Despite heart disease being the number one killer of women globally, most women are unaware of their risk, believing that heart disease is man’s disease. Women delay seeking medical attention for heart attack symptoms and are more likely to die in the weeks and months following a heart attack than men. Given this fact, perhaps it’s not surprising to learn that while cardiovascular mortality is clearly falling in men, in women it has not slowed to the same rate and in younger women particularly, cardiovascular mortality is on the rise. Appreciation of these facts has led to a, much needed, focus on women’s heart disease at a scientific, clinical and social level to try to determine the contributing factors to the difference in outcomes between genders.
One such factor is that our understanding of heart disease in women has been based on research undertaken mainly in men. This fails to account for the fact that women’s hearts and men’s hearts are different. Women have different risk factors for heart disease than men, and often experience very different symptoms. Women also can experience different types of heart attacks to men meaning that the underlying biology and necessary treatment is different.
The traditional risk factors for cardiovascular disease are well appreciated by most and include high blood pressure, high cholesterol, diabetes, smoking and being overweight. These are risk factors in both women and men, although interestingly smoking and diabetes carry a higher risk of heart disease in women than in men. There are also novel or non-traditional ‘female specific’ risk factors in women, which are non-modifiable. While these are not treatable conditions, they are markers of elevated risk and provide insight into which women should be more closely monitored and have their modifiable risk factors (like blood pressure and cholesterol) more aggressively treated. These include hormonal factors such as early menopause (menopause before 50, with a dose dependant relationship meaning the earliest menopause is associated with the greatest risk). In fact every woman’s risk of heart disease rises at the time of menopause, as changes in lipid profile, body composition and vascular function all occur in response to a hormonal shifts. In addition to age of menopause, age at menarche (when menstruation first begins) also has an association with cardiovascular risk, with women who undergo early (<10 years of age) or late (>15 years of age) menarche having higher risk of cardiovascular disease. In addition to hormonal factors, pregnancy complications are also a clearly established risk factor for premature cardiovascular disease. The numerous changes in the cardiovascular system that occur during a normal pregnancy makes pregnancy a stress test for the cardiovascular system. Women who experience pre-eclampsia, gestational diabetes, gestational hypertension, premature delivery or deliver a small for gestational age infant are more likely to develop cardiovascular disease at a younger age. These risk factors are not taken into consideration when using the traditional cardiovascular risk calculators which may result in an under-estimation of a woman’s risk. Other risk factors such as inflammatory conditions including rheumatoid arthritis and lupus also significantly increase an individual’s risk of cardiovascular disease. It’s important that women discuss their obstetric history, timing of menopause and other medical conditions with their GP when talking about cardiac risk.
As well as having unique risk factors for heart disease, women often present in unique ways. While men classically present with central chest pain that may radiate to the jaw or left shoulder or arm, women are more likely than men to experience other more general symptoms such as overwhelming fatigue, breathlessness, sweating, nausea, dizziness, arm pain/heaviness, chest tightness or pressure, or heartburn-like symptoms. In some cases, women do experience chest pain but have co-existing symptoms (such as dizziness, nausea or fatigue) which can be distracting to both the patient and investigating team making it harder to diagnose a heart attack in a timely fashion. Delays to diagnosis can mean loss of heart muscle and loss of life. Arming women with knowledge of the atypical symptoms that they may experience when having a heart attack is essential to improving access to timely care and bettering outcomes for women with heart disease.
The era of Women’s Cardiology is late to the arena but finally here. There is more research than ever being undertaken to better our understanding and knowledge of heart disease in women and Women’s Heart Clinics are being developed around the world to provide expert care to women experiencing heart disease and those at risk of heart disease. We’re working hard to increase awareness and education so that women everywhere can understand their risk, know the symptoms, and seek help early should they need it. Speak with your GP about your cardiac risk and develop a plan to minimise it.
Dr Monique Watts
Cardiologist – MBBS BMedSci, FRACP
Women’s Heart Clinic at The Alfred
Victoria Heart
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