Heart attack in women - what to know
If you had to guess, would you say the number one cause of death for women in the United States was breast cancer? Heart attack in women is actually our top killer. And most of us don’t know that! While death due to cardiovascular disease has declined over the last couple of decades, the annual mortality rate is actually higher for women than men. This means that every year, more women than men die of heart disease. So what’s going on? Are women just tiny men or are we different? Here’s what we need to know.
Do women have heart attacks?
About 1 in 3 American women will die from heart disease (that’s compared to 1 in 31 from breast cancer). It’s responsible for more deaths than all cancers combined. So, no, it’s not a man’s disease and it’s time to put that myth to bed already. In fact, 45% of women over age 20 years already have some form of cardiovascular disease! Ugh.
Atypical symptoms of a heart attack in women
While women often have the classic symptom of chest pain when they are having a heart attack, they are more likely than men to have atypical symptoms. Almost as commonly as chest pain (which may be crushing, pressure, or tightness), women will experience something else such as shortness of breath, extreme fatigue with walking, nausea/vomiting, extreme anxiety, back pain, or jaw pain. Women are also more likely than men to have symptoms brought on by stress or in their sleep. And unfortunately, more than half of women who die suddenly from heart disease will have had no prior symptoms whatsoever.
Risk factors for heart disease in women
While the top risk factors for heart disease are the same in women as they are in men - high blood pressure, high cholesterol, family history, diabetes, above ideal body weight, smoking, crappy standard American diet, and not enough exercise - there are several risk factors unique to women.
While many of them cannot be modified specifically, they are super important to call out and recognize in order to have a more complete understanding of our overall cardiovascular risk and help us make treatment decisions, whether lifestyle or medication related
Pregnancy related risk factors - Pregnancy related complications including gestational hypertension or pre-eclampsia, gestational diabetes, recurrent miscarriages, and premature delivery increase risk of future cardiovascular events by as much as 2 to 4 fold.
This is a very important risk factor for women, given that adverse pregnancy outcomes occurs in 10 to 20% of all pregnancies.
Of these complications, preeclampsia (particularly if it occurs early) has the strongest association with increased cardiovascular risk.
Early menopause - Prior to menopause, women have a lower risk of heart disease than men their same age. Risk for cardiovascular disease increases dramatically in women after menopause, who then assume the same risk of heart disease as similarly aged men.
Premature menopause, typically defined as occurring prior to age 40, deserves particular mention. While the complete effects are poorly understood, it is likely due at least in part to the loss of the protective effects of estrogen and the associated physiologic changes that occur, including worsening cholesterol issues, changes in body fat distribution, decreased glucose tolerance, higher blood pressure, and dysfunction of the blood vessel wall.
Other hormonal factors - Hormone replacement therapy in postmenopausal women, which was thought would be protective, was found in a very large study to have no cardioprotective effect and may actually result in harm if taken > 10 years after the start of menopause.
Oral contraceptives (aka birth control pill) in premenopausal women may also be associated with an increased risk of heart attack - the overall risk is quite low in average risk women, but it may not be the best choice in women with heart disease or multiple risk factors (particularly smoking).
Polycystic ovary syndrome (PCOS), a common hormone disorder that often results in infertility, insulin resistance and abnormal cholesterol, is also associated with increased risk for heart disease.
Inflammatory and autoimmune diseases - Women are much more likely than men to have inflammatory or autoimmune disease, which increases risk for heart disease. Lupus, in particular, is quite common in women and was associated with up to a 50 fold increased risk of heart attack in one study. Other conditions that may be associated with higher risk include rheumatoid arthritis, psoriasis, and inflammatory bowel disease (IBD).
Higher levels of inflammation (despite normal cholesterol levels) and increased time during “flares” has be important contributors to particularly increased risk.
Psychologic stress - Anxiety, depression, acute and chronic emotional stress, post-traumatic stress disorder (PTSD) and early-life adversities, while not unique to women, are more common than in men and are particularly strong risk factors for heart disease in women.
Not only does psychological stress and depression lead to riskier health behaviors, like smoking and poor diet (kale usually doesn’t win over chocolate cake or chips when we’re stressed), but it also results in alterations in the stress response pathways, leading to dysfunction of the artery walls, dysregulation of the part our nervous system that controls our heart rate and blood pressure (autonomic nervous system), and increased inflammation.
What else can cause heart disease in women?
While the most common cause of heart disease in women is still coronary artery disease resulting from cholesterol buildup in the arteries (atherosclerosis), women are more likely than men to have other causes of heart disease, which are less well understood.
One of these causes is microvascular dysfunction, a disorder of the the coronary circulation that does not involve blockages in the major branches of the heart arteries. Another is spontaneous coronary artery dissection, which is when the walls of the heart arteries separate and can cause impairment of blood flow and heart attack. Both of these disorders are less well understood than atherosclerosis, and if not considered, can result in misdiagnosis and worse outcomes.
Heart disease in women is poorly recognized
Unfortunately, due to years of under-recognition of the prevalence of heart disease in women, heart attacks are more likely to be missed in women. It’s complex, but likely related to delay in both diagnosis by doctors and other healthcare professionals as well as the fact that women are far less likely to recognize symptoms and seek out medical care promptly.
Risk factors in women are also chronically underdiagnosed and undertreated. With regards to diabetes, women are consistently less likely to be diagnosed and treated appropriately compared to men. Women are also less likely to receive guideline-recommended therapy for cholesterol lowering medications like statins.
Women are also significantly underenrolled in clinical trials - meaning, despite heart disease’s prevalence in women, we still do not make up our fair share of representation in trials that are designed to test the efficacy and side effects of drugs. While this has improved in recent years, enrollment of women still remains suboptimal - for instance, in the major contemporary blood pressure trial (which is responsible for the recent changes to blood pressure treatment targets reflective in the 2017 guidelines), only 36% of participants were women. This is also true for most of the major statin trials. As a result, we are less likely to understand and appreciate any major sex-specific differences in treatment effect.
Heart disease in women - the take home
It’s critical that women recognize that heart disease can affect them. Many women don’t seek care for concerning symptoms because they mistakenly think that it can’t or won’t happen to them. We need to be our own advocates, and in turn, advocate for our friends and family.
While some things are out of our control, like age & family history, there’s still a lot that can be done to prevent heart disease. It starts by recognizing our own personal risk factors, including those that are unique to us as women, and then creating a plan to work on the changes that we can do something about.
Would you like to discuss your heart health with a female cardiologist?
