Women and Cardiovascular DiseaseA Woman's Heart - Unique Features of Cardiovascular Disease in Women

With the recognition that women face a greater risk of death due to cardiovascular disease, guidelines for heart-disease prevention for women have been drafted. An updated set of guidelines from the American Heart Association that focuses on long-term preventive strategies was published in 2011. Recommendations include:

• Lifestyle changes, including smoking cessation and moderation in alcohol consumption
• Increased physical activity, with at least 150 min/wk of moderate exercise, 75 min/wk of vigorous exercise, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity
• Consumption of a diet rich in fruits and vegetables; whole-grain, high-fiber foods; and oily fish, with limited consumption of saturated fat, cholesterol, trans-fatty acids, sodium, and sugar
• Weight control through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain or achieve an appropriate body weight
• Maintenance of an optimal blood pressure of <120/80 mm Hg. Pharmacotherapy is indicated when blood pressure is ≥140/90 mm Hg (≥130/80 mm Hg in the setting of chronic kidney disease and diabetes mellitus)
• Encouraging healthy lipid levels through lifestyle approaches: LDL-C <100 mg/dL, HDL-C >50 mg/dL, triglycerides <150 mg/dL, and non–HDL-C (total cholesterol minus HDL) <130 mg/dL. LDL-C–lowering drug therapy is recommended simultaneously with lifestyle therapy in women with CHD to achieve an LDL-C <100 mg/dL. In women >60 years of age and with an estimated CHD risk >10%, statins could be considered if hsCRP is >2 mg/dL after lifestyle modification and no acute inflammatory process is present.
• Lifestyle and pharmacotherapy can be useful in women with diabetes mellitus to achieve an HbA1C <7% if this can be accomplished without significant hypoglycemia.
• Regardless of the cardiovascular-disease status, the routine use of low-dose aspirin in women 65 years or older needs to be considered only if benefits are likely to outweigh risks.

While risk factors¹¹ for cardiovascular disease are similar in women and men, there are some risks that are higher or have a greater prevalence in women than men. In addition, there are some unique risk factors for cardiovascular disease in women.

Risk factors that are similar in women and men include:

Non-modifiable risk factors

• Advancing age
• Family history
• Ethnicity

Modifiable risk factors

• High blood pressure
• High total cholesterol
• Low HDL cholesterol
• Combined hyperlipidaemia
• Unhealthy diet
• Physical inactivity
• Stress

Risk factors that are higher or have a greater prevalence in women versus men include:

Non-modifiable risk factors

• Advancing age
• Family history
• Ethnicity

Modifiable risk factors

• High blood pressure
• High total cholesterol
• Low HDL cholesterol

Unique risk factors for cardiovascular disease in women include:

• Oral contraceptive use
• Hormone-replacement therapy
• Polycystic ovary syndrome

Outcomes for Women after a Heart Attack
Heart attacks occur in both women and men, but a women’s risk for having a heart attack increases significantly after menopause. Unfortunately, a woman’s likelihood of survival after a heart attack is lower than that of a man. Data from the American Heart Association indicate that more women than men will:

• Die within the first year after suffering a heart attack
• Suffer another heart attack or fatal coronary heart disease within the first 5 years after a heart attack
• Develop heart failure within 5 years of surviving a heart attack
• Suffer from stroke within the first 5 years after a heart attack¹²

In addition to these data, younger women who have a heart attack have higher mortality than men of the same age, even though they generally suffer from less-severe coronary narrowing, smaller heart attacks, and have more-preserved cardiac function.3 Young or middle-aged women exhibit higher rates of adverse outcomes, complications, and disability after heart attack or ACS compared with men.¹³
 

The American Heart Association also states that women are not as likely to receive aggressive diagnosis and treatment for cardiovascular disease in comparison to men. Women also receive fewer interventional treatments, with and without the placement of stents, than men (only 34% for women).¹⁴
 

Differences in the Presentation of a Heart Attack
Knowing and acting on the heart-attack symptoms in women and men can mean the difference between life and death. Many women do not recognize the atypical symptoms of a heart attack that often are present in women, or they disregard them as symptoms of other non-life-threatening conditions. While both sexes may have the typical pain, pressure, or discomfort in the chest, women tend to experience these less often than men, and women commonly present with symptoms other than chest pain.
 

Heart-attack Symptoms in Women
The most common symptoms of a heart attack are-common in both women and men:¹⁵

• Discomfort or pain in the chest
• Discomfort or pain in the left shoulder, arms, elbows, back, or jaw

Other symptoms of heart attack that are often more common in women than in men include:^16,17

• Shortness of breath or difficulty breathing
• Nausea or vomiting
• Lightheadedness
• Cold sweats

• Loss of appetite/heartburn
• Weakness or unusual/unexplained fatigue
• Heart flutters
• Cough

Cardiovascular disease is largely preventable, and simple blood tests can help assess a person’s risk. Blood tests commonly used in risk assessment of cardiovascular disease include:

• Apolipoprotein A1
• Apolipoprotein B
• BNP/NT-proBNP
• Fibrinogen
• HDL cholesterol
• Homocysteine
• hsCRP
• Interleukin-6

• LDL cholesterol
• Lipoprotein (a)
• Myeloperoxidase
• Total cholesterol
• Troponin I

Reducing the burden of cardiovascular disease in women includes:

• Understanding risk factors
• Making rapid, accurate diagnoses when symptoms occur
• Implementing appropriate therapies
• Monitoring treatment

Laboratory diagnostic testing plays an integral role in helping care for women throughout the continuum of cardiovascular disease and of life.
 

Throughout a woman’s lifetime, there are a number of conditions and diseases that affect her differently, or to a greater extent, than men. Many of these conditions and diseases are interconnected, where the onset of one leads to a greater risk of developing another. With an enhanced understanding and focus on the unique healthcare needs of women, healthcare providers across the continuum of care can be better equipped to prevent, detect, and treat the most threatening diseases affecting their female patients throughout all stages of their lives.