The Latest on Heart Disease in Women

Men or women, which gender is at greater risk for having cardiovascular disease (CVD)? The perception of medical professionals and the general public alike is that heart problems affect men more than women. However, last year the American Heart Association (AHA) released an update on CVD in women that has helped to dispel this misconception by providing new guidelines to determine a patient's risk. This new information is important to understand because heart disease is the leading cause of mortality in the US based on information provided by the AHA.

In general, we understand the risks associated with heart disease. We learn about this information through television commercials advertising cardiac medications, health magazines or conversations we have with our doctors. Risk factors for heart disease are categorized as not modifiable or modifiable. The first step in order for doctors to make an appropriate determination of one's chance for developing heart disease is to assess risk. The clinical manifestations of heart disease in women present differently than they do in men. This resulted in less aggressive approaches toward treating CVD in women for a long time. The latest information provided by the AHA shows some interesting findings regarding risk in women.

Non-modifiable risk factors:

Sex - Annually, over 500,000 woman die from CVD; while the numbers for men are decreasing
Age - Men develop CVD at younger ages; however, after menopause women match men in both incidence and prevalence (studies show that hormone replacement therapy (HRT) in women is not cardioprotective and the AHA does not recommend HRT to prevent or treat CVD in postmenopausal women)
Race - Mortality among African-American women is greater than for white and Mexican-American women
Genetics - Family history of CVD is associated with a strong genetic link

Modifiable risk factors:

Diabetes - Overall, women with diabetes, particularly African-American and Hispanic women die at a greater rate than women or men without diabetes
Hypertension (HTN) - The risk increases for CVD in women with elevated blood pressure than it does for both men and women without HTN
Smoking - Younger women who smoke lose their premenopausal CVD protection, add-on oral contraception to the mix and this further increases the risk for a heart attack or stroke as compared to women who just take the pill and do not smoke
Dyslipidemia - Research has demonstrated that high levels of "bad" cholesterol (LDLs) increases the risk of CVD related deaths in women more so than in men
Obesity - Weight gain is an indicator of CVD risk that can be assessed through measuring BMI and waist circumference
Sedentary lifestyle - Exercise increases "good" cholesterol (HDLs) and reduces the risk of heart disease in women by 50%
Stress - This further compounds a woman's risk for developing CVD and studies show that stress is an indicator for a poor outcome in these women

It appears that both risk factor categories work synergistically. That is, the more risk factors one has the greater their chances at having CVD. So reducing modifiable risk and implementing an exercise routine will minimize a woman's chances of developing heart disease. You can assess your own 10-year risk for a heart attack by using the AHA heart attack calculator. The risk calculator includes 17 questions in which you will need to know your own cholesterol levels to use this online tool.

Besides identifying risk factors, women and men have differences in the way CVD presents itself clinically. We all think of the classic presentation of pain due to CVD as a male clutching his chest. We've seen this example of substernal pain in movies or television shows. It is described as a heavy or crushing pain that occurs during exertion, but may also happen at rest. This cardiovascular disease symptom is most common in men. Whereas, the pain of heart disease in women is more generalized and presents as pain in the left chest, arm, shoulder, back or abdomen. The symptoms in women with acute signs of CVD vary greatly as well.

Diagnosing and treating women with CVD has variability as well when compared to men. For instance, ECG findings also differ. So, women experiencing a heart attack do not usually have a specific ECG wave like the one found in men with the same condition. This can lead to the possibility of an incorrect diagnosis for women, especially when they present with atypical symptoms. Although men at high risk undergo exercise stress test to diagnose CVD, the stress echo, an exercise echocardiogram is better at pinpointing heart disease in women. The most reliable method for CVD diagnosis in women is a coronary angiography.

The AHA has specific guidelines to help prevent the progression of heart disease in women who either have risk factors or has been diagnosed with CVD. The measures include making lifestyle changes to prevent or improve modifiable risk factors such as high cholesterol, hypertension and diabetes. This can be done by eating food low in fat, cholesterol and sodium as well as increasing fiber and omega-3 fatty acid (e.g., tuna and salmon) intake. Health improvements can be made by decreasing alcohol consumption, the cessation of cigarettes for smokers and exposure to second-hand smoke for nonsmokers. The use of medications for CVD such as statins (cholesterol-lower drug class) and beta-blockers provide management and control for dyslipidemia and HTN. Although for reasons that are not clear women do not participate in rehabilitation after a heart attack, PCI or CABG surgery. It has been shown that rehabilitation for CVD patients is important to improving their overall health.

Cardiovascular disease is still a major health concern for both women and men. But, many aspects that contribute to heart disease can be prevented by the lifestyle choices that are made. With the release of the American Heart Association's new guideline for diagnosing and managing CVD in women, both the patient and practitioner can make more informed decisions about care.

Source: Dennis Cheek, RN, PhD, FAHA, Melissa Sherrod, RN, and Jennifer Tester. "Women and Heart Disease." Nursing 2008 38.1 (2008): 36-41, http://www.americanheart.org/presenter.jhtml?identifier=3045524