Heart Disease Overlooked in Women

Coronary artery disease (CAD) continues to be neglected in women, despite it killing at least as many women as men, a state-of-the-art review found.

In addition, women are less likely to receive preventive therapies, such as lipid-lowering therapies and lifestyle advice compared with men at a similar risk level, according to Martha Gulati, MD, and Kavita Sharma, MD, from The Ohio State University in Columbus.

CAD is a leading cause of death of women and men worldwide. Yet CAD’s impact on women traditionally has been underappreciated due to higher rates at younger ages in men,” they wrote.

Women are disproportionately affected by microvascular coronary disease and they have unique risk factors for CAD, including those related to pregnancy and autoimmune disease, they wrote in a review in this month’s edition of Global Heart, the journal of the World Heart Federation.

In their review, the authors summarized “the current state of knowledge about women and CAD,” including risk assessment, unique sex-specific CAD characteristics, and management strategies in 2013.

CT scans and other imaging techniques show that women have narrower coronary arteries than do men, and are more likely to suffer CAD due to microvascular disease. So while appearing not to have major coronary artery obstructions, women suffer symptoms due to blockages of these smaller vessels.

Women without obstructive CAD suffer repeated hospitalizations and testing due to symptoms of ischemia.

In contrast, obstructive CAD is more commonly found in men who are symptomatic and can be treated with aggressive medical therapy or stenting. This type of CAD is less frequently seen in women.

Pooled estimates from multiple countries revealed that women, both pre- and postmenopausal, are also 20% more likely to suffer angina than men (pooled sex ratio of angina prevalence. “Trial data indicate that CAD should be managed differently in women,” they said.

Specifically, more women than men die of CAD, and more women have died of CAD than of cancer, including breast cancer, chronic lower respiratory disease, Alzheimer’s’s disease, and accidents combined.

Overall, rates of CAD have declined by 30% in the last decade, but rates have actually increased in women younger than 55, researchers said.

Despite these known facts, women are still less likely to receive preventive recommendations, such as lipid-lowering therapy, aspirin, and lifestyle advice, than are men at a similar risk level, Gulati and Sharma pointed out.

In terms of coronary artery bypass grafting (CABG), female sex is an independent risk factor for morbidity and mortality, the authors also noted.

“Women have a higher risk of morbidity and mortality and they experience less relief from angina than do men after CABG, despite comprising less than 30% of the CABG population,” they explained, adding that this sex discrepancy seems to be reduced when an off-pump CABG is performed.

Traditional risk factors such as age, family history of CAD, hypertension, diabetes, dyslipidemia, smoking, and physical inactivity are important predictors of risk in women.

Yet, women tend to a dramatic increase in CAD after the age of 60, in contrast to men who tend to have a more linear increase in CAD as they age.

This difference in the development of CAD creates a situation where the disease isn’t identified until much later in the course of the disease.

There also are risk factors that appear to affect men and women differently.

Obesity, for example, increases the risk of CAD by 64% in women but by only 46% in men.

Younger women (less than 50 years) who experience a CAD-related myocardial infarction (MI) are twice as likely to die as men in similar circumstances, researchers noted.

And as women age, they continue to have notably different risk factors than men.

Women over the age of 65 are more likely to die within the first year after an MI compared with men (42% versus 24%).

Women are also more likely than men to suffer autoimmune diseases, raising their risk of CAD, as well as polycystic ovary syndrome, pre-eclampsia, and gestational diabetes, which can also ultimately increase risk of CAD in women.

Another risk factor is breast cancer treatment, which has improved survival for this disease in its early stages, but “the gains are being attenuated by increasing CAD risk. Whether the increased CAD risk is due to the breast cancer therapies or to the disease itself — which is associated with some of the same risk factors for CAD — remains unknown,” Gulati and Sharma wrote.

campaign, running in partnership with this month’s Women’s European Football Championships, researchers pointed out.

Such awareness is greatly needed, for women and healthcare providers alike, the researchers said. In 1997, only 30% of American women surveyed were aware that the leading cause of death in women is CAD; this increased to 54% in 2009.

But in a survey performed in 2004, fewer than one in five physicians recognized that more women than men die each year from CAD. Furthermore, cardiac rehabilitation after heart attacks is underused, particularly in women, as demonstrated in numerous national studies. Women are 55% less likely to participate in cardiac rehabilitation than men are.

“Increasing data demonstrate that some treatment strategies have sex-specific effectiveness,” the investigators concluded. “Further research regarding the pathophysiology of CAD in women, diagnosis, and treatment strategies specific to women is required. CAD is not a ‘man’s only’ disease, and we eagerly await future studies that examine its unique presence in women.”