Written by Dr. Farah Al-Khitan, Ashchi Heart & Vascular
Ischemic heart disease (IHD) is the leading cause of death in women as in men, although presentation in women is on average 7-10 years later. Recently a decrease in IHD incidents and resulting mortality among men has been noticed but not so among women due to lack of early diagnosis, prevention, and treatment. Mortality among women remains higher than in men.
Coronary Artery Disease in Women
In women, the issue of Coronary Artery Disease (CAD) is underestimated, which results in underdiagnosis and undertreatment. Diagnosing angina pectoris is based on medical interviews. Unfortunately, clinical practice shows that there are significant differences in symptoms between men and women. The difference is particularly important because the data gathered during interviews and the degree of symptoms initiates the diagnostic process. The symptoms of angina pectoris as the first manifestation of coronary artery disease differ among men and women. Women more often report atypical anginal symptoms or uncharacteristic chest pain accompanied by increased sweating, dyspnea, nausea, and vomiting, which, in most cases, does not lead to further non-invasive CAD diagnostics.
Coronary Artery Disease
The widely known risk factors for CAD are identical in both sexes; frequency and intensity vary. Smoking is a known modifiable risk factor that increases the risk of CAD in women as much as five times compared to non-smokers. Tobacco smoking in combination with oral contraception increases the risk of CAD 13 times. It appears that tobacco smoking is one of the more substantial risk factors for coronary artery disease in women, even more so than in men, especially in individuals over 50.
Hypercholesterolemia is also a risk factor for CAD both in women and in men. Studies have shown that the concentration of total cholesterol, LDL, and lipoprotein was a more potent risk factor for developing CAD in men; in women, hypertriglyceridemia was a more decisive factor.
Diabetes mellitus (DM) is another significant risk factor for CAD. Type 2 DM is associated with higher CAD risk in women than in men. Coronary artery disease statistics have shown that mortality due to myocardial infarction is substantially higher in women with type 2 DM than in men with type 2 DM and women without this condition.
Atypical Symptoms, Men Vs. Women
Due to atypical symptoms of IHD and later presentation in women, the outcomes of both chronic and acute coronary syndromes are worse in women than in men, concerning older age and comorbidities. Recognition and quality of care of IHD are still not the same for both sexes. Non-invasive CAD diagnostics in women are less sensitive and specific than in men; this pertains to electrocardiographic stress testing. Women are more likely than men to exhibit non-specific changes in resting ECG, lower voltage of QRS complexes, high resting heart rate, which, combined with the smaller diameters of coronary vessels and lower fitness, reduces the specificity of stress testing (sensitivity and specificity of the test in women is 60–70% vs. 80% in men). Studies also found that most women won’t achieve 4.7 METs on exercise stress. In other words, they will only finish stage 1 on Bruce protocol. Therefore, referring women for echocardiographic tests using dobutamine or perfusion scintigraphy (SPECT) is ideal.
Diagnosis
Coronary angiography remains the gold standard to diagnose CAD. Women are also less likely to undergo coronary angiography and coronary revascularization. More than 50% of women undergoing coronary angiography receive the diagnosis of insignificant changes in the coronary vessels or “clear coronary vessels.” Coronary atherosclerosis is not the only cause of myocardial ischemia; spasms, microcirculatory dysfunction, and spontaneous dissection are also causes of ischemia that happen to be more prevalent among women. Women undergoing percutaneous or surgical coronary revascularization are more likely to suffer from ischemic stroke or hemorrhagic complications. The in-hospital mortality rate after CABG is higher among women. Their potentially worse prognosis is associated with the fact that coronary artery disease in women occurs approximately 7–10 years later than in men. Furthermore, older women more often suffer from concomitant diseases such as diabetes or chronic kidney disease. Therefore the challenge remains in diagnosing and treating coronary artery disease in women.
Check out this video by Go Red for Women about a “little heart attack” by Elizabeth Banks.