Issue 3 Stories
Womens Health

Change of Heart

New Research Highlights Differences in Heart Disease in Women

The myth that heart disease is more of a health concern for men than for women needs to be put to rest. More women die of heart disease than from any other cause of death, according to Brad Rash, MD, a cardiologist at Sentara RMH Medical Center. In fact, heart disease kills one in four women in the United States.

“The fact that more women than men die each year from heart disease has been true at least since the 1980s, when people began to be more aware of the prevalence of heart disease in women,” says Dr. Rash. “It appears now that women as a group may always have had heart problems, but until the last five to 10 years, they have been under-represented in heart-related clinical trials.”

Because women were missing from research studies for so long, only recently have health professionals learned that women tend to experience heart disease differently from men. For example, the age of onset is different between men and women, the causes are likely to be different, symptoms are different, and women’s outcomes are different.

Differences in Diagnosis and Treatment

“Men and women are both susceptible to coronary heart disease, plaque, blockage and rhythm problems,” says Anna Baer, MD, a cardiologist at Sentara Martha Jefferson Hospital. “However, while men can present at a relatively young age, women are more likely to experience symptoms after menopause.”

The reason, Dr. Baer explains, is that estrogen is a protective factor for women until they stop menstruating. When women do develop heart problems, the disease often progresses at an accelerated rate, leading to poor outcomes and more deaths.

“On average, women develop heart disease 10 years after men,” notes Dr. Rash. “But as women get older, the number of women with heart disease gradually begins to exceed that of men with heart disease.”

Other factors that increase women’s risk are polycystic ovarian syndrome, hypoestrogenemia, early menopause, diabetes, and central obesity or metabolic syndrome.

While many women do experience the “classic” symptoms of heart disease, such as chest pain and heavy sweating, they’re more likely than men to have atypical symptoms. These include:

Shortness of breath

Extreme fatigue

Nausea and lightheadedness

Heart palpitations or an irregular heartbeat

Chest discomfort, also known as angina, such as pain, tightness or pressure in the center of the chest that lasts more than just a few minutes, or that comes and goes

Chills and cold sweats

Discomfort or a heaviness in other areas, including a pain or discomfort in the left arm or both arms, the back, the upper back, the neck, the jaw, or the stomach

Heartburn or indigestion

“These symptoms of heart disease can be harder to recognize, so many women might not get them evaluated by a physician soon enough,” Dr. Baer says. “They may not suspect they have cardiac problems until later.”

Another big difference between heart disease in men and women is the occurrence of angina, which is more common in women, according to Dr. Rash.

Angina, which occurs when there’s not enough blood flow to the heart muscle, is often a result of narrowed blood vessels, usually caused by atherosclerosis, or “hardening of the arteries.”

Women also suffer more than men from microvascular disease, also known as small vessel disease or small artery disease, which is coronary artery disease that affects the smaller vessels that branch off of the larger coronary arteries. These smaller heart vessels regulate 80 percent of the heart’s blood flow. Microvascular dysfunction can cause chest pain, but traditional tests often aren’t able to diagnose this problem. For that reason, Dr. Rash believes the evaluation of cardiovascular symptoms for women should be different than that for men, especially if symptoms are made worse by exertion.

“Women need a PET scan or MRI, which are better imaging techniques,” says Dr. Rash. “Not taking into account biological differences between men and women is one reason women tend to have poorer outcomes with heart disease. Possibly due to microvascular disease, women more often experience angina, even though their heart catheterizations may not show blockages.”

Women also may not respond to traditional treatments in the same way men do. For instance, stents don’t seem to be as effective in women, says Dr. Baer. In addition, Dr. Rash notes that no studies have shown whether beta blockers or nitroglycerin are effective in treating microvascular angina in women.

Keeping on Top of Heart Health

Since research on women’s hearts and microvascular disease is a relatively new field, emerging technologies and treatments are just beginning to identify methods for dealing with the disparities between men’s and women’s conditions.

“The lack of knowledge about the differences in outcomes and disease processes between men and women really concerns me,” says Dr. Rash.

So he started a women’s heart clinic, which is open once a month at Sentara RMH Funkhouser Women’s Center, to address the concerns of women with heart issues. He also follows research on women’s heart health closely, especially through Sentara’s partnerships with academic centers conducting clinical trials.

“It’s an intriguing field, because there’s so much we don’t know,” he says. “There’s not much data yet.”

Another cardiovascular issue in women that health professionals are beginning to learn more about is spontaneous coronary artery dissection, or SCAD, a condition in which a tear occurs in one of the arteries supplying blood to the heart. SCAD can diminish or block blood flow to the heart, resulting in a heart attack or other heart problems.

“More than 90 percent of SCAD cases involve women,” Dr. Rash says. “and women seem to be particularly susceptible after pregnancy.”

Women should see their primary care physicians regularly, notes Dr. Rash. Screening for cholesterol should start when women are in their 20s, so that any familial tendencies toward high cholesterol can be found and treated early.

“It’s disturbing to see a 45-year-old come in with cholesterol problems, when we easily could have addressed the issue at an earlier age,” says Dr. Rash.

“Women often put off their own health needs and put other people first,” he adds. “They’re more likely to seek medical attention for someone else than for themselves—but women need to pay close attention to their own cardiovascular health.”

Focusing on Prevention

At Sentara RMH and Sentara Martha Jefferson Hospital, the focus on women’s heart health revolves largely around education and awareness, with the goal of preventing long-term problems. One big step women can take to prevent heart problems is to learn to manage stress.

“In women, heart disease is more commonly related to stress,” says Dr. Baer. “When women go through a stressful event, that stress can weaken their heart muscle.”

Dr. Rash says he often hears his female patients talk about the stress they experience in their daily lives.

Regular exercise has been shown to reduce stress and heart risk, and Dr. Rash believes it can make a big difference in outcomes.

“Exercise is still grossly underestimated as a deterrent to heart issues,” he states. “It’s the most natural way to reduce the risk for developing heart disease.”

Studies show that people who walk briskly for two to three hours per week greatly reduce their heart disease risk.

“Inactivity is the enemy,” Dr. Rash says. “I often tell patients: ‘You don’t have to train for a 10K—even a 10-minute walk can help.’”

Diet is another major factor in helping to ward off heart disease. Although U.S. Department of Agriculture dietary guidelines have moved away from discouraging cholesterol intake, such as in the consumption of eggs, saturated fats are still a no-no.

“The best eating plan is a Mediterranean-type diet, especially when you use healthy fats like those found in olives and nuts,” says Dr. Rash.

Meals should be built around vegetables and fruits, some whole grains and lean proteins like fish, and small portions of meats and sweets. And keep white, starchy carbohydrates to a minimum. Following this plan will help to reduce “bad” cholesterol.

“Lowering cholesterol reduces your risk of heart disease,” says Dr. Rash. “We’ve seen this effect demonstrated in large studies involving tens of thousands of patients, so the link is fairly well understood.”

Portion control is also key, adds Dr. Baer. In other words: eat less.

And last but not least, heart disease is much more likely to occur in women who smoke.

“There’s no question about it,” Dr. Rash says, “If you smoke, you need to quit.”

Dr. Baer believes that educating both physicians and the public about heart disease in women is starting to yield positive results. Women are getting checked out sooner, they’re becoming less likely to ignore symptoms, and they’re more closely following the advice of their physicians.

“We’re making progress,” she says. “More and more, women are actively engaging in taking better care of their hearts.”

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