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Q&A: Awareness of women’s heart health critical for diagnosis, treatment
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The signs of CHD are sometimes different in women than in men, although knowledge gaps remain on how to diagnose and treat women with it.
In honor of National Wear Red Day, which raises awareness that CHD is the leading cause of death in women, Cardiology Today spoke with MaryAnn McLaughlin, MD, associate professor of medicine, assistant professor of population health science and policy, medical director of the cardiac health program and co-director of the women’s cardiac assessment and risk evaluation program at Mount Sinai Heart, about the importance of treating women with CHD and what to be aware of when caring for them.
Question: Why is it so important for cardiologists to focus on heart disease in women?
Answer: Importantly, heart disease is the leading cause of death in women in the United States. Approximately 300,000 women will die each year, and it accounts for 1 in 4 of all female deaths. Almost two-thirds of women who die suddenly of CHD have no previous symptoms that have been reported. What physicians are responsible to do is to make sure that women understand which symptoms could be associated with heart disease and to discuss ways of preventing heart disease.
Q: Why don’t women have these reported symptoms? Are doctors missing them or are women not telling their doctors how they feel?
A: There’s a combination of reasons. I always tell a story about how many years ago now, my mother-in-law, who was a smoker, was developing a cough, some chest pressure and jaw pain. She went to the emergency room. She told them she’d taken an aspirin and she was worried that she was having a heart attack. The doctor laughed and said, “I think it’s bronchitis. We’re going to keep you overnight and we’ll do a stress test.” They did a stress test, she failed and she had a 95% blocked artery.
For me, it was eye-opening, because she said that she only knew because of me, her daughter-in-law, but this was an [ED] physician and she was at the time in her 50s or so. She wasn’t that old and she had been a smoker.
We’ve been getting the word out about women’s typical symptoms, which would be chest pressure, like someone’s sitting on the chest, which happens in men and women. Someone would say that their chest feels tighter suddenly, like there’s a sensation all around the chest and there’s a tightening. There could be increasing nausea and then overwhelming fatigue out of the blue, like feeling like you have a bad case of the flu and you don’t feel like doing anything. That could be one of the warning signs. Other signs include nausea and sweating, pain that radiates to the jaw or to the middle of the back.
When you compare men and women symptoms, most women do have the classic symptoms of a chest pressure, someone sitting on your chest, difficulty breathing, sweating, nausea, but compared with men, women are more likely to complain of the nausea symptoms or maybe some pain in the jaw or back.
What’s also important is that not only physical stress, but mental stress can trigger MI in women. Physical stress is more likely to be the event in men than women.
Importantly, there are risks or diagnoses associated with pregnancy that can affect a woman’s heart disease risk down the road. Any woman who’s had gestational diabetes is at risk for developing diabetes 5 years later. Any woman who’s had a baby who was more than 9 lb is at increased risk for developing diabetes down the road. Any woman who develops hypertension near the end of pregnancy, pregnancy-induced hypertension or preeclampsia, is at increased risk for developing hypertension down the road. Those are all very important things when we talk about pregnancy risks with doctors.
In 2011, the latest guidelines specific to women and heart disease were produced by the American Heart Association and the American College of Cardiology. In there, the authors wrote that women with connective tissue disorders such as lupus and rheumatoid arthritis are more likely to be at risk for heart disease or MI down the road.
Depression is definitely a risk factor for heart disease and should be actively discussed with the patient’s physician.
Q: What lifestyle changes can women make to prevent CHD?
A: Importantly, women need to know their numbers. They need to know their BP. They need to know that ideal BP is 120 mm Hg systolic/80 mm Hg diastolic. The new guideline that just came out from the AHA and ACC now says that when BP creeps up to 130 mm Hg/80 mm Hg, that can be a diagnosis of hypertension.
They need to make sure they maintain a healthy weight and they don’t smoke. They need to make sure that if they feel depressed, they talk with someone and get treated for depression because that’s a risk factor for heart disease.
Ideally, they want to keep their waist circumference 35 inches or less because it’s been shown that a waist circumference of 40 inches or less in men and 35 inches or less in women is important for reducing cardiac risk due to abdominal fat. There are a lot of proteins in abdominal fat that are a direct cause of heart disease.
Secondly, they need to watch their sugar intake, to eat a diet that’s more heavily plant-based and to be checked for diabetes, especially if it runs in their family.
Q: What else can cardiologists do to work with women to reduce their risk?
A: No. 1, physicians should talk to every woman in their visits — whether it’s with an internist or gynecologist — about their risks, including their cholesterol levels. Having high cholesterol is an increased risk for heart disease.
Physicians should talk to the patients about their family history of MI, sudden death and stroke in all women who come to their offices. If your parent had a MI or a blocked artery that led to a stent or bypass surgery, that can be a risk in you, especially if that occurred in a parent who’s younger than 60 years.
The physician should be asking those questions about family history of heart disease, about smoking, about depression. They should be doing a quick screening of that, about healthy lifestyles, which include a health diet that’s more plant-based.
The other interesting dietary issue that came out in a very large Women’s Health Initiative study and the Nurses’ Health Study is that women who ate two to three servings a week of dark berries — blueberries, blackberries, raspberries and strawberries; eggplant was also included — had a lower risk for heart disease or MI, so important diets that are high in not only vegetables, but certain fruits and also low in fat and low in processed foods.
Q: What further research is needed in this field?
A: More genetic research needs to be done because there are many people who have people in their family who have had sudden death, and they say, “Well, it’s because my father had a bad lifestyle.” So, they’ll come to me and say, “My father smoked and he was overweight. He didn’t take care of himself and he died at age 50, but that doesn’t mean I will.” We don’t know for sure what that genetic issue was. Maybe there is some increased risk. Going forward, if we could see more specifically what an individual’s risk would be by using more genetic testing, that may help.
There are two other cardiovascular diseases that are much more prevalent in women, and this is where also research needs to be headed. One is called spontaneous coronary artery dissection. It’s not very common, but 80% of cases are women. More commonly, it happens around the time of hormonal change, so in patients after pregnancy, like 1 month after delivering a baby, patients who have recently started on a birth control pill or patients who are perimenopausal. I’ve had several of those types of patients in my office, and one was just walking down the street and she felt this pressure in her chest and it accelerated. She went to the emergency room. The first ECG was normal, her blood tests were normal. Luckily, they kept her, and then several hours later, it progressed. They took her to the cardiac cath lab and they could see that the coronary artery had a tear. The tear then is precipitated and a blood clot forms. Then all the labs and ECGs look abnormal.
I had another patient who had two young children, and she was in her 40s and premenopausal at the time it was happening. She was having her period that day. She was having an argument with her husband and her husband left. She felt like she had this pressure in her chest and felt like she was giving birth through her chest. She called 911 and then she passed out in the kitchen with her 2- and 4-year-old there. The ambulance showed up, she was revived and taken to the emergency room. She also had spontaneous coronary artery dissection.
It’s a disorder that’s scary to talk about because it’s hard to prevent right now, so we really need to learn more about the effect of hormones on the arteries.
Takotsubo cardiomyopathy, also known as broken heart syndrome, also occurs more predominately in women compared with men. Eighty percent of the patients who have it are women. It’s characterized by sudden increase in adrenaline levels, whether it’s for good stress or a bad stress, but mostly bad stress like sudden death of someone you love or terrible news. Sometimes it may not be that traumatic. It could be at someone’s wedding where you’re overwhelmingly happy, but with a high adrenaline level. It feels just like a MI. When patients get to the emergency room, the ECG shows changes of a MI. When they go to have an angiogram of the heart, the arteries are completely fine, but the heart muscle had become very weak. It’s the small blood vessels. They say that there’s an increase in adrenaline that stuns the heart and it becomes weakened. It usually improves. Again, these are areas that we don’t understand very well about how to prevent. – by Darlene Dobkowski
*Photo credit: Mount Sinai Health System
For more information:
MaryAnn McLaughlin, MD, can be reached at Guggenheim Pavilion Floor, 6th Floor, Room 6-272B, 1190 5th Ave., New York, NY 10029; email: maryann.mclaughlin@mountsinai.org.
Disclosure: McLaughlin reports no relevant financial disclosures.