Focused Cardiovascular Care for Women is the name of an important report about women’s heart health published in February of this year. One of the report’s highlights (or lowlights!) was that very few if any hospitals actually offered focused cardiac care specifically for women before the year 2000.(1) One reason for this may have been that, as the report’s authors explained, “the concept of Women’s Heart Clinics was met with hesitation from many cardiologists.”
Yes, you read that right, ladies. Until recently, even the very idea of establishing a heart clinic devoted to the unique realities of the female body was not warmly welcomed by the very physicians you’d think would be most supportive.
That kind of thinking reminded me of yet another report that recently made headlines: the first scientific statement on women’s heart attacks ever issued by the American Heart Association.(2) The conclusions of this historic document can be summed up best, I think, by my heart sisterLaura Haywood-Cory, who survived a heart attack caused by Spontaneous Coronary Artery Dissection (SCAD) at the age of 40. Laura came up with the best ever overview of the current cardiology gender gap when she wrote this:
“Sucks to be female. Better luck next life.”
The AHA statement came out in January, and basically concluded that heart disease in women is essentially under-diagnosed, and then under-treated even when appropriately diagnosed compared to our male counterparts.
I honestly don’t know which part of writing that last sentence upset me more: the conclusions of the statement, or the fact that it was the first time in the 92-year history of the AHA that the organization decided to finally issue an official scientific statement about women’s heart attacks!
The good news however, is that the need and value of specialized cardiac care for women is being officially recognized at last.
Women’s Heart Clinics are now present in many major cities and in many teaching hospitals, as the report published in the journal Mayo Clinic Proceedings (MCP) tells us. The authors of this report – a list that reads like the rock stars of women cardiologists, by the way – explain why:(1)
“Cardiologists in training are frequently seeking special training and experience in the care of women’s hearts at teaching hospitals that offer these programs. Importantly, road maps to integrate sex- and gender-based evidence into medical and inter-professional education are needed for effective translation into better outcomes for all patients.
“Women’s Heart Clinics may also serve as centers to organize and communicate with lay advocates for female heart health who serve as invaluable resources to bridge the gap between health care services and the community.”
As one of those lay advocates for female heart health, this is all very good news to me.
What kinds of specific issues in women’s heart health are covered in these Women’s Heart Clinics? If it’s not on this list, it probably hasn’t been invented yet. The heart conditions covered in this report generally fall into these categories:
- those that are unique to women
- those that present with different symptoms in women compared to men
Focused Cardiovascular Care for Women contains the most comprehensive list of issues unique to women’s heart health that I’ve seen. (CAROLYN’S NOTE: I have tried to summarize and translate the key doctor-speak points published in the MCP report, but in case you need further translation, check out my patient-friendly, jargon-free glossary of complex cardiac terms).
1. Heart conditions unique to women
♥ During and After Pregnancy:
This has been called a “natural cardiac stress test”, and may identify early signs of heart disease because of increased demands on the heart during pregnancy.
- Adverse pregnancy outcomes: Women with a history of gestational hypertension, diabetes, preeclampsia, eclampsia, or pre-term delivery are at an increased risk of future heart disease. See also: Pregnancy Complications Strongly Linked to Heart Disease
Peripartum Cardiomyopathy (PPCM): This rare type of heart failure may develop in the last month of pregnancy or within five months of delivery; it’s recognized as an important cause of pregnancy-related death. See also: Young, Pregnant and a Deadly Heart Condition
♥ Polycystic Ovary Syndrome (PCOS):
This is a metabolic disorder that affects 6-10% of women of reproductive age. Classic features of PCOS include infertility, menstrual irregularities, excessive hair growth and a higher risk of developing Type 2 diabetes.
♥ Menopause and the Dilemma of Menopausal Hormone Therapy (MHT)
Many women seen in Women’s Heart Clinics are peri- or postmenopausal, are having menopausal symptoms, or expressing concerns about the link between Menopausal Hormone Therapy (MHT) and higher risk of heart disease. The average age of menopause in North American women is 51 years. Women with premature menopause (occurring before the age of 40) experience earlier onset of heart disease than women who experience menopause after age 40. The results of hormone studies have been mixed, making it a challenge for doctors to advise women on both the risks and benefits of MHT. According to the US Preventive Services Task Force, MHT reduces the risk of bone fractures, but may increase the risk of stroke, clotting events and gallbladder disease. Menopausal Hormone Therapy is currently not recommended to prevent chronic conditions.
2. Heart conditions occurring in both sexes but with sex-specific differences
♥ Ischemic Heart Disease (IHD)
IHD happens when coronary arteries are unable to supply freshly oxygenated blood to the heart muscle. In women, IHD includes obstructive coronary artery disease but also coronary microvascular disease, endothelial dysfunction, Spontaneous Coronary Artery Dissection (SCAD), or stress-induced cardiomyopathy.
There are marked differences in IHD between women and men. The three most important characteristics are:
- women have angina more often than men do
- women show less obstructive coronary artery disease
- women have poorer end results than men do
In addition, current heart disease risk calculators used by physicians to determine a patient’s risk of heart disease are based on studies in mostly (white) male populations and do NOT accurately predict cardiac risk in women.
- “Female-Specific” IHD
According to the Women’s Ischemia Syndrome Evaluation (WISE) study, the angiograms of two-thirds of the women studied did not show typical findings of blocked arteries despite their cardiac symptoms. Instead, these women often had coronary microvascular disease. IHD risk factors unique to women include ovarian function, menopausal hormone therapy, and pregnancy complications – in addition to traditional cardiac risk factors.
- Coronary Vasospasm (or variant angina)
If no coronary artery blockages are apparent, sometimes a spasm disorder called coronary vasospasm is linked to heart attack. Smoking can be a trigger for this condition. Medications that promote dilating and prevent constricting of the arteries are usually the first step in treatment. Meanwhile, nitroglycerin can also be used short term to manage painful angina attacks.
- Stress-Induced Cardiomyopathy
Sometimes known as Broken Heart Syndrome or Takotsubo Syndrome, this can mimic a heart attack, but an angiogram shows “normal” coronary arteries. The majority of patients with this condition are postmenopausal women (61-76 years of age). The accompanying symptoms of chest pain and shortness of breath are often, yet not always, preceded by intense physical or emotional stress.
- Spontaneous Coronary Artery Dissection (SCAD)
SCAD was previously considered rare, but it’s emerging as an important cause of heart attack and sudden death, especially in younger women. Approximately 80% of SCAD patients are young, healthy women, often with few if any conventional heart disease risk factors. Recent studies suggest that SCAD is a factor in up to 30% of heart attacks in women under age 50, and it’s the most common cause of pregnancy-associated heart attack. It may be associated with the condition called fibromuscular dysplasia, and may run in families. It’s really important to make an accurate diagnosis because some interventional treatments that are commonly recommended for non-SCAD heart attacks may involve less success and more frequent complications. SCAD patients treated with coronary artery bypass surgery, for example, have a high rate of subsequent bypass graft failure. We also know that the part of the artery that tears during SCAD often heals on its own.
♥ Heart Failure
Heart failure is seen with either reduced or preserved ejection fraction (or EF: that’s a measurement of how much blood is pumped out of a filled ventricle in the heart with each heartbeat; the normal rate is 50-60%). Women are more likely than men to develop heart failure in the setting of preserved left ventricular ejection fraction (HFpEF). They’re also generally older and have a higher likelihood of having diabetes and high blood pressure. Obstructive sleep apnea and obesity are commonly associated with this condition. There is no specific treatment yet for HFpEF.
♥ Postural Orthostatic Tachycardia Syndrome (POTS)
The overwhelming majority of patients with POTS are women of childbearing age. No clear cause for this condition has been identified. Common symptoms include light-headedness, blurred vision, weakness, cognitive difficulties, fatigue, palpitations, shortness of breath, dizzyness, or gastrointestinal symptoms. Exercise training and reconditioning is emerging as an important strategy to improve the quality of life of these women.
♥ Atrial Fibrillation (AF) and Increased Stroke Risk
The incidence of AF is lower in women than in men; however, women who have AF have a higher incidence of stroke and a higher mortality rate than those observed in men. Assessment of women’s stroke risk must take into account age- and sex-specific differences. Stroke prevention should focus on risk factors like reproductive factors, migraine with aura, obesity, and metabolic syndrome. Being female is substantially associated with stroke, especially in women 75 years and older. Since AF increases with age, and women have a higher life expectancy, it’s anticipated that there will be an increasing number of elderly women with AF. At present, women with AF are less likely to receive anticoagulation therapy than men are.
♥ Autoimmune Disorders: An Emerging Risk Factor for Cardiovascular Disease
Autoimmune diseases like rheumatoid arthritis (RA) and lupus (systemic lupus erythematosus or SLE) are far more common in women (RA: 4% in women vs 2% in men; SLE has a 10:1 predominance in women). Both are associated with an increased risk of cardiovascular death associated with chronic inflammation – often in the absence of traditional heart disease risk factors. And even when traditional risk factors are present, they tend to be under-recognized and under-treated in this population. It’s extremely important for rheumatologists and cardiologists to recognize autoimmune disorders such as RA and SLE as significant risk factors for cardiovascular disease and to apply this knowledge to patient care.
♥ Peripheral Arterial Disease (PAD)
This diagnosis affects the arteries of the lower extremities, affecting our ability to walk. PAD not only reduces our quality of life, but is also linked with a significantly higher risk of cardiac events. Until recently, men have been traditionally believed to be at higher risk for PAD, but emerging studies have actually reported higher rates of PAD in women. This is especially true for women under 40 or over 8o who represent a greater population burden of PAD affecting the lower limbs than our male counterparts do. Women living with PAD may actually have few if any symptoms, or present with atypical symptoms, but ironically are more functionally impaired with either reduced walking distance or speed than men are. This lack of symptoms helps to explain why diagnosing PAD based on symptoms alone is misleading. Only 10% of all PAD patients will experience the classic intermittent claudication (a cramping discomfort that comes on with exertion and goes away with rest). Other risk factors unique to women with PAD include taking birth control pills and a history of high blood pressure during pregnancy. Overall, mortality is higher in women with PAD than in men (58% vs 42%).
But wait, there’s more . . . As the MCP report explained:
Women Respond Differently to Drug Treatments: As we age, blood pressure control is more likely to be achieved in men than in women. Thus stroke risk may not be managed as efficiently in women. Drugs to treat heart rhythm conditions like Atrial Fibrillation have different effects, interactions, and need for dosing adjustments in women than in men. Similarly, studies on antiplatelet drugs have found higher rates of bleeding complications in women, suggesting the need for dose adjustments according to sex. Aspirin that’s effective in preventing heart attacks in men over age 45 may not be so in women older than 65, although it’s effective for stroke prevention in younger women. Unfortunately, there’s a shortage of reliable data behind medication recommendations, mostly because so few women were specifically included in clinical trials, data analysis and reporting.
Treatment Guidelines are Applied Differently in Women: Although the current recommended treatment for coronary artery disease is similar for both men and women, women are less likely to receive guideline-based treatments for chronic stable coronary artery disease. And even after correct diagnosis and treatment, women are less likely to be referred for cardiac rehabilitation.
“The medical community in general, and women specifically, lack information on cardiovascular health and disease in women. This ignorance makes it less likely that women will receive guidance on:
- preventing heart disease
- preventive strategies and referral for needed diagnostic testing
- cardiac rehabilitation
“The public health cost of misdiagnosed or undiagnosed cardiac disease in women is significant. And although awareness of heart disease as a leading cause of death in women is increasing, minority and younger women are less often aware, resulting in inadequate or nonexistent medical care and decreased likelihood of adopting necessary lifestyle changes.
“Specialized centers of focused cardiovascular care for women, like that provided in Women’s Heart Clinics, are uniquely capable of identifying, characterizing, treating, and preventing heart disease in women, while also addressing important research gaps and developing new diagnostic tools and treatments.
“Women’s Heart Clinics have the potential to help correct gender inequalities, as well as educate women on how to recognize cardiovascular disease symptoms either unique to or more common in women.
“The disparities in treatment and survival rates between men and women clearly indicate the need for integrated multidisciplinary women’s heart programs. Such programs provide sex-specific heart disease care for both women with existing heart disease and those at risk of developing it. Cardio-oncology and cardio-rheumatology subspecialty focused clinics have also been set up in conjunction with Women’s Heart Clinics because of the increased frequency of women presenting with conditions that are recognized to occur more commonly in women (eg, breast cancer and autoimmune disorders), which have a cardiovascular effect.”
And as the MCP report reminds all physicians, “the need and value of specialized heart care for women is now recognized.”
(1) Focused Cardiovascular Care for Women. Mariana Garcia, Virginia M. Miller, Martha Gulati, Sharonne N. Hayes, JoAnn E. Manson, Nanette K. Wenger, C. Noel Bairey Merz, Rekha Mankad, Amy W. Pollak, Jennifer Mieres, Juliana Kling, Sharon L. Mulvagh. Mayo Clinic Proceedings, February 2016. Volume 91, Issue 2, 226 – 240.
(2) Laxmi S. Mehta et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association.
Q: Does your local hospital have a Women’s Heart Clinic?
NOTE FROM CAROLYN: I wrote much more about focused cardiac care for women (or the lack thereof) in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 20% off the list price).
* Heart Sisters posts written about cardiac research on women’s heart disease presented during the 2011 or 2014 Canadian Cardiovascular Congress in Vancouver, BC Canada. In the 2011 conference, out of over 700 scientific papers presented, four focused specifically on women’s heart disease. Three years later, that number had jumped to 12.