Difference in a Women's Heart
There are unique aspects to the risk factors, symptoms, presentation, disease course, and testing of cardiovascular disease in women. The role of female hormones on the heart is unique to women as well.
Women have a lack of appreciation of their individual risk for heart disease. Women do not associate heart disease as being part of their disease "spectrum". There are several reasons for this lack of knowledge. Ask anyone to imagine a patient in the emergency room who has chest pain. Chances are, they will imagine a man with the sudden onset of crushing chest pressure or pain. This is what we call the male model of heart disease. While familiar to most people, this model is not that accurate for women. Cardiovascular disease is under recognized, underdiagnosed and undertreated by women patients and by some physicians, adding to the problem. While most women have asked their relatives about family history of cancers, especially breast or ovarian cancers, few ask about heart disease, especially occurring at an early age. While many women know that their cholesterol is "okay", few know whether the breakdown of individual components in the lipid or cholesterol values puts her at increased or reduced risk.
Identification of the absence of significant cardiovascular disease is as crucial as the accurate diagnosis of its presence. Women have more chest symptoms that are not related to traditional blood vessel blockages. This has confused the situation and misled physicians as well as women themselves. Traditional stress tests are inaccurate and show false abnormalities in about 40% of premenopausal women and up to 60% of postmenopausal women tested, even if they do NOT have heart disease. Diagnostic testing that relies only upon the EKG is not gender sensitive and misleads both patients and their physicians. Patients must have confidence in their physicians' ability to chose the correct tests to perform and to interpret those test results properly in order to accept results that exclude disease. The Women's Heart Institute recognizes that gender sensitive evaluations are key to maintaining patient confidence.
Coronary Heart Disease (CHD) risk factors include those we cannot modify:
increasing age |
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| women get their heart disease an average of 10 years later than men; however, younger (below the age of 50) women who do have heart disease have substantially higher risk of complications and death than men with heart disease the same age | |
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family history of early coronary heart disease |
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| a family history of heart disease in a woman is a stronger predictor of heart disease than a family history of disease in a man | |
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diabetes mellitus |
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| more women than men get diabetes; diabetes removes the age differential for heart disease in women; a woman with diabetes has 3 to 7 times the risk of heart disease while a man with diabetes has 2 to 3 times the risk | |
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African-American race |
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| African-American women have the greatest risk of heart disease of any gender or ethnic group, with heart disease their number one cause of death after age 35 | |
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male gender (more men have early CHD) |
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The coronary heart disease risk factors that we can modify include:
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lipid levels (total cholesterol, LDL, HDL, Lp(a) and triglycerides) |
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| LDL (low density lipoprotein) is considered the greatest predictor of heart disease in men, while HDL (high density lipoprotein), Lp(a) and triglyceride levels appear to be greater predictors for women | |
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hormonal status |
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| a premenopausal woman gets heart disease less often while a post-menopausal woman the same age has at least three times the risk; estrogen has beneficial effects on lipids and blood vessel function but may also interact with blood clotting mutations to increase blood clots and acute cardiac events in certain women | |
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tobacco use |
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| teenage women are the group that are increasing their smoking the most; teenage smokers find it hardest to quit; a woman who smokes gets her first heart attack 19 years earlier than a nonsmoker, compare to 7 years earlier for a male smoker | |
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hypertension |
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| women develop hypertension more often than men after age 45; over half of all women over age 64 have hypertension | |
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left ventricular hypertrophy (thickening of the heart muscle) |
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physical activity |
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| 60% of women report no regular physical exercise or activity | |
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obesity, especially around the waist area |
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| obesity is more common in women, impacting many other risk factors | |
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antioxidant level |
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environmental tobacco smoke |
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elevated levels of homocysteine |
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| clotting factors |
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| clotting abnormalities can cause a heart attack, more often seen immediately after pregnancy, in women on oral contraceptives, and in the months after restarting hormones after menopause; mutations in clotting factors interact with other cardiac risk factors and can be identified with blood tests | |
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endothelial function (how the heart blood vessels respond to stress) |
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| estrogen maintains normal blood vessel responses to stress, even in the face of blood vessel damage; estrogen improves lipid levels and reduces inflammatory changes in blood vessel lesions; healthy blood vessel function may not be able to be restored after years of estrogen deficiency, but appears to be able to be maintained in laboratory studies, with continued use | |
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individual response to overall stress levels |
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Many of these risk factors have an impact in women which is substantially different from that in men. Because these are so common, the unique aspects of risk factors for CHD in women must be taken into account.
Symptoms for coronary heart disease in women vary from those in men. The male model of heart disease gives the classic description of angina (or chest pain indicating a lack of blood flow to the heart muscle) as a substernal (below the breastbone) pressure, tightness, squeezing, burning, or heaviness. This sensation may radiate to the throat or either arm. The discomfort comes on with physical activity and is relieved by rest.
Women with coronary heart disease may be older, have more diabetes and hypertension, and may be more likely to be smokers. These risk factors contribute to a difference in the classic pain signals that a woman's body has compared to a man's. Other factors that are still being studied may also contribute to a difference in the way women feel cardiac symptoms. The usual symptom that a typical male patient will complain of is a substernal discomfort, usually a pressure or tightness under the breastbone, that can spread to the left arm or neck. Women may have this classic symptom but more often, may have abdominal, shoulder, arm, neck or back discomfort, complain of shortness of breath. If a woman has discomfort in the abdomen (leading to the belief that they have stomach problems), in the back, or in the jaw or throat, she may not recognize this as a cardiac symptom. Many times, there will only be a sensation of uneasiness or feeling "sick" that is difficult to describe. Women have a significantly higher number of silent episodes of angina and even silent heart attacks, where their symptoms are not even recognized. Of course, women also can have the classic chest symptoms as men do, especially in addition to some of these other symptoms. Women with arthritis or osteoporosis or who are less physically active may not have the early warning signals of cardiac symptoms with physical activity. Instead, they may complain of symptoms at rest or at night, often with emotional upsets. While often belittled by physicians, this discomfort with emotional stress or at rest may actually represent more severe disease than that seen with increased physical activity.
The presentation of coronary heart disease in women includes the way a women feels her symptoms as well as how she responds to them. As women do not often view heart disease as part of their disease spectrum, they will frequently continue activities when they feel ill, either mistaking their symptoms as not serious, or just not realizing that they represent a cardiac condition. Women will present to a hospital with a heart attack up to one hour later than a man will. When arriving in the emergency room, she is less likely to complain of cardiac symptoms and more likely to attribute her symptoms to some other kind of disorder. This delays and seriously impacts her ability to get appropriate emergency care. Because a woman's symptoms of angina may be substantially different from a man's, she is less likely to complain of them when visiting the doctor. Since physicians often ask about "chest pain", many women will deny this, but not think to explain what they are actually experiencing. In addition, so many physicians are accustomed to minimizing symptoms that come on at rest, so they miss many serious cardiac conditions in women who are not physically active.
Last updated on October 17, 2002.