At The Heart of Women’s Problems

This lyric came to mind when reading a recent press release from the Irish Heart Foundation. Consultant physician Dr Kate McGarry, chairwoman of the foundation’s council on women and cardiovascular disease, said a woman died every two hours in Ireland from heart, stroke and  blood-vessel diseases: “When it comes to health issues, women are more concerned about breast cancer, even though seven times as many die from heart disease and stroke in Ireland each year.”

Why the awareness gap, given that some 5,000 Irish women die of cardiovascular disease every  year?

The answer is partly historical and partly medical. Much of our current knowledge about heart disease can be traced back to the Framingham heart study. Launched in 1948 and still running, it set out to follow the cardiovascular health of more than 5,000 men and women aged 30-62 years when the study began. The researchers  added 5,000 daughters and sons of the original participants in an extension to the study in 1970.
But because two-thirds of the women studied were pre-menopausal, the initial studies  suggested few women had evidence of heart disease.

Unfortunately, despite more recent advances in knowledge, to some extent doctors have continued to have a blind spot when it comes to the male-female divide in heart disease.

In fairness to them, making a diagnosis of coronary heart disease is more difficult in women. Rather than the classic crushing chest pain, sweating and nausea experienced by many men who are having a heart attack, women’s symptoms can be more subtle. Tiredness, shortness of breath and pain in the neck or the jaw may be prominent.

Women themselves do not associate these symptoms with heart disease, while health professionals may reasonably consider other causes first when women present like this.

Older women, in whom the incidence of heart disease is similar to that of men due to the loss of the cardio-protective effect of oestrogen after menopause, may choose to cut down on physical activity that causes them discomfort rather than go to their doctor to have the symptom  investigated. And then there is the old chestnut: are women more stoic than men when it comes to pain?

Some diagnostic tests are less reliable in women. The exercise ECG – where you walk at an increasingly fast pace while your heart rate, blood pressure and heart rhythm are monitored – can appear normal in some women subsequently shown to have definite coronary heart disease when they undergo an angiogram.

However, even when the diagnosis has been made, it seems women are not treated as vigorously as men. In research presented this week at the annual congress of the European Society of Cardiology in Stockholm, Dutch researchers looking at data from the Euro Heart survey found women over 60 with coronary artery disease were less likely than men of the same age to be treated with a coronary bypass operation.

Czech researchers who looked at patients with acute coronary syndrome found a gender disparity in the numbers treated with a stent to bypass their heart blockage: 67 per cent of women had a procedure compared with 76% of men.

Meanwhile in Finland, a study of people at high risk of heart disease found poor risk factor control in both sexes, but concluded that young women in the high-risk category were not being identified or adequately treated.

And a Portuguese study of 3,500 people with stroke found women experienced more extensive strokes with greater levels of disability than men, a result partly explained by a greater prevalence among women of atrial fibrillation, a heart rhythm disturbance.

It seems women with heart disease are also being studied less. An Italian researcher reported last year that in 62 randomised clinical trials published between 2006 and 2009, just a third of enrolled participants were women.