin in the prevention of another heart attack.
- A 1998 study published in the British Medical Journal found that of the almost 32,000 patients who received artificial pacemakers in 1992 and 1993, women were more likely to receive less sophisticated models. The authors believed that the patient's gender influenced the physicians decision of which pacemaker to use.
- A 1999 study published in the New England Journal of Medicine found that a patient's race and gender could significantly influence treatment recommendations. The study was conducted using actors as patients who reported the same symptoms and had the same lab test results. Yet black males and white females were 40% less likely to be recommended for a potentially life-saving cardiac surgery than white males were. Black females were 60% less likely to be recommended for the surgery.
- A 2000 article published in the New England Journal of Medicine reported that of 10,000 people who reported to a hospital emergency room, a small number had heart problems but were mistakenly sent home instead of being hospitalized. These people were more likely to be women under the age of 55, minorities, and people whose electrocardiogram (EKG) was normal.
- Another 2000 article published in the Journal of the American Medical Association suggested that hospitalized women with heart disease were less likely to have tests or procedures (e.g., catheter-based procedures) done while in the hospital.
- A 2000 study published in the Archives of Internal Medicine found that men were more likely to be prescribed cholesterol-reducing drugs than women were, despite a 1999 report published in the Journal of the American Medical Association stating that men and women benefit equally from the drugs.
How can you make sure you get good medical care?
We know that there remains a great deal to understand about heart disease and women. As we wait for continued research on women and heart disease, we also usher in a new generation of doctors whose training has included both genders. In the meantime, there are some basic strategies that you can use to get the best possible medical care. Suggestions include:
- If you feel strongly that something is wrong but your doctor cannot find a problem, get a second opinion.
- Prepare for your visit. Write down questions that you want your physician to answer.
- Educate yourself as much as possible about your health condition. When using the web for research, use medical sites that are reputable, for example, a medical school/university, National Library of Medicine, medical professional society, and hospital.
- Ask questions. If your physician recommends something other than what you have read about, ask why.
- Ask more questions. If you do not fully understand what your doctor has said, ask questions until you do.
- Lead a heart healthy life-style: maintain a healthy weight, eat heart-healthy foods, don't smoke, and exercise every day.
(Published March 2003)