The Heart of a Woman

Gender differences in heart disease

For decades, women have been striving for equality, but one place they have reached parity is in heart disease. As with men, cardiovascular disease is the No. 1 killer of women — causing a third of deaths among all women.

We talked about women and heart disease with Dr. Martha Gulati, associate professor of cardiology and Section Director for Preventive Cardiology and Women’s Cardiovascular Health at The Ohio State University Wexner Medical Center in Columbus, Ohio.


There are many types of cardiovascular disease (for descriptions of the major ones, see "A Glossary of Heart Disease,"). This article focuses on ischemic heart disease, one of the most common types in women. Ischemic heart disease is the term given to heart problems caused by narrowed heart arteries. When arteries are narrowed, less blood and oxygen reach the heart muscle. This is also called coronary artery disease and coronary heart disease. It can lead to a heart attack.


Not all women have the symptoms that people commonly associate with a heart attack — crushing chest pain, shortness of breath and pain radiating to the left shoulder and arm. "About a third of women have what are called ‘atypical symptoms,’" Gulati said. "I don’t love that term because it makes the symptoms sound abnormal, and in a third of women they are typical." These symptoms include neck and jaw pain or even back pain, but don’t necessarily include pressure or pain in the chest. Women may also describe profound fatigue or the sudden onset of fatigue. Another symptom is feeling short of breath doing activity that they could do before with no problem.


Part of this difference in symptoms may be explained by the fact that the disease in women seems to affect different blood vessels. "Often when a man comes in with a heart attack, we will find a tight, obstructive lesion in one of his major coronary arteries," Gulati said. "In many women we are finding that it is actually the smaller vessels that are causing the problem." Gulati quickly adds that many women have blockages in the large coronary arteries, but many other women do not have those obstructions and yet have heart attacks or symptoms and signs of ischemia. "There is evidence of ischemia and they have symptoms of it, but when we test, we don’t find a blockage in a vessel." In addition to the three large coronary arteries that feed the heart muscle, tiny blood vessels and capillaries cover the heart so doctors can’t see the blockages during routine cardiac catheterization, a procedure to examine how well your heart is working.

"We used to call this kind of ischemia without a blockage ‘cardiac syndrome X.’ Now we are calling it ‘female-specific ischemic heart disease’ because we are finding this pattern much more common in women," Gulati said. More research on ischemic heart disease is needed to find out if this explains the difference in heart attack symptoms between men and women.

At this time, coronary artery disease and ‘female-specific ischemic heart disease’ are treated with the same medications, but other drugs may target those smaller vessels better. "Right now we do not have those answers," Gulati said. "There are ongoing studies trying to determine that."



We do not know as much about women’s heart disease as men’s because it has not been studied as much. "When I was in medical school in 1995 very few women were even included in clinical trials," Gulati said. So it was not possible to say what the best treatment options were. "In the past decade women have been included more, so now we have evidence-based treatment. Now there are drugs that we believe a female heart attack survivor should be on, no matter what. For instance, they should be on an aspirin and a statin. They should also be on an ACE inhibitor and a beta-blocker, as well as a blood thinner [antiplatelet agent]."

But even with best practices established, there is still a treatment gap between men and women. Women are much less likely to be given lifesaving treatments. "We should be gender blind and color blind when we are taking care of patients," Gulati said. "There is no reason that people should be denied lifesaving therapy. The American Heart Association has been instrumental in developing treatment guidelines for women, and they have certainly made a difference because we are seeing a decline in women’s mortality rates in the United States."


Another way that men and women differ is in their attitude toward getting help. Women tend to delay going to the doctor for preventive care or to the ER when they are having an event. They put others’ needs first because that is what wives and mothers do, but that is the wrong response. "If you think you are having a heart attack, what is the one thing that you need to do?" Gulati asked. "It is not ‘tidy the house or make sure there is enough food.’ It is not ‘call your doctor and see if they think that this is anything to worry about.’ The first response should be ‘call 9-1-1.’"

GoRed® Real Women 2014-15; from left to right: Veronica Sanchez, Lisa Deck, Mariam Giardini, Debra Koziol, Rhonda Hall, Amanda Gonzalez, Laura Bell Bundy, Julia Allen, Betty De Aragon, Jen Thorson


It is critical for women to be their own advocates in the healthcare system, which does not traditionally identify women as having heart disease. "If you’re at the ER, say, ‘Listen, I’m a diabetic. I have high blood pressure. My mother or father died from heart disease. How do you know it is not my heart?’" Gulati said. If you’re at the doctor’s office on a routine visit, ask to have your heart disease risk calculated. There’s a risk calculator on the American Heart Association website to help physicians while assessing a patient. "We can calculate short- and long-term risk, as well as lifetime risk," Gulati said. "Those numbers are a good place to begin a conversation about preventing heart disease. We are better educating our healthcare teams about women and heart disease, but women still need to be their own champions."

Heart disease is the No. 1 killer of women. If you have any of the symptoms that make you think, ‘Could this be my heart?’ you need to be seen right away. (See "Women can have different symptoms than men" below.) However, long before there are symptoms, women need to be more proactive about prevention. "Women are very good at going for their Pap smear and mammogram," Gulati said. "But they have a 1 in 8 chance of breast cancer and a 1 in 3 chance of having cardiovascular disease. A mammogram is important, but every woman needs to be screened for heart disease."


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