In January 2016 the American Heart Association (AHA) released an important Scientific Statement on heart attacks in women. First the good news: Women, like men, have experienced “stunning improvements” in mortality rates from coronary heart disease (CHD), including heart attacks. Overall, age-adjusted coronary death rates have fallen by at least two-thirds since 1980. This can be attributed to reductions in major risk factors via lifestyle changes and medication, along with improved medical treatments.
Now the bad news: Improvements in women lag behind those in men. “Coronary heart disease remains understudied, underdiagnosed, and undertreated in women,” according to the AHA. This is especially true of black women as well as women under age 54 of all races.
Many women still think that CHD is a man’s disease when, despite the dramatic progress, it remains their leading killer. Cardiovascular disease, which includes CHD along with strokes and heart failure, kills 10 times as many American women as breast cancer—400,000 versus 40,000 a year. It takes the life of one in every three women—more than all cancers, chronic respiratory diseases, and accidents combined.
The AHA report, published online in the journal Circulation, presents the latest data and understanding about how and why heart attacks in women often have different underlying causes, symptoms, and outcomes than in men. Not only are women less likely to realize when they are having a heart attack, but it’s often more challenging for doctors to diagnose it. This helps explain why while fewer American women have heart attacks than men each year, they are more likely to die when they have one.
Why women are overlooked
For decades much of what doctors knew about CHD was based on research in men. Men got more attention from doctors and researchers largely because they tend to have heart attacks at a younger age (average age 65) than women (average age 72). This age disparity leads many women to discount their risk. Why the age difference? Higher levels of estrogen before menopause may help protect women, in part by improving blood cholesterol levels, especially HDL (“good”) cholesterol. What’s more, women tend to have lower blood pressure than men through middle age. But after menopause, women’s cardiovascular risk rises, and by about age 75 it is equal to that of men.
Knowledge about women and CHD has grown in the last two decades, largely because more women have been included in clinical trials. Major efforts have been made to reach out to women (and their doctors) to help them understand their special risks. Since 1999 the AHA has released several sets of guidelines for cardiovascular disease prevention in women.
Whether you’re a woman or a man, it’s essential to understand how to protect your cardiovascular health. Women, in particular, often fail to accurately assess their coronary risk, even when they have a family history, according to the AHA. One key step is to talk with your doctor about your risk factors and the appropriate preventive strategies.
How heart disease is different in women
CHD is an equal opportunity ailment, but researchers are finding ways in which it differs by gender. Understanding these disparities can help improve prevention and treatment for women.
- Coronary risk factors. Many of these differ in degree between women and men. For example, all people with diabetes are at elevated risk for CHD, but for women the excess risk is more than twice as great as for men. High blood pressure is also more strongly associated with heart attacks in women. What’s more, women have higher rates of obesity and kidney dysfunction as well as psychosocial risk factors linked to CHD (depression, anxiety, and emotional stress).
- Differing mechanisms. In simplest terms, heart attacks are caused by plaque build-up and clot formation in the coronary arteries, which obstruct blood flow to the heart. But the way the blockages form differs somewhat in men and women, especially younger women. And women are more likely to develop narrowing and blockage in smaller branches of the coronary arteries (microvascular disease), rather than in the larger branches, as happens more in men. Though women often have less severe blockages (as detected by angiography), the resulting restriction of blood flow to the heart is just as dangerous. Stress testing is less likely to reveal problems in women than in men, and electrocardiograms in women are less likely to show the typical findings of a heart attack. Such differences help explain why women are more likely to experience misdiagnosis and delayed treatment.
- Atypical symptoms. Though left-central chest pain or discomfort is the most common symptom of a heart attack in both men and women, fewer women (about one-quarter to one-half, especially in middle age) have this classic symptom. Instead, women having a heart attack are more likely than men to report a variety of others symptoms, notably unusual fatigue, shortness of breath, weakness, dizziness, palpitations, indigestion, nausea, and pain in the jaw, neck, upper back, or arm, as well as a feeling of dread or intense anxiety. Such symptoms are often mistaken for a panic attack, but they call for immediate medical attention. Unfortunately, people in distress are likely to be treated less aggressively if they have no chest pain. “The absence of chest pain appears to be a stronger marker for mortality risk among women than men, especially young women,” according to the AHA report.
- Delay in seeking and getting treatment. Because their heart attack symptoms are different, more diverse, and less well known, women are less likely to recognize their symptoms, more likely to dismiss them, and thus more likely to wait longer to seek help. They often fear being perceived as hypochondriacs if it turns out not to be a heart attack. After experiencing such atypical symptoms, Rosie O’Donnell, for example, waited until the next day to see her doctor, by which time she had a 99 percent artery blockage. Doctors may not recognize a woman’s symptoms, either. Prompt treatment means a better prognosis—a small delay, sometimes even minutes, can make a big difference.
- Problems with treatment. Women less frequently get prompt, appropriate medical treatment during a heart attack than men do, according to the AHA. Moreover, when they do undergo bypass surgery to restore blood flow, women are about twice as likely as men to die during or shortly after the surgery. This is partly because diagnosis and treatment are often delayed, but also because the affected blood vessels are usually smaller (which makes the procedure technically more challenging), and women tend to be older and have more risk factors than men.
- After a heart attack. Women are less likely to receive appropriate medication after a heart attack and more likely to have complications, such as bleeding and heart failure. They are also less often referred to a cardiac rehab program—and when it is prescribed, women are less likely to participate in it or complete it.
- Racial disparities. Black women have a higher incidence of heart attacks and much higher death rates than their counterparts in other racial or ethnic groups, largely because they have more coronary risk factors (such as diabetes, obesity, high cholesterol, and high blood pressure) and are less likely to be treated for them. They are also less likely to get vital treatments such as angioplasty.
- Fewer preventive measures. Women are less consistently prescribed statins, low-dose aspirin, and blood pressure drugs when appropriate, compared to men.
Never too young
Coronary heart disease does not occur only in older women—every year more than 30,000 American women under 54 have heart attacks. Rosie O’Donnell, for instance, had one at age 50 in 2012.
Heart attacks are relatively infrequent in middle-aged people, of course. Men are still twice as likely as women to have a heart attack in middle age, but this gender gap has narrowed since 1990. While deaths from heart attacks in men under 54 have continued to drop, those among women (especially black women) in that age group have been creeping up. Why? For one thing, a disproportionate number of younger women are obese and have diabetes compared to men, and fewer of them are getting their high blood pressure and high cholesterol under control. While smoking rates in men have declined substantially, those in young women have dropped less. In addition, young women are even more likely than older women to have atypical symptoms, which are more often dismissed and undertreated.
If you think you are having a heart attack
Getting expert medical help immediately is essential if you think you may be having a heart attack. Don’t try to explain your symptoms away. Do the following:
- Call 911 immediately.
- Then chew and swallow a whole adult aspirin (or four “baby” aspirins). If there’s a blood clot, the aspirin will help prevent its progression.
- Don’t drive yourself or be driven to the hospital by someone else. Wait for an ambulance—the emergency medical workers can begin treatment immediately and communicate with the hospital so that a medical team is ready when you arrive.
Also see 13 Tips for Preventing Heart Disease.