Heart disease is often thought of as a man's problem, but it is the leading cause of death for women in many countries, including the United States. Despite its prevalence, heart disease in women can present differently than in men, making it crucial to recognize and understand its unique signs and symptoms. This article highlights the importance of recognizing heart disease in women, the risk factors, symptoms, and preventive measures. (Garcia, M et al., 2016)
Understanding Heart Disease in Women
Heart disease encompasses a range of cardiovascular conditions, including coronary artery disease, heart failure, arrhythmias, and more. Coronary artery disease (CAD) is the most common type, characterized by the narrowing or blockage of the coronary arteries due to plaque buildup. This can lead to heart attacks, angina (chest pain), and other serious complications.
The most commonly faced heart problem is Myocardial infarction (MI), it is a term used for an event of heart attack which is due to the formation of plaques in the interior walls of the arteries resulting in reduced blood flow to the heart and injuring heart muscles because of lack of oxygen supply. (Lu, L, et al., 2015)
Coronary artery disease (CAD) can be defined as a vascular disease limited to the epicardial coronary arteries. It should not be confused with ischemic heart disease (IHD), which includes ischemic disease originating in the coronary arteries, the microcirculation, or from an imbalance in myocardial oxygen supply and demand. (Garcia, M et al., 2016)
For the sizeable proportion of women presenting for coronary artery disease (CAD) evaluation, our traditional disease management approaches that focus on the detection of critical stenosis often fail to identify those women critically at risk. More than a quarter of a million women die each year in the U.S. from IHD and its related conditions, and current projections indicate that this number will continue to rise with our aging population.
Recent estimates from the Centers for Disease Control (CDC) reveal that 38% of all deaths in women are related to coronary heart disease as compared with 22% resulting from cancer. Indeed, since 1984, more women than men have died annually from IHD, refuting the notion that this is a “man’s disease” and suggesting that it might be relabeled as a “woman’s affliction”. (Wilmot, K. A et al., 2015)
Differences Between Men and Women
Research has shown that heart disease can manifest differently in women compared to men. Women are more likely to have non-obstructive coronary artery disease, where the large arteries are not significantly blocked but the smaller arteries are affected. This condition is called microvascular disease or small vessel disease. These differences can result in varying symptoms and challenges in diagnosis.
In the majority of cardiovascular diseases (CVDs), there are well-described differences between women and men in epidemiology, pathophysiology, clinical manifestations, effects of therapy, and outcomes. These differences arise on one hand from biological differences between women and men, which are called sex differences. They are due to differences in gene expression from the sex chromosomes and subsequent differences in sexual hormones leading to differences in gene expression and function in the CV system, e.g. in vascular function and NO signaling, in myocardial remodeling under stress, or metabolism of drugs by sex-specific cytochrome expression.
Gender differences are unique to the human. They arise from sociocultural processes, such as different behaviors of women and men; exposure to specific influences of the environment; different forms of nutrition, lifestyle, or stress; or attitudes towards treatments and prevention. These are equally important for CVDs. Both sex and gender (S&G) influence human development. (EUGenMed, T et al., 2015)
Recognizing the Signs and Symptoms
Common Symptoms in Women
While chest pain is a well-known symptom of heart disease, women often experience it differently. They might describe it as pressure, tightness, or discomfort rather than sharp pain. Furthermore, women are more likely to have symptoms unrelated to chest pain, which can be easily overlooked or misattributed to other conditions. Women have a different pattern and distribution of non–chest-related pain symptoms. Compared with men, women’s ischemic symptoms are more often precipitated by mental or emotional stress and less frequently by physical exertion. (Mieres, J. H et al., 2014)
- Chest Discomfort
Chest discomfort remains the most common symptom in both men and women, but it may present as a squeezing sensation or pressure rather than outright pain. It can occur during rest, physical activity, or even during periods of emotional stress. (Mieres, J. H et al., 2014), (Writing Committee Members, Gulati, M, et al., 2021)
- Shortness of Breath
Shortness of breath can occur with or without chest discomfort and may be more noticeable during physical activities or even at rest. It can sometimes be mistaken for anxiety or a respiratory condition. (Mieres, J. H et al., 2014)
- Fatigue
Unusual fatigue is a common yet often overlooked symptom of heart disease in women. Women may feel excessively tired despite getting adequate rest and may struggle with daily activities that were previously manageable. (Mieres, J. H et al., 2014)
- Nausea and Dizziness
Women may experience nausea, lightheadedness, or dizziness, which can be mistaken for gastrointestinal issues or vertigo. These symptoms can occur suddenly or gradually. Studies that have systematically evaluated sex differences in presenting symptoms have not found a pattern of symptoms uniquely ascribed to male or female patients, but significant overlap in qualitative descriptors exists. Proportionately, women more often report epigastric discomfort and associated nausea. (Mieres, J. H et al., 2014)
- Pain in Other Areas
Heart disease can cause pain in areas other than the chest, and radiation of discomfort to the arms, neck, and interscapular areas such as the jaw, shoulders, upper back, or abdomen. This pain may come and go, making it difficult to pinpoint its cause. (Mieres, J. H et al., 2014)
Silent Heart Attacks
Silent heart attacks are more common in women than in men. These are heart attacks that occur without the typical symptoms like chest pain. Women might experience mild discomfort, shortness of breath, or fatigue, which they may not recognize as signs of a heart attack. Silent heart attacks can cause significant damage to the heart and increase the risk of subsequent heart issues. Some studies show that silent myocardial infarction carries a worse prognosis than recognized myocardial infarction. (Soliman, E. Z. 2019), (Sueda, S, et al., 2015)
Risk Factors for Heart Disease in Women
The concept of “risk factors” in coronary heart disease (CHD) was first coined by the Framingham Heart Study (FHS), which published its findings in 1957. FHS demonstrated the epidemiologic relations of cigarette smoking, blood pressure, and cholesterol levels to the incidence of coronary artery disease (CAD). The findings were truly revolutionary for they helped bring about a change in the way medicine is practiced. (Hajar, R. (2017).
There is also increasing evidence that biological differences may impact the expression of cardiovascular risk factors and impart a differential risk for women compared with men. Hypertension, diabetes mellitus, and smoking are more potent risk factors for MI in women than in men. Additionally, there are several nontraditional cardiac risks unique to or predominant in women, including early menopause or menarche, gestational diabetes mellitus, hypertension, preeclampsia and eclampsia during pregnancy, and systemic inflammatory disorders. (Aggarwal, N. R et al., 2018)
Several risk factors can increase the likelihood of developing heart disease in women. Some are common to both genders, while others are more specific to women.
- High Blood Pressure
Hypertension, or high blood pressure, is a major risk factor for heart disease. It can damage the arteries and lead to the buildup of plaque, increasing the risk of heart attacks and strokes. Women who develop high blood pressure during pregnancy (preeclampsia) are at higher risk later in life.
Hypertension is one of the risks in the development of CHD. The American President Roosevelt died from a cerebral hemorrhage, sequelae of hypertension. (Hajar, R. (2017).
- High Cholesterol
Another major risk for CVD is cholesterol. In 1953, an association between cholesterol levels and CHD mortality was reported in various populations. Elevated levels of low-density lipoprotein (LDL) cholesterol, known as "bad" cholesterol, can contribute to plaque buildup in the arteries. Conversely, low levels of high-density lipoprotein (HDL) cholesterol, or "good" cholesterol, can also increase the risk of heart disease. It was also found that LDL cholesterol levels in young adulthood predict the development of CVD later in life. (Hajar, R. (2017).
- Diabetes
Diabetes significantly increases the risk of heart disease in women. Women with diabetes are more likely to develop heart disease at a younger age compared to men with diabetes. High blood sugar levels can damage blood vessels and the nerves that control the heart. The role of diabetes in the pathogenesis of CVD was unclear until 1979 when Kannel et al. used data from the Framingham heart study to identify diabetes as a major cardiovascular risk factor. The Kannel article changed the way the medical community thought about diabetes. It is now accepted as a major cardiovascular risk factor. There is a clear-cut relationship between diabetes and CVD.
Diabetes is treatable but even if glucose levels are under control it greatly increases the risk of heart disease and stroke because people with diabetes also have other conditions that are risks for developing CHD such as hypertension, smoking, abnormal cholesterol, obesity, lack of physical activity, and metabolic syndrome. The good news is that by managing these risk factors, people with diabetes may avoid or delay the development of CVD. (Hajar, R. (2017).
- Obesity
Excess body weight, particularly around the abdomen, is associated with an increased risk of heart disease. Obesity can lead to other risk factors like high blood pressure, high cholesterol, and diabetes. The prevention and control of overweight and obesity in adults and children has become a key element for the prevention of cardiovascular diseases. (Mehta, L. S et al., 2016)
- Smoking
Smoking is a major risk factor for heart disease. It damages the lining of the arteries, promotes the buildup of plaque, and reduces oxygen in the blood. Women who smoke have a higher risk of heart disease compared to men who smoke.
The Framingham study showed that smokers were at increased risk of myocardial infarction (MI) or sudden death and that risk was associated with the number of cigarettes smoked each day. These results were confirmed by other epidemiological studies. The deleterious effect of smoking on health has been proven in many studies, in particular on atherosclerosis. (Mehta, L. S et al., 2016)
- Menopause
The decline in estrogen levels during menopause is associated with an increased risk of heart disease. Estrogen is believed to have a protective effect on the cardiovascular system, so its reduction can lead to changes in blood vessel walls and lipid profiles.
Menopause is a critical reproductive aging event signifying the end of fertility. The menopause transition (MT) is a complex phase marked by dynamic changes in hormonal and menstrual bleeding patterns as well as multiple physiological and psychological symptoms. A recent American Heart Association scientific statement identifies the MT as a uniquely impactful period associated with acceleration in CVD risk. During the MT, women experience adverse changes in several lipids/lipoproteins measures that have been linked to a greater risk of CVD thereafter. (O’Kelly, A. C et al., 2022)
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Preventive Measures and Lifestyle Changes
Preventing heart disease in women involves addressing risk factors and adopting a heart-healthy lifestyle. Regular health screenings for blood pressure, cholesterol, and diabetes are crucial for early detection and management. A heart-healthy diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats, while reducing the intake of saturated fats, and sodium, is essential. Regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise per week, helps maintain a healthy weight and improves heart health. Quitting smoking and limiting alcohol intake significantly reduce risk, as does managing stress through relaxation techniques and seeking support when needed. Adhering to prescribed medications for conditions like high blood pressure, high cholesterol, or diabetes is also vital. (Mehta, L. S et al., 2016)
Conclusion
Heart disease in women is a significant health concern that requires attention and action. Recognizing the signs and symptoms unique to women, understanding the risk factors, and adopting preventive measures are key steps in reducing the impact of heart disease. By increasing awareness, advocating for women's health, and supporting ongoing research, we can work towards a future where heart disease in women is better understood, prevented, and treated.
References
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Wilmot, K. A., O’Flaherty, M., Capewell, S., Ford, E. S., & Vaccarino, V. (2015). Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women. Circulation, 132(11), 997-1002.
Aggarwal, N. R., Patel, H. N., Mehta, L. S., Sanghani, R. M., Lundberg, G. P., Lewis, S. J., ... & Mieres, J. H. (2018). Sex differences in ischemic heart disease: advances, obstacles, and next steps. Circulation: Cardiovascular Quality and Outcomes, 11(2), e004437.
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