July 2020, Volume XXXIV, Number 4
Women’s heart health disparities
By Courtney Jordan Baechler, MD
very year, more women die of heart disease than from all forms of cancer, Alzheimer’s disease, and chronic lower respiratory disease combined. While heart disease is the leading cause of death for both women and men, regardless of race and ethnicity, women represent more than half of all cardiovascular-related deaths. Sixty-four percent of these women have had no previous symptoms. Unfortunately, the statistics speak for themselves. One woman dies every 80 seconds from cardiovascular disease.
The reasons for these discrepancies may include reproductive factors, including those related to pregnancy and childbirth; disparities in the treatment of women; elevated plaque levels; acute and chronic conditions; responses to extreme stress; and psychosocial factors. Additional research is critical.
What the numbers say
Let’s break it down and see how we got here and what we can do to change outcomes. We know that our risk of heart disease starts early. Reproductive factors, including early menarche, early menopause, and miscarriage, are associated with an increased risk for coronary artery disease. We also know that high blood pressure during pregnancy, pre-eclampsia, and gestational diabetes increase the risk of developing heart disease later in life.
Additionally, while men are more likely to be classified as overweight, statistics show that women are more likely to be classified as obese or extremely obese. Unfortunately, these risks start to develop during reproductive years, when weight gain often starts for women, and during multiple pregnancies. Many women do not return to pre-pregnancy weight.
One woman dies every 80 seconds from cardiovascular disease.
We also see gaps in care as these risk factors develop during times focused on reproductive health care, when women may encounter less focus on lifelong, chronic disease mitigation. For many women, their obstetrician and gynecologist (ob-gyn) becomes their primary care physician.
We have a lot of work to do in the area of preventive care. In a study of more than 20,000 women who had a calcium score assessment, women who had a significant level of calcified plaque had a 75% higher mortality than men who had a similar level of plaque. Studies also show that women are less likely to be advised on their cardiovascular risk by physicians. Women are also less likely than men to be placed on lipid-lowering treatments. Diabetes is a significant risk factor for heart disease, but women with diabetes fare considerably worse than men. Women with diabetes are more likely to develop congestive heart failure, coronary heart disease, myocardial infarction, and ultimate death from coronary heart disease, than men with diabetes.
We might hope that it gets better with acute presentations, but that is not the case. Men and women with symptoms of heart attacks present differently. While the most common presentation for both genders is chest pain, women are more likely than men to present with fewer common symptoms, including shortness of breath, jaw pain, back pain, and nausea and/or vomiting.
Unfortunately, when women do present to the hospital, they are less likely to receive guideline-directed care or evidence-based medicine. If they present with chest pain, they are less likely to get a cardiac catheterization than men. Women are 2–3 times less likely to receive implantable cardiac defibrillators than men and 1.5 times less likely to be referred to cardiac rehabilitation than men. Finally, women are 25% more likely to die after a heart attack than men.
A few areas of study warrant additional attention. One of these is a condition called Myocardial Infarction with Non-obstructive Coronary Artery Disease (MINOCA). Angiograms appear normal in nearly half of women who have experienced a heart attack. Many women who come in experiencing symptoms of heart attacks and troponin elevations, and are taken for cardiac catheterization, are found to have no clear culprit for the heart attack. The large arteries appear clear of significant plaque (defined as <50% stenosis). The role that microvascular arteries may play is a growing area of study, particularly in women’s heart disease. It may require more aggressive treatment to improve outcomes and decrease the risk of developing more aggressive heart disease later.
Another area is Spontaneous Coronary Artery Dissection (SCAD), an acute condition that occurs when a tear forms in one of the coronary arteries. There are typically no pre-disposing risk factors for this condition, which occurs primary in women in their thirties and forties. As SCAD causes slow blood flow, or ultimately complete blockage of blood flow, it can cause heart attacks, arrhythmias, or even sudden death. An awareness of SCAD is critical for clinicians, emergency medicine technicians, and patients because of the uniqueness in presenting patients, and in their subsequent treatment. SCAD is more common in women. It has some association with recent childbirth (during the first few weeks after delivery), and is more common in patients with fibromuscular dysplasia, inherited connective tissue diseases, and in those with severe hypertension and illegal drug use.
Takotsubo syndrome, or stress-induced cardiomyopathy—sometimes referred to as broken heart syndrome—is another area to highlight for women’s heart disease. Takotsubo is an acute and reversible form of heart failure that occurs at a much higher rate in women. It is usually triggered by an extremely stressful event. Patients present with symptoms of a heart attack. It is common to see EKG changes, troponin elevations, and wall motion abnormalities on echocardiogram. When the patient is taken for cardiac catheterization, the coronary arteries appear normal, but the echocardiogram continues to show a decrease in left ventricular function with a classic Takotsubo pattern. Upon further history, it is usually found that these patients had a stressful event prior to their clinical presentation. Ongoing research shows that these events can reoccur for patients with high rates of both morbidity and mortality. Further understanding of those who are most likely to be affected by this condition and minimizing the risk is an area of active study.
Overall mental health also contributes to women’s heart health. Thirty-two percent of all coronary artery disease is thought to be secondary to psychosocial factors such as depression, stress, anxiety, and social isolation. Each year, one in five women has a mental health challenge, and depression is two times more common in women. Women are twice as likely to experience post-traumatic stress disorder and are two times as likely to experience generalized anxiety disorder. Income disparities can contribute to this risk. Women earn less than their male colleagues. In fact, women who work full-time are paid about 25% less than their male counterparts. Finally, 65% of women are the primary caregiver (either for their own children, their parents, or both).
While genetics are always important to understanding health differences between men and women, the human genome project showed that between all genders and races, we are 99% similar. It begs the question to examine societal structures on the various pressures on women throughout life, as well as the way we access care—when, where, and how—our access to insurance, and our ability to partake in research.
Overall mental health also contributes to women’s heart health.
For nearly 50 years, medical research has honed and crafted the art of detecting and treating cardiovascular disease, drastically reducing the mortality rate of a cardiac event. However, the studies that produced these medical advances primarily included men. Until recently, there had been little effort to ensure that women made up roughly half of all research participants. Even then, the data that was collected for women was combined with the men’s research data, missing the unique characteristics of the women participants. As a result, women’s cardiovascular research lags that of men by up to 35 years.
Responding to the need
The Minneapolis Heart Institute Foundation’s Penny Anderson Women’s Cardiovascular Center focuses on understanding heart disease in women—preventing it, treating it, and optimizing patient care. Our active research and databases started in the areas highlighted above, including SCAD, Takotsubo’s, and STEMI (ST-segment elevation myocardial infarction). Additionally, we are actively enrolling women in the WARRIOR study (Women’s Ischemia Trial to Reduce Events in Non-Obstructive CAD) to determine whether intensive medical treatment to modify risk factors and vascular function in patients with coronary arteries showing no flow limit obstruction but, with cardiac symptoms, will reduce the patient’s likelihood of dying, having a heart attack, stroke/TIA, or being hospitalized.
Perhaps most importantly, we are examining why women are not participating in research more equally. To fully understand why we don’t have equal representation, even in 2020, takes a qualitative and quantitative approach to better understand where bias might occur. We also need to ensure that we are offering an approach that includes all voices and reaches women where it’s easiest for them to participate in research with the trust, time, and outcomes they deserve.
We have recognized the importance of strong partnerships between obstetricians and cardiologists in the development of our Cardiopregnancy Program to ensure the best outcomes for moms and babies. However, we recognize that, in addition to recognizing high cardiovascular risk during pregnancy, we also need to further establish protocols that address ongoing strategies for lifelong risk mitigation prior to conception and for the many years afterwards. Part of this strategy will require additional prevention strategies and protocols that close these gaps in the years when many women get care only from their ob-gyn. There is an opportunity to partner in more aggressive ways with our primary care doctors and ob-gyns to ensure we have optimal prevention strategies, as well as cardiovascular disease recognition, similar to what men receive. Additionally, with the recognition that 80% of health occurs outside of our clinical walls, we are uniquely positioned to better partner with community organizations where our female patients live, work, and play to best prevent these outcomes and ensure we have truly met their needs.
A personal perspective
This is an exciting time to do more than analyze the data and to truly create action plans that close these gaps. To be successful, it’s going to take all of us working in partnership in innovative, disruptive ways to create a movement that closes these gaps forever.
© Minnesota Physician Publishing · All Rights Reserved. 2019
Courtney Jordan Baechler, MD, is a board-certified internist and cardiologist, focusing on the prevention of heart disease and behavioral change that supports overall well-being. Dr. Jordan Baechler serves as medical director of the emerging science centers at the Minneapolis Heart Institute Foundation, focusing on the women’s science center and the prevention center. Her previous roles include an appointment as assistant commissioner for the Minnesota Department of Health.