by Carolyn Thomas ♥ @HeartSisters
Earlier this year, the American Heart Association published a comprehensive article called “The Slowly Evolving Truth About Heart Disease and Women”. This fact-packed article felt like an emotional roller coaster ride – from despair to frustration and then maybe even hope for our future. So I’m sharing my favourite excerpts from this article today – especially for my readers living with heart disease. Get onboard and buckle up as we explore some heart truths together with the AHA:
1. BACK THEN:
Until the middle of the last century, heart disease was considered a man’s problem. “If women had a role to play, it was in taking care of the men in their lives. The American Heart Association hosted a public conference for women in the 1960s – but it was called “How Can I Help My Husband Cope with Heart Disease?” The organization also published a 1968 nutrition pamphlet titled “The Way to a Man’s Heart.”
Cardiologist Dr. Gina Lundberg at Emory University School of Medicine continued the history lesson:
“That attitude persisted throughout the 20th century, a time when questions about a woman’s health were centered only on the parts of her body covered by a bikini. It was, ‘Get a pap smear and a mammogram and you’re good!’ We left out all the things we were checking men for, like diabetes and cardiovascular disease.
“And we believed that women had some natural protection from heart disease until their hormone levels dropped during menopause. After menopause, it was thought that hormone replacement therapy could prolong that protection – a premise since amended to apply only to women who take it during the early stages of menopause.
“It wasn’t until the turn of the century that evidence emerged that both women and men faced a substantial risk from heart disease, beginning at a much earlier stage in life and sometimes with differing symptoms.”
Then we had a long wait until the mid-1980s for the landmark Framingham Heart Study when reporting sex-specific patterns of heart disease finally began.
Doctors still viewed heart disease as a man’s problem. Even in animal research labs, only male animals were studied. This started to change in the 1990s: “Atlanta cardiologist Dr. Nanette Wenger and others led a push for the equitable inclusion of women in all research funded by the National Institutes of Health. This inclusion became official NIH policy in 1989, and was written into law in 1993.”
But Dr. Wenger herself later observed that the law was “little more than a directive. It had no teeth.”
Cardiologist Dr. Jennifer Mieres, who was also lead author of the AHA’s 2014 scientific publication on diagnostic testing for women, reminded us that the prevention and treatment of heart disease in women was based on evidence that came predominantly from studies on white middle-aged men.“We were applying a one-size-fits-all approach. Clearly, that wasn’t working for women.”
A 1999 report from the AHA and the American College of Cardiology revealed that doctors were less likely to advise female patients to reduce their cardiovascular risk factors by losing weight, or eating a healthier diet, or becoming more physically active. Women were also less likely than men to be referred by their doctors to cardiac rehabilitation following a heart attack or bypass surgery. See also: Failure to Refer: Why are Doctors Ignoring Cardiac Rehab for Women?
When an AHA survey found that women paid more attention to health messaging in the media than to their own doctors, national campaigns were launched in 2003 and 2004 to help raise awareness of heart disease and stroke as leading killers of women.
And for a while, those campaigns helped. The number of women recognizing heart disease as a major health risk nearly doubled, from 7% in 1997 to 13% in 2003. By 2009, 65% of women understood heart disease was their leading cause of death. Mortality from cardiovascular disease began to decline in women, though at a far slower rate than it did in men.
But those optimistic gains did not last. By 2019, only 44% of women surveyed recognized heart disease as their No. 1 killer and a majority failed to recognize common heart attack symptoms.
I wrote about the devastating results of that AHA national survey on women’s awareness, in which over half of women surveyed could not even name chest pain as a cardiac symptom! Awareness results were in fact worse than the AHA’s previous national survey results 10 years earlier. We were going backwards. Young women, Hispanic women and Black women experienced the greatest drop in awareness.
2. RIGHT NOW:
Dr. Lundberg reported a survey of physicians that found weight issues and breast health ranked higher than heart health when primary care physicians were asked about their level of concern for various health issues in their female patients.
And a staggering 70% of physician trainees report they aren’t getting enough, if any, education in gender-based medical concepts during postgraduate training. In a nationwide survey, only 22% of primary care physicians and only 42% of cardiologists said they feel extremely well prepared to assess cardiovascular risks in women.
“We are behind in implementing risk prevention guidelines for women,” Dr. Lundberg explained: “Many women are being told to just watch their cholesterol levels and see their family doctor in a year. But that’s a year of delayed care.”
Heart attack hospitalization rates among women under 55 have increased as rates among men of the same age have dropped. And recent studies show women are more likely than men to die after a heart attack.
Research also shows that women continue to be under-treated for cardiovascular problems compared to men. They are less likely to be treated for high cholesterol with statins, which have been shown to lower risk for heart attacks and strokes. They are also less likely than men to be prescribed blood-thinning drugs to prevent or treat blood clots as treatment for atrial fibrillation.
Although they are more likely to be diagnosed with heart failure, women are substantially less likely than men to receive lifesaving treatments for it, including heart transplants. They are also less likely to receive guideline-directed treatment to restore blood flow to the heart, such as bypass surgery or inserting stents to open blocked arteries after a heart attack or unstable angina, or to receive treatment in a timely fashion.
3. IN OUR FUTURE:
The AHA reminds us that, despite women’s disappointing lack of awareness of heart disease, progress toward understanding the unique cardiovascular risks women face has surged.
Dr. Lundberg, for example, explained that over the past 20 years, there have been significant strides in showing how menopause affects our heart health. For example, menopause symptoms like hot flashes and night sweats have been linked to an increased risk for high blood pressure, a major risk factor for cardiovascular disease.
But she calls the the link between pregnancy complications and cardiovascular disease risk “one of the biggest women’s health discoveries of the past decade“, adding:
“Now we know that if a woman has gestational diabetes, hypertension, preeclampsia or eclampsia and other pregnancy complications, they are at increased risk for cardiovascular disease later in life. Research has also shown that having high blood pressure before becoming pregnant might double a woman’s risk of developing cardiovascular disease within the next decade.
We also know that other unique cardiac risk factors in women include:
- starting early menopause before age 40
- having endometriosis or polycystic ovary syndrome
- autoimmune disorders e.g. rheumatoid arthritis or lupus
And we know more now about other differences between men’s and women’s heart disease. Women, for example, are more likely than men to have a heart attack caused by plaque erosion, spontaneous coronary artery dissection (SCAD) or problems other than a large blockage in a coronary artery, while men are more likely to have heart attacks caused by plaque rupturing inside that artery.
What we don’t know yet, however, is why certain racial or ethnic populations are more likely to face more and worse heart disease experiences in their future. Black women, says Dr. Lundberg, have the highest rates of high blood pressure, stroke, heart failure and coronary artery disease. They have also been far less likely to be included in clinical research. Both structural racism and what’s called “social determinants of health” play a role here (e.g language barriers, or having less access to health care, heart-healthy foods, etc.)
Dr. Lundberg believes that one of the biggest challenges for women with heart disease will actually be finding a doctor who will understand what they’re going through, as she explains:
“There are not enough women – and especially not enough women of color – who are entering the field of cardiology. If you’re a male taking care of a female, you may have a bias that women are more dramatic about pain, or don’t have as serious a heart problem. But if you are a woman taking care of a woman, you may listen differently. The medical workforce should reflect the diverse population being served.”
And one of the best predictors of improved heart health is how women take care of ourselves. Dr. Lundberg recommends that all women promote good habits within their own families (starting much earlier in life, including regular physical activity and the importance of eating a healthy diet):
“People need to be better educated about health in general. I’m a big believer that it should start in kindergarten.”
♥
Thank you to Drs. Mieres, Lundberg and Wenger for your tireless work to improve women’s heart health, for being so quotable, and also thanks to the ©American Heart Association 2023
♥
Q: What’s your reaction to what the AHA (and female cardiologists) are saying about the realities of women’s heart disease?
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NOTE FROM CAROLYN: I wrote more about disparities in cardiac care between men and women in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Heart Sisters 
Hi Carolyn,
Always enjoy your posts, thank you!
My 89 year old aunt in England was recently hospitalized with congestive heart failure, high BP and afib (after a lifetime of almost no health problems). Anyway, on release from hospital, it seems that all her stats (ie. heart rate, BP, afib) are now connected by internet to the hospital. So that if her condition changes, it is instantly relayed to the hospital so that she can be either admitted again or otherwise treated.
Why don’t we have this in Canada? Or do we? I haven’t heard of such a program. If it worked as it should, it would surely save lives and prevent further problems.
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Hello Sue – As I was reading your comment, I was struck by how reassuring this kind of post-hospital follow-up would be for your aunt. She wouldn’t have to worry if her afib symptoms were getting worse – the tech would enable clinicians to know for sure and make further recommendations!
Yes, there are projects like this in Canada. I know, for example, that Hamilton Health Sciences Hospital in Ontario has been working on a remote home monitoring device that continuously tracks patients’ vital signs around the clock in hospital and also at home to detect signs of post-surgical complications. G.E. Health Care has been working on a wireless version, too.
This sounds like the way of the future – and I too think this might help prevent further problems for many patients during the most vulnerable first 30-days post-hospital discharge period (especially post-surgery when patients are at higher risk of complications).
Take care. . . ❤️
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Thank you, Carolyn! I always appreciate your informative posts. As part of a 55+ choir at Cordova Bay, I’ve shared your column links with a number of women. Are you still speaking at various venues? Tuesdays starting in September are speaker program days. If you are, let me know the best way to contact you and I will pass it on to the new person in charge of finding speakers.
Enjoy the rest of the summer. Here’s a youtube video of Josh, my oldest son, performing The Last Rose of Summer https://www.youtube.com/watch?v=dFE4yg2Rrz4 recorded in Tasmania on a lever harp and posted to his YouTube Channel.
Best,
Marty
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Hello Marty – thanks for your kind feedback! I’d love to come out and speak to your choir group on a Tuesday in September. Ask your ‘new person’ to get in touch via my HEART SISTERS Contact Me page – with a couple of possible dates (and time of day you meet) and I’ll get back to them to confirm.
That harp performance by Josh (set in that stunning Tasmania wilderness!) is SO beautiful! I could listen to that all day… ❤️
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Your piece is pretty much spot on with my experience.
I do think we have to educate ourselves and pay attention to our own health. It seems to me that there’s a tendency among many medical providers to have a very narrow focus- sometimes they focus on one system and ignore the rest, when our bodies are large systems made up of many smaller, intricately connected systems.
I also want people to look at and pay attention to me and not make stereotyped assumptions. Every time there’s a problem, I strategize about how best to communicate what is happening in a way that keeps me from being pigeon-holed into an assumed diagnosis.
Part of the problem is that many physicians are overworked and that specialists do have a natural focus on their specialization. The best physicians I know actually listen carefully to their patients. I don’t believe I was ever asked about pregnancy complications -ever- but I did have them and sure enough, problems materialized as I aged.
Now I’m happy to say that I have a cardiologist who is an FMD and women’s cardiology specialist, and a female family doctor, and my male rheumatologist is the one who connected the dots, listened, figured out what was happening and got me to the right specialist.
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Hi Helen – I have observed the specialists you describe (which was why I was so impressed by the orthopedic surgeon I was referred to a few years ago when my knee arthritis became so painful I could no longer walk with my 3x weekly walking groups. I was completely expecting him to recommend knee replacement surgery (because that’s what surgeons do, right?)
But to my amazement, he asked about what kinds of specific activities I used to enjoy doing that were too painful now. I told him that what I really really miss were my walking groups – and his immediate response was to recommend getting fitted for a skookum high-tech knee brace made in Germany: “Let’s see if this can help you get back to your walking groups!” And it did!!
The physiotherapist techs who fitted me in their clinic were so helpful (and most of the cost was paid for by my workplace extended health benefits coverage!) I may need surgery some day, but today is not that day, and meanwhile I can walk pain-free.
“Motion is lotion” – as our local Arthritis Society staff tell me!
I loved your description of being pigeon-holed into an assumed category! “Every time there’s a problem, I strategize about how best to communicate what is happening in a way that keeps me from being pigeon-holed”
Q: Why is it the patient’s job to strategize how to speak to a doctor to prevent being stereotyped?!?
Take care. . . ❤️
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I have never heard of plaque erosion and a quick search renders a lot of scientific materials that I don’t quite understand. Would really like to learn more if you have a patient source (you know in everyday speech!)
But what I really wonder is why the heart orgs aren’t leading with headlines like “Discoveries of Women’s Unique Cardiac Risks”. These are so very newsworthy but most media deliver the same old-same old or gloss over it all.
Except you of course – who give us the real scoop and thank goodness for this blog!
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Hi again Tomi – I too looked up “plaque erosion” after reading your comment and you are SO RIGHT! Almost every website I found is 100% medical bafflegab, not patient-friendly at all!
So I looked at a number of sites that can be roughly – and I do mean roughly (remember that I’m not a doctor and have no medical training!) translated into plain English (if you happen to have a medical dictionary handy!)
Here are the very basic basics: there is coronary artery plaque – and then there’s coronary artery plaque! One kind is made up of more smooth-muscle cells and collagen. This kind of blockage tends to be relatively stable, with connective tissue that’s called a FIBROTIC CAP separating the artery’s blood flow from the blockage. But plaque that’s composed of more fat and lipids (cholesterol) tends to be vulnerable to plaque rupture especially with a thinning fibrotic cap – which can cause a sudden blockage in the artery that stops blood flow to the heart muscle (a heart attack). I also learned that this fibrotic cap is one of the reasons heart patients are prescribed statin drugs (statins can reduce not only the size of coronary artery plaques, but also make plaque contents more stable). Plaque erosion by comparison is not associated with high lipids (cholesterol) and is the prime cause of coronary blockages in pre-menopausal women. Apparently, “the mechanisms of plaque erosion are unclear and there are no consistent risk factors, although patients are often smokers.”
Hope this helps a bit! ❤️
PS: Dear readers – if you have a simpler Plain English definition of these two types of coronary artery blockages, please let us know!
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Thank you!
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You’re welcome! 🙂
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The other day I was talking with my son about the evolution of our knowledge and interest in nutrition. As a child in the 50s it was actually a status symbol of the post-war “modern” age to serve white bread sandwiches and TV dinners.
So we baby boomers started our lives and built our bodies on poor nutrition. I even remember my mother making my sister’s baby formula with some “doctor recommended” version of evaporated milk and Karo corn syrup!
Our world is in a constant state of discovery and evolution. What seems to us like it is taking forever to be revealed – like the details of women’s heart disease – is a mere nano-second in our history as a planet.
Today, your article stimulated a question in me as to when did women begin to be seen as an inferior version of men?
All I can say is may we always remain curious, seek out answers, help each other through the ups and downs of human progress and may we continue to evolve: physically, mentally and spiritually.
Blessings!
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Hello Jill – I too grew up in the 50s, and I clearly recall the day our family witnessed these amazing frozen dinners in tin foil trays being heated up in our oven for the first time!!! They were deemed “time-savers” – no mention of taste or nutrition!
The corn syrup/evaporated milk baby formula practice was considered to be superior at the time because the recipe was handed out like a doctor’s prescription! Pouring, stirring and measuring seemed so much more “modern” than breastfeeding – a natural practice which, post-war, was at an all-time low. Only peasants did that… 😉
As to your question (“When did women begin to be seen as an inferior version of men?”) – I suspect it started back around the time when Eve was blamed for that Garden of Eden incident. . .
Take care with all that evolving, Jill! ❤️
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Where I live in the US, there are not enough doctors of any sort being of any gender or skin color.
Looking all the way back to the 1960s, I relate to much of what you have posted here.
At 64 years of age, I have been living with a diagnosis of Congestive Heart Failure for 17 months after 12 days ICU hospitalization, then afterwards treated by a male primary care physician in a health care center who abruptly moved away, leaving me with no doctor at all; and now my meds are being prescribed by a Indian female physician assistant whom I have seen only once about 3 months ago, who is assistant to a white male doctor that I have never met in a health care center, not a private practice which have become or are becoming extinct in the United States as far as I can tell.
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Hello TD – where I live (on the west coast of Canada), we also have a severe shortage of family physicians – just as the U.S. and many other countries are experiencing.
I too lost my longtime family doctor last month when she wrote a “Dear Valued Patient” letter announcing her upcoming retirement, with no replacement doctor available for her patients (I wrote about how devastating this loss can be in this post), FYI.
Aside from the worsening working conditions of family docs everywhere, there are simply far more Baby Boomer-age docs retiring/leaving family medicine compared to the number of graduating medical students who are choosing family practice as a career option. The math is pretty clear.
I suspect this may feel even worse in your country, because of your dependence on a for-profit corporate health insurance industry.
Good luck to you. . .❤️
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True about our country’s dependence on for-profits in the healthcare and insurance sectors.
Sorry for your loss of a long term family doctor. We do become emotionally attached to people we learn to trust over a long period of time.
I had experienced that as well when I lost my female family physician of ten years because she needed to relocate to another city to a health care center and closed her private practice after a devastating Hurricane Harvey took a toll on her business. I saw that she re-established herself in that type of health care center environment and transferred back to my city. I had already started with this new Indian female physician assistant who I like very much and 5 minutes from home that I have decided to stay with their care for now.
Thank you for adding the link to your other post. I will read it a little bit later this morning!
I’m happy to have found you!! 🍎❤️
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You’re so right – after several years with the same family doctor, it was awful to suddenly discover that she was retiring – and had been unable to arrange another doctor to replace her in the clinic. But after 29 days of panic (no family doctors in my town are accepting new patients) an amazingly lucky thing happened (after I’d asked all my friends and family members to ask their own family docs if they might consider taking on one more patient) when my friend Peggy called me one morning with the great news that her own doctor had agreed to be my new doctor (Peggy must have done a pretty good sales job in recommending me!)
I had my first ‘meet & greet’ appointment last week with my new doctor – she is wonderful (and YOUNG, which means I hope she’ll have a nice long career as my doctor!)
I’m glad you are liking your female physician assistant (and 5 minutes from home!? Bonus!) I’m a 30-minute drive from my new clinic, but I was feeling so desperate that I was willing to drive as far as it takes if it meant a reliable medical clinic!
Take care… ❤️
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Hi Carolyn! I just finished reading your linked post and was back here to read your reply.
You have been very lucky with having only 4 family physicians in such a long life! It would take me a while to remember how many family physicians I have had in my long life! Many, many more than you for sure.
Some insurance companies do require the patient see the primary care physician and then that physician does the referrals; and I’m learning that this new style of health care centers here in the US are essentially doing that same type of scenario, including referrals to way more preventative specialists that I don’t care to go to without any real reasoning.
I wonder if there’s some type of financial kick back to the referral health care centers. I know that sounds negative on my part, but I would not be surprised as it is all for profit in the US.
I am clear that these health care professionals are not truly caring about me personally as not one has ever telephoned to follow up with how I was doing, not after a new prescription or a minor illness visit. They are just performing that job and it would be off to the next better-paying opportunity they can catch.
I am so happy that you have Peggy in your life!! A 30-minute drive is very reasonable. I found my new provider by asking my neighbors and the neighbors whose wife has Congestive Heart Failure suggested this care center as they have lived on this street for over sixty years. They started with this location when it was a private practice a century ago and stayed with them as the private practice changed into the health care center. And it is where I am getting my prescriptions refilled for now. There was a time recently that I had no doctor and no medication dealing with a lot of health issues. It was painfully awful time in my life.
So as the saying goes, “It’s who you know, not what you know”… 🍎❤️
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Hi again TD – that’s exactly what I thought after Peggy called me with the terrific news! “It’s WHO you know!”
When I met my new family doctor last week in person for the first time, I asked at the end of our ‘meet & greet’ appointment what had changed her mind about accepting a new patient (like all other family practice clinics in my town, she had posted “Sorry, not accepting new patients” and “Sorry, NO WAITING LIST” signs in her office – and her reply was “True, I am not accepting new patients EXCEPT if one of my favourite patients asks me if I’d take on a family member or good friend!” ❤️
So it’s not just “WHO” you know – it’s “WHO KNOWS YOU, TOO!” 🙂
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Thank-you Carolyn for these blogs. They are informative, and I do find it quite surprising at what the stats show re: how much the Doctors are not being taught about women and heart disease.
If I hadn’t read so many articles on women and heart disease and how their symptoms are often different from men, I may not have called 911 when I had mine.
I did not have any pain, only pressure, but knew it was very different than anything I had ever had before. Fortunately for me, the paramedics had me into the Heart Institute quickly and I had one stent put in for a 100% blocked artery.
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Hello Nola – I’m glad you were familiar enough with women’s cardiac symptoms to call 911! And you bring up an important way to tell if symptoms are potentially dangerous or not: if they feel “very different than anything you had ever had before”. THAT is the question all women should ask themselves when unusual or NEW symptoms strike!
I too am shocked that we’re still seeing published studies in medical journals about how few medical students are taught about women’s unique cardiac risk factors that impact our diagnostic tests, procedures and outcomes compared to men. I wrote here about researchers in Ottawa who not only had their own study published, but then came up with nine free educational modules that any med school professor can use to teach about women’s heart disease to any medical students, anywhere. Instead of just being glad that their paper was accepted for publication – these researchers decided to offer actual practical solutions to help med students.
I hope your heart is doing well now – take care . . . ❤️
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