We know we are not the same, however men and women spend their lives together despite the acknowledged differences in behaviour, reasoning and special skills like communication, aesthetics, organisation and others, which I clearly do not want to attribute to any one side, but will use to make my actual point clear: do we also understand the gender differences when it comes to cardio-vascular disease and the impact this lack of knowledge has in real life?
For decades, cardio-vascular disease, heart attacks, strokes and heart failure have been primarily attributed to the male population, and this has been evaluated by numerous research studies. Men are seen as being at risk starting at the age of 40, and their symptoms are clear cut. The well-known chest pain with radiation to the left arm is well documented with the purpose of saving male lives. In the same decades, female cardiovascular disease has emerged, progressed and caused unnecessary deaths because it is often unnoticed, under-diagnosed and misinterpreted. The lack of clear knowledge about risk factors or symptoms is simply due to the lack of medical data and research specifically dedicated to female disease. Only in the last 20 years has the female aspect of cardiac disease started to spark the interest of the medical society. Why? At some point it became evident that whilst male cardiovascular disease started to improve in statistical analysis, 1 out of 3 women were still dying of cardiac disease, as compared to 1 in 25 deaths from breast cancer, a disease every woman is highly aware of. Also, more women than men with acute heart attacks are likely to die, and the time from the onset of symptoms to diagnosis is far longer in women than in men, leading to lost treatment time and a gloomier prognosis.
Male cardiac disease progresses in a linear fashion from the 40s. Therefore, the absolute risk for cardiac disease also increases slowly over time. That's why men start to slowly show signs of increased blood pressure, cholesterol levels, especially LDL, and body fat. They have time to become aware of their risks and to start controlling them: to stop smoking, to adjust to the fact that blood pressure and diabetes must be controlled, lose weight and change their bad lifestyle habits– and have their hearts checked regularly.
By contrast, female cardiac disease is linked to a specific event in a woman's life: the menopause. Up to this point, high oestrogen levels have a protective effect on several aspects of our cardiovascular system. This hormone keeps our vessels intact, lowers blood pressure, helps with sugar metabolism, reduces visceral fat, a protective benefit we pay for with the distribution of fat around our hips, and reduces inflammation. At the moment of menopause, the oestrogen level falls and we lose its protective effect. Now we start catching up with the boys all too quickly: blood pressure rises, the fat distribution changes. We develop diabetes and the so-called metabolic syndrome. Most women are more focused on their physical changes and their aesthetic look, while the changes within are mostly left unattended.
As a doctor I do get to see that very surprised reaction when I tell my female patients that their blood pressure is sky high, and I always get this as a response: It cannot be, my blood pressure has been rather too low ALL MY LIFE. And they are right – only that in the meantime, menopause had struck! The risk grows exponentially over time until it reaches the same level of our male age group. Diabetic women however continue to be at higher risk for heart attacks than their male counterparts and the same applies to smokers. On the other hand, LDL cholesterol levels don't seem to be as important in women as in men, but a lowish HDL cholesterol has a huge impact on the risk level. There is also a significant difference in symptoms between men and women.
Women tend to have what doctors call “atypical” complaints, such as an increase in stomach aches and nausea, shortness of breath with physical exertion or at rest, apparently ‘out of nowhere’. They may also experience general fatigue, weakness and an incapacity to keep up with their usual physical activity. The typical chest pain radiating to the left arm is a rather rare symptom.
Last but not least we get to the differences in the disease itself. In women the very small arteries tend to be affected and these vascular changes may not even be seen during coronary angiogram. Nevertheless, conservative medical treatment is indicated in these cases and will lead to an improvement in the patient's prognosis and quality of life.
So what can we do to get better at taking care of our women's hearts?
First we must clearly increase awareness of the existence of these differences and so improve the diagnostic procedure. ‘Atypical’ symptoms must be seen as typical for women and be taken seriously by doctors, and regular cardio-vascular check-ups based on the female risk profile should be conducted regularly. We must shorten the time taken to reach a diagnosis and to the onset of treatment. Doctors must understand the different approach needed to the female heart and treat risk factors and disease accordingly. And of course, ongoing medical scientific studies will also continue to lead the way until the gender gap is finally closed – at least from our heart's point of view.
Dr. Manuela Reisbeck
CardioCare International Heart Center, Marbella