07 Aug, 2014 Heart disease: not just a man’s problem
When you think of a candidate for a heart attack, you probably don’t think of a woman. But heart disease is the biggest killer of women in Australia, yet many aren’t aware of their risks.
Picture someone having a heart attack, and most likely, the image you see is of an older man, clutching his chest and wincing.
What you’re less likely to picture is a younger woman, maybe in her forties, with some shortness of breath, struggling with fatigue, complaining about an ache in her jaw or her arm but deciding not to go to the doctor because she doesn’t have chest pain.
But we need to shift our thinking as heart disease is the number one killer of women in Australia. Each day it claims the lives of 25 Australian women – three times as many as breast cancer. Also women are more likely to die from a heart attack than men (more men than women have heart attacks, but men are much more likely to survive).
Yet there is clear evidence that women are less likely than men to go to a doctor when they have symptoms, less likely to be correctly diagnosed when they are having a heart attack, and less likely to receive the recommended treatment.
One reason is the general lack of awareness around heart disease risk factors, an issue for men and women. Heart Foundation data suggest many women don’t know high blood pressure and high cholesterol are risk factors, although one in three adult women has high cholesterol (90 per cent of them don’t know it) and one in four aged over 35 has high blood pressure (only a third of them know).
Changes after menopause
But the uniquely female experience of menopause throws a spanner in the biological works because of the impact of hormones on the risk factors for heart disease, says US cardiologist Associate Professor Joanne Foody, from Harvard Medical School.
“Women undergo pretty significant changes in their cholesterol levels, their blood pressure and even their insulin resistance as they go through peri-menopause and menopause,” says Foody, also director of the Pollin Women’s Heart Centre at Brigham and Women’s Hospital, Boston
“Unfortunately women who were completely healthy and had no risk factors, within the course of a couple of years that can change dramatically.”
Different symptoms to men
Women also tend to experience different heart attack symptoms to men, says Ms Julie-Anne Mitchell, national spokesperson on women and heart disease for the National Heart Foundation.
“What we know is that 40 per cent of women won’t experience that crushing chest pain, and are more likely to experience non-chest pain symptoms, so it might be intermittent jaw pain, it might be pain down their arm or between the shoulders,” says Mitchell.
“It might not be any pain at all – it might be sweatiness, a feeling of nausea or it could be just thinking they’re overwhelmingly fatigued and can’t take another step.”
Unfortunately, because the dominant image of heart attack revolves around the older man with chest pain, a woman having a heart attack may not recognise her own symptoms, and often nor do health professionals.
Responses from doctors
A 2008 survey of Australian GPs found major differences in the way doctors diagnosed and treated heart disease in women compared to men. Associate Professor Fiona Turnbull, lead author on the study, said the AusHEART study was revealing because it showed that the differences between men and women were more obvious the higher the patient’s level of risk.
“In terms of patients that were fairly low risk, who had less than a 15 per cent chance of having major event in next five years, there weren’t really any gender differences,” says Turnbull, from The George Institute for Global Health and Office of the Chief Scientist.
“But when it came to people who were at highest risk, so generally people who have already had some sort of event, there were significant differences in the way GPs not only assessed their level of risk and the way they managed them as well, and also to some extent in the way patients managed their own illness.”
The survey also found that women who were diagnosed and treated for heart disease were less likely than men to achieve their targets for lowering blood pressure and cholesterol.
However, Foody says women themselves are partly responsible for this failure in treatment.
“When I’m offering women medicines like a beta-blocker after a heart attack, or a cholesterol-lowering medication or aspirin, women tend to be much more resistant than my male patients to take the therapies,” says Foody.
She says women are more likely to be sceptical of the need for medical therapies, and have specific questions or concerns about side effects.
“Often the men have a very supportive spouse to say, ‘no you’re going to take your medicine, you’re going to do this’, to really support them – we know that as far as adherence, married men are the most adherent patients and married women are actually the least adherent patients.”
Changing research focus
The solution to all these challenges is complex, because it requires a change in awareness and practice throughout the medical system and even extending into the research field.
Women are rarely represented equally in clinical trials of any kind, but this becomes a particular problem in heart disease when the results of those trials are used to identify risk factors, calculate risk, and explore treatments for heart disease.
For example, some methods used to calculate a person’s risk of having a heart attack – which work by examining their risk factors such as high blood pressure and high cholesterol – don’t include diabetes as a risk factor, even though diabetes increases a woman’s risk of heart disease much more than it does for a man.
“For too long there has been underinvestment in cardiac care for women and we need to address this, investigate the physiological differences between men and women, redress the fact that at the moment, randomised controlled trials only include about 25 per cent of women,” says Mitchell.
Organisations such as the National Heart Foundation are now actively campaigning to raise awareness of heart disease in women and fund more research into this area, with initiatives such as the Go Red campaign.
The organisation now recommends all women aged over 45 – or aged over 35 for Aboriginal and Torres Strait Island women – should have a regular heart health check, to examine their lifestyle and measure risk factors such as diabetes and blood pressure.
“Once you’re equipped, once you know your own risk, you can take steps to address that,” Mitchell says.
“We don’t want a heart attack to be a woman’s first indication that she has heart disease.”