16 January 2019
Women should pay attention to their bodies, trust their instincts, and be suspicious of troubling symptoms, even if they are not “typical”. Photo: Reuters
Women should pay attention to their bodies, trust their instincts, and be suspicious of troubling symptoms, even if they are not “typical”. Photo: Reuters

Diagnosing heart disease: women are different

In the matter of heart disease, it is true, as the title of a popular book suggests, that men are from Mars and women are from Venus.

The traditional model of heart disease has been based on men’s disease, but women can have different symptoms and different diagnostic findings, and they are certainly offered fewer diagnostic and therapeutic options.

Women are less likely to be offered cholesterol screening and cholesterol-lowering medications. They are less likely to receive potentially life-saving therapies such as heparin, beta blockers, and aspirin during an evolving heart attack, and they are less likely to be referred for cardiac rehabilitation.

Atypical symptoms may be the result of differences in anatomy and biology, but disparities in approach to evaluation and treatment are due to the fact that, until recently, neither women nor their health care providers fully understood that heart disease is a very real threat to women.

In fact, it is the leading killer of women in the United States. Nearly 500,000 women die each year from cardiovascular disease, a rate nearly double the death rate from all forms of cancer.

More women than men die of heart disease every year, and while mortality rates for men have declined steadily over the last 30 years, the cardiovascular disease mortality rate for women has not changed.

Nandita S. Scott, MD, cardiologist at the Massachusetts General Hospital Corrigan Minehan Heart Center and co-director of Corrigan Women’s Heart Health Program, says, “Statistics show that women who are having a heart attack typically arrive at the emergency room a full hour later than men. In a situation where every minute is crucial in saving heart muscle, women must have a higher index of suspicion and seek care sooner.”

Different presentations

Chest pain, or angina, caused by blockages in the coronary arteries that send blood to the heart, has been viewed as the “typical” presentation of heart disease. Women’s heart disease symptoms, however, may be atypical and difficult to interpret. Although women may experience chest pain, other symptoms – including upper abdominal pain, fullness, shortness of breath, nausea, and neck, back, and jaw pain – are also common.

Dr. Scott says, “Such presentations may indeed indicate the presence of heart disease, particularly in younger women, and should be taken seriously.”

For women only?

And ironically, when women do experience angina, although it may be due to blockages in the coronary arteries, it may also be caused by other syndromes that are much more prevalent in women, especially post-menopausal women.

Stress cardiomyopathy is a relatively newly-described form of heart disease with signs and symptoms commonly associated with heart attack, including chest pain, shortness of breath, and heart rhythm irregularities. However, the symptoms are caused not by coronary blockages, but rather by heart muscle weakness precipitated by severe stress.

Cardiac syndrome X also is characterized by chest pain, often following exercise, and often by abnormal exercise stress tests, but again, there is no evidence of coronary artery blockage. Doctors are not certain what causes cardiac syndrome X, but many speculate that it may be caused by constriction of the small vessels that feed the heart

“Neither disease necessarily has a benign prognosis, and it is very important for women and their doctors to seek a diagnosis and begin appropriate treatment, even after coronary blockage has been ruled out,” says Dr. Scott.

Different diagnostic tools

Not surprisingly, results of diagnostic imaging may need to be interpreted differently for women. For example, treadmill stress tests may yield both false positive and false negative results due to hormone influence.

In addition, because women may have less exercise capacity, results of treadmill testing may be indeterminate. In nuclear stress testing, the breasts can compromise the images of the heart.

Dr. Scott notes: “In order to get the most useful diagnostic information and identify the most appropriate therapy, doctors must be familiar with the benefits and drawbacks of each diagnostic modality in women.”

What should women do?

Every woman should know her personal cardiovascular risk factors and work with her doctor to manage them. Women should pay attention to their bodies, trust their instincts, and be suspicious of troubling symptoms, even if they are not “typical”.

Says Dr. Scott: “If you feel your heart health concerns are not being adequately addressed, you should seek care from a doctor who understands the unique aspects of evaluating and treating cardiovascular symptoms in women.

“Additional research is needed to investigate gender-specific differences in the presentation, evaluation, and treatment of heart disease. A better understanding of these factors will allow us to tailor therapy based on gender.”

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More health and well-being tips from MassGeneral Hospital experts:

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A healthy heart for all ages

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