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Physicians Update

 
Spring 2011

Women and Heart Disease

05/13/2011

PU-Spring11-Women and Heart DiseaseHeart disease isn’t just a man’s disease. Heart attack, stroke and other cardiovascular diseases are devastating to women, too. In fact, coronary heart disease is the single leading cause of death for American women.

Many women continue to view heart disease as something more likely to affect men — and based on patterns of practice (ordering of coronary angiograms and prescribing potentially lifesaving beta-blockers, for example), many physicians share their bias, despite evidence that they shouldn’t. Last year, barely more than half of women responding to an American Heart Association survey said they would call 911 if they suspected they were having a heart attack. Karol Watson, M.D., Ph.D., cardiologist and co-director of the UCLA Center for Cholesterol and Lipid Management, notes that part of the problem is that although heart disease is the leading killer of women in the United States, the symptoms in women tend to be more subtle than in men.

How do men and women experience heart disease differently?

Although women tend to have the same constellation of symptoms as men, they’re much less dramatic. When men have a heart attack, it tends to be a sudden, complete occlusion of the artery that supplies blood to the heart from a blood clot. That’s why men are more likely to experience a crushing kind of pain — the classic “I have an elephant sitting on my chest,” which is what we’re taught to look for when it comes to heart disease. For women, it’s more likely to be a small clot that forms and then breaks up, followed by another small clot forming and breaking up. It’s much more subtle — women might just say, “I don’t feel right” — and so sometimes healthcare providers don’t recognize it.

When providers do order diagnostic tests, do these differences translate to more difficulty drawing conclusions?

If you’re doing an angiogram, all you’re looking at is the lumen of an artery. You compare one segment to another, and if there are blockages of the entire artery, the lumen will look equal all the way around. Men tend to have one severe stenosis — a blockage that looks like a wide-open garden hose that is suddenly pinched off in the middle. But that is typically not what it looks like in women, which makes it more difficult to detect.
It turns out that almost all of the tests for diagnosing heart disease were developed and validated in men and, as a consequence, they are much more accurate in men. Researchers are trying to refine risk assessment in women, because we know we’re not doing as good of a job. We hope to have some answers soon.

What, if anything, is known about differences in how men and women experiencing a heart attack respond to treatment?

PU-Spring11-Dr. Karol WatsonOne difference is that angioplasty to open a clogged artery in the midst of a heart attack has been shown to be beneficial for all high-risk patients, but less benefit is apparent among women. Among low-risk patients (both men and women), medical therapy appears to be just as effective.

Are there differences in prevention strategies?

There are. With both men and women you want to treat the same risk factors — lowering blood pressure and cholesterol, treating diabetes — but preventive medications are different. For example, low-dose aspirin has been recommended for men older than 50 to prevent heart attacks, based on findings in men from the Physicians’ Health Study. For years we extrapolated those findings to women, but the recent Nurses’ Health Study found that low-dose aspirin did not prevent heart attacks in women, although it did lower the risk of stroke.

Beta-blockers are prescribed more in men than in women after a heart attack. Does this have anything to do with their relative effectiveness?

No. As far as we know, there is no difference and the recommendations are the same. It’s just that all preventive strategies are more likely to be offered to men than women after a heart attack.

How do known heart disease risk factors compare?

The risk factors are the same, but we’re learning that diabetes and obesity affect women’s risk to a greater extent than they affect men. And, unfortunately, these are the ones that are on the rise in our society.





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