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Women experience different MI causes, symptoms than men
The American Heart Association has issued a new scientific statement that underscores knowledge gaps in the causes, symptoms and outcomes of acute MI in women and outlines steps needed to better understand and treat CVD in women.
This release marks the first scientific statement from the AHA on MI in women. Writing group chair Laxmi S. Mehta, MD, FAHA, a noninvasive cardiologist and director of the Women’s Cardiovascular Health Program at The Ohio State University, and colleagues noted that improvements in treatment, prevention and awareness in recent years have been associated with substantial decreases in deaths due to CVD. However, the annual CVD mortality rate has remained higher in women than in men since 1984.
“Despite stunning improvements in cardiovascular deaths over the last decade, women still fare worse than men and heart disease in women remains underdiagnosed, and undertreated, especially among African-American women,” Mehta said in a press release.
Pathophysiology, clinical presentation
The symptoms of heart disease may be different in women and men. Rather than central chest pain, women may be more likely to feel pain in the upper back, arm, neck and jaw. Symptoms of fatigue, weakness, dyspnea, indigestion and nausea/vomiting are also more common in women than men.
In addition, the prevalence of microvascular disease, non-STEMI, nonobstructive CAD and spontaneous coronary artery dissection are elevated in women. Menopausal women, in particular, are more prone to “broken heart syndrome,” or Takotsubo cardiomyopathy, Nanette K. Wenger, MD, FAHA, MACC, member of the AHA Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, said in an interview. Wenger is also professor of medicine (cardiology) emeritus in the division of cardiology at Emory University School of Medicine, consultant at Emory Heart and Vascular Center, director of the cardiac clinics at Grady Memorial Hospital and a member of the Cardiology Today Editorial Board.
Women and men also exhibit differences in plaque characteristics, with women having more plaque erosion than plaque rupture. Mehta told Cardiology Today that plaque erosion is most often seen in younger women who are smokers and who are less likely to have a high cholesterol level.
Differences in risk factors
Prevalence of risk factors, age, race and ethnicity may also be factors in the increased acute MI rate in women. Women have a higher prevalence of diabetes, HF, hypertension, depression and renal dysfunction.
Previous research has demonstrated that the age at first MI is younger among non-white women compared with non-Hispanic white women. Black women, in particular, have the highest rate of acute MI compared with women of all other races and ethnicities. Black women are also more likely than non-Hispanic white women to experience sudden cardiac death as the first symptom of CHD. Black and Hispanic women tend to have more CV-related risk factors such as diabetes, obesity and high BP at the time of MI compared with non-Hispanic white women. Compared with white women, black women are also less likely to be referred to cardiac catheterization and other important treatments, according to a press release.
Asian Indian and American Indian women are two other high-risk groups. The CHD mortality rate among Asian Indian women increased from 2003 to 2010. American Indian women have almost two times the number of CV events compared with the general U.S. population, and three-quarters of those events occur in American Indian women with diabetes.
“Black and Hispanic women tend to have more comorbidities or risk factors at the time of the heart attack,” Mehta said. Black and Hispanic women are also less likely to receive cholesterol-lowering medication and smoking-cessation counseling, she said.
“If there were greater prescribing of and adherence to both cholesterol-lowering medication and smoking cessation, maybe some of the racial disparities would be [eliminated],” Mehta said.
Psychosocial risk factors and stress may also play a role in onset and progression of CVD in women.
“We have to do considerable research into the psychosocial aspects of acute MI,” Wenger told Cardiology Today. “For example, with angina, men have more physical activity precipitated symptoms, whereas women have more emotional stress precipitated symptoms. The question is: How much of a role do emotional stress, anxiety and depression play and why is it more predominant in women? There is a great deal of research that needs to be done on this.”
Mortality higher
These differences in pathophysiology and clinical presentation often translate into worse outcomes for women.
Within 1 year of acute MI, the rate of death is 26% among women vs. 19% among men. Within 5 years of acute MI, the rate of death is 47% among women and 36% among men. This trend of higher mortality in women persists in the long term, according to current data.
Wenger told Cardiology Today that young women, in particular, do worse after MI and CABG.
According to Mehta, one reason for the poorer outcomes is that women with nonobstructive disease are less likely to be treated with guideline-directed therapies or have issues with adherence to guideline-directed therapies.
Increased awareness
Understanding differences in acute MI between women and men can help improve prevention and treatment, according to the statement.
“Coronary heart disease afflicts 6.6 million American women annually and remains the leading threat to the lives of women. Helping women prevent and survive heart attacks through increased research and improving ethnic and racial disparities in prevention and treatment is a public health priority,” Mehta said. – by Tracey Romero
- Reference:
- Mehta L, et al. Circulation. 2016; doi:10.1161/CIR.0000000000000351.
- For more information:
- Laxmi S. Mehta, MD, FAHA, can be reached at The Ohio University Medical Center, DHLRI, Suite 200, 473 West 12th Ave., Columbus, OH 43210; email: laxmi.mehta@osumc.edu.
- Nanette K. Wenger, MD, FAHA, MACC, can be reached at 49 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303; email: nwenger@emory.edu.
Disclosure: Mehta and Wenger report no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures.
Perspective
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Optimistically, this statement by the AHA should make an impact on future research and on clinical practice, but, with a more likely business as usual response, it will not. We should take Tables 3 (Gaps in Knowledge of AMI in Women) and 4 (Priorities to Improve Outcomes in Women with Acute MI) from the statement seriously at the NHLBI, the AHA and other funding agencies. For example, less than 10% of the NHLBI CVD budget is spent on CVD in women and less than 3% of the Go Red funds raised by women for the AHA goes to research on CVD in women. African American women are clearly at higher risk and deserve specific attention in research and policy. Other women such as those who are Hispanic and/or Asian are likely not at higher risk and may be at lower risk for [acute MI], but more data are needed (and are forthcoming) to state this for certain. We need advocacy for social justice.