Heart disease risk in women: Risk profile, diagnosis, symptoms are different than in men

Public service campaigns have made more women aware of their risk but discrepancies remain in understanding and treatment.

In 1997, only 37% of women were aware that heart disease was the leading cause of mortality in women. That number has now increased to 55%, partly due to targeted awareness campaigns such as the American Heart Association’s Go Red for Women, NHLBI’s Heart Truth Campaign, the Sister-to-Sister Campaign, as well as research results related to women and heart disease.

“All the effort that has gone into awareness campaigns for women with heart disease is finally now getting its payoff,” said Lori Mosca, MD, director of preventive cardiology at New York Presbyterian Hospital.

Mosca, who directed a survey of 1,008 women, said that a lower percentage of minority women recognize their risk of heart disease. “Our most significant challenge in women’s heart disease prevention is reaching out to racial and ethnic minority women. Our survey found that they have half the rate of awareness compared to white women, which is a paradox because they have a 70% increased risk.”

Risk-benefit profiles differ

Rita Redberg, MD, professor of medicine, director of women’s cardiovascular services at the University of California San Francisco, said that physicians also need to be aware of how heart disease differs in women and how the risk-benefit profiles vary between men and women. Women still have much higher procedural complications rates for PCI and bypass surgery, she said.

“When we are designing trials and collecting data, we need to have enough women in the trial to be sure that we understand the risk-benefit profile as well in women as we do in men,” she said.

Rita Redberg, MD

According to Elizabeth Barrett-Connor, MD, professor of family and preventive medicine at the University of California San Diego, the paradigm is changing, with more women being included in research trials. “When we started doing the hormone replacement trials, which were the first big trials that were just conducted among women with heart disease as an outcome, the conventional wisdom even at the NIH was that you won’t be able to recruit women.”

“Well, how did they know since they had never tried? Actually, they found out that women are very anxious to be in research and that they do it for more altruistic reasons. They strongly verbalize that one of the reasons they are in these trials is that they want these answers for their daughters and their granddaughters.”

Many of the trial participants, Barrett-Connor said, have taken an active public role, trying to convince other women “to worry about their heart or to be in a study to see the important piece of information they want to convey.”

Discrepancies in management

Growing numbers of studies “continue to point out discrepancies in the management of women with acute coronary syndromes, myocardial infarction and coronary disease, but we haven’t yet refined what is optimal management in women,” Marian Limacher, MD, said.

“We see higher risk factor rates, lower intervention rates, but not necessarily differences in outcome. So the questions become what is optimal and can we improve outcomes for women,” said Limacher, professor of medicine, division of cardiovascular medicine, at the University of Florida.

Release of guidelines related to diagnostic testing, prevention and angioplasty over the past two years have been vital for increasing practitioners’ understanding of women and heart disease, said Nanette Wenger, MD, professor of medicine at Emory University.

Yet even with these advances, some segments of the population continue to be underserved in clinical trials and in diagnosis and care: elderly, women, and racial and ethnic minorities, Wenger said.

The Women’s Health Study, which enrolled 39,876 women, was a landmark trial for understanding heart disease in women. It was the first randomized trial that looked at the effects of both vitamin E and aspirin among women.

“It was probably the largest trial we are ever going to see in primary prevention in women, and it was particularly significant because it was of stand-alone medications that are relatively inexpensive,” said C. Noel Bairey Merz, MD, director of the Preventive and Rehabilitative Cardiac Center Cedars Sinai Medical Center.

The trial found that vitamin E did not produce a benefit. “This was another nail in the coffin for vitamin E, but it’s a particularly important one because women seem to love their vitamin E, and I have no idea why,” said Wenger.

Data regarding aspirin were mixed. After a median 10.1 years of follow-up, researchers assessed a primary composite outcome and noted 477 events in the aspirin group compared with 522 in the placebo group (P=.13). However, there was a significant difference in stroke, with 221 events in the aspirin group compared with 266 in the placebo group. Aspirin did not prevent MI in women under age 65.

“The only previous randomized, primary prevention trials of aspirin had been conducted in men, and so it was very significant to determine the effect in women,” Limacher said.

Disparities in diagnosis

Physicians interviewed for this article also said the treatment gap must be addressed, a discrepancy that begins with a misunderstanding of how symptoms may differ between men and women.

“The typical male heart attack feels like an elephant sitting on your chest. There is a sense of intense pressure and impending doom. Women are less likely to offer that complaint and more often come in with milder symptoms or nonspecific complaints, so the diagnosis may be missed,” Barrett-Connor said.

Women also tend to present later. “Women are less likely to have heart disease until we’re about 70 years old,” Redberg said. “But when women do finally present, they are sicker and they do worse, which makes their treatment more challenging.”

Lori Mosca, MD

Diagnosing and treating the patient with multiple risk factors is a challenge, Mosca said. “Diabetes is a much stronger risk factor in women than it is in men and is essentially an epidemic now in women. Clinicians have so many questions about how best to treat these patients.”

Roger Blumenthal, MD, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, said that risk factor evaluation needs to be refined in women to reflect the differences. Framingham Risk Score tends to classify women into a much lower risk category for the same number and severity of cardiovascular risk factors as men. Based on the Framingham cohort and offspring data, 98% of asymptomatic women aged 59 and younger and 92% of those aged 69 and younger are classified as low risk. Even among women aged 70 and older, only 44% are classified as intermediate or high risk.

“For scores derived from Framingham, there needs to be some sort of multiplier for women who have a family history of coronary disease or if they have metabolic syndrome. Women with either of these conditions are at least two times as likely as those women without them to have a cardiac event over the next five to 10 years,” he said.

Educating women about preventing heart disease must continue to be emphasized. “More testing is not necessarily going to save lives,” Mosca said. “We know that heart healthy lifestyles and risk factor management save lives, so there needs to be an increasing emphasis on these approaches.”

Moving beyond awareness of heart disease to actually doing something to prevent it is an important step, said Blumenthal. Regardless of whether a woman has the metabolic syndrome or a family history of heart disease, Blumenthal said, the medical profession needs to “encourage our patients to get a pedometer and accumulate about 10,000 steps a day every day of the week. The way we’re going to prevent more heart disease is to motivate women as well as men and children to start walking more, to get more physical activity and to be smart about their dietary habits.” – by Jeremy Moore

Drs. Bairey Merz, Blumenthal and Redberg are members of the Cardiology Today Editorial Board on the Preventive Cardiology section.