Women's Heart Disease Subtle Signs

It's a common occurrence. A nauseated woman in her fifties wakes up. She dismisses it and goes about her day, feeling a little tired and short of breath during her morning stroll. After experiencing shooting agony in one arm, her pals advise her to see a doctor. Despite her belief that it is nothing, she goes to the emergency hospital and has a battery of testing. She is sent home after being told that there isn't a blockage in one of the three main arteries and that she is more likely to have a stomach problem or worry.

There is no substantial obstruction or pain in the chest. Isn't it possible that it's a heart attack?

For years, the incident described above would have gone unnoticed. That's because, until recently, our understanding of heart attacks was mostly centered on men. Men who have heart attacks have chest pain as a result of blockages in their cardiac arteries.

Doctors are now learning about the differences between men and women when it comes to heart attacks and heart disease. A lesser-known type of cardiovascular disease that is more common in women than in males is "broken heart syndrome," the name given to a transient ailment that arises when stressful or unexpected conditions induce acute chest pain and stiffness.

We spoke with Erica Spatz, MD, MHS, a clinical investigator with the Yale Center for Outcomes Research and Evaluation (CORE), which focuses on health care quality, on how women's knowledge of heart disease is evolving. Read on to learn more, and don't miss these Sure Signs You've Already Had COVID to protect your health and the health of others.

1 What Are the Differences in Heart Disease Risk Factors for Men and Women? Do Hormones Have an Impact?

Yes. Women's cardiovascular health is influenced by their hormonal cycles. Estrogen protects the heart in the premenopausal years by relaxing the arteries and promoting healthy cholesterol. However, as estrogen levels drop in the perimenopausal years, cardiovascular risk factors such as high cholesterol and hypertension appear, even in women who previously had normal or even low cholesterol and blood pressure. Due to the preventive effects of estrogen, the incidence of heart disease in women begins to rise at the age of 65, roughly 10 years later than in males.

The jury is still out on whether hormone replacement therapy (estrogen plus or minus progesterone) raises or decreases the risk of heart disease. Estrogen was supposed to protect women from acquiring heart disease in the 1980s and 1990s, and it was widely used for this purpose. The Women's Health Initiative, on the other hand, reported a greater risk of heart attack and stroke when they investigated the effects of estrogen in a randomized clinical trial. Recently, the pendulum has begun to swing back—but not completely. Estrogen is generally safe, and it may reduce cardiovascular risk in women under the age of 60 or who haven't gone through menopause for more than ten years.If a woman is thinking about taking estrogen to treat menopausal symptoms, this is a good time to talk about cardiovascular risk and make a joint decision about whether hormone replacement treatment is best for her.

2 What About Women's Different Heart Attack Symptoms?

The most common symptom in both sexes is chest pain, but women may not feel as if an elephant is sitting on their chest. They may have chest pain or a dull aching, as well as shortness of breath, jaw pain, or nausea. When they go for a stroll or do something that is normally easy for them, the symptoms can be more diffuse, such as dizziness, clammy skin, or extreme exhaustion. It's common for women to experience a slew of symptoms—chest pain, for example, but also a slew of other symptoms that mask the chest pain. All of this could lead to under-recognition of symptoms by both women and doctors.

3 Is it true that women's heart attacks differ from men's?

Sometimes. Not only can symptoms differ, but test results may not follow a predictable pattern. The typical pathophysiological processes that contribute to heart attacks are not always present in women (and that most of our tests are designed to detect). Our tests are meant to check for blockages in one of the three main arteries that carry blood to the heart, but many of the women we meet in the ER do not have blockages in those arteries. Despite the fact that they have all of the symptoms, ECG findings, and blood test results that indicate a heart attack, we don't locate a substantial blockage.

4 How Can You Tell If They've Had a Heart Attack?

Women's non-traditional heart attacks are becoming more widely recognized. Some of our newest imaging tests and catheter-based assessments can detect disease in the small arteries of the heart, which can contribute to heart attacks [known as microvascular dysfunction]. In some circumstances, a cardiac event may be caused by a dynamic arterial spasm. The spasm may have started with the chest pain, but by the time the women arrive to the catheterization lab, the spasm has subsided and the artery appears normal.

Both microvascular dysfunction and coronary vasospasm can go undiagnosed, and the occurrence may be rejected as "not cardiac"—instead, clinicians may blame the symptoms on anxiety or a stomach issue. "Well, you had a heart attack, but the heart arteries were clear, so good luck," some women are told when they leave the hospital.

Uncertainty about treatment and prognosis might result from a lack of a definitive diagnosis. Because doctors didn't find anything the first time they had that kind of discomfort, women are typically hesitant to seek help the second time they encounter it.

5 Isn't the VIRGO Study a Step Towards Raising Awareness About These Different Heart Attacks?

That's correct. The director of CORE, Harlan Krumholz, MD, undertook a comprehensive study to better understand the experiences and outcomes of heart attack patients, as well as to compare men and women. They discovered numerous distinct risk variables among women, including depression, low social support, and socioeconomic status, in collaboration with Rachel Dreyer, PhD, assistant professor of emergency medicine and biostatistics, who now oversees the VIRGO project. They also discovered that women and men recover from heart attacks in various ways.

We collaborated on a study to create a classification system for different types of heart attacks, particularly those that are more common in women. We discovered that one out of every eight women in the study did not have evidence of a classic heart attack and did not fit into our traditional classification system known as the Universal Definition [a tool developed by the American Heart Association and other organizations to define different types of heart attacks] after reviewing nearly 3,000 case reports. As a result, we created VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), an alternative taxonomy that captures distinct types of heart attacks as well as the molecular and pathological factors that underpin them.The taxonomy also recognizes that we don't always know what causes a heart attack. This is equally essential because it can lead to more study and breakthroughs. This classification isn't in use right now, but the principle is, and more practitioners are becoming aware of women's heart disease and adopting newer diagnostic methods. Furthermore, additional research is being conducted to determine prognosis and the best treatment techniques for various types of heart attacks. This is an exciting time, and I am confident that we are entering a new age of cardiovascular health for women.

6 There has been a lot of discussion over statin therapy. What Should Women Know About That?

Statins are cholesterol-lowering drugs that reduce LDL, or bad cholesterol, and are a staple in the prevention of heart attacks and strokes, leading in a 30 percent to 40% reduction in risk. The fact that statins are prescribed to so many people, especially as they get older, is one reason for the pushback. As cardiologists, our duty is to find out who will benefit from statins and who will not since they were never going to have a heart attack in the first place.

Women have historically been under-prescribed preventative drugs due to doctors' perceptions that they are less at risk for heart disease than men. Some women, on the other hand, have been advised they need to take a statin and think to themselves, "Maybe that's not suitable for me." It is critical that tailored approaches to the decision to take a statin be promoted.

There is a strong recommendation for women with existing heart disease to take a statin since there is a significant reduction in the risk of future heart attacks. We need to incorporate women who don't have heart disease in shared decision-making, which includes discussions about their personal risk of heart disease and the possibility for statins to reduce that risk. Then, based on their tastes, values, and objectives, decide what is best for them. Some of the studies I'm conducting with women is to encourage these discussions about what factors contribute to cardiovascular risk and how much statins can reduce that risk.

7 Hypertension is Another Big Topic, Correct?

The most essential risk factor that we can control is hypertension. With a strategic focus on the New Haven community, Yale New Haven Health Heart & Vascular Center and Yale Medicine are collaborating to enhance blood pressure regulation. We're working with pharmacists to incorporate more person-centered blood pressure monitoring methods, such as remote monitoring [blood pressure monitoring at home] and telemedicine visits.

We're also looking for and addressing factors that contribute to poor blood pressure regulation, such as inadequate diet, financial stress, and transportation. This program is still in its early stages, but we hope to expand it to some key populations, such as postpartum women who have had hypertension or preeclampsia (high blood pressure and signs of damage to another organ system during pregnancy) and are at risk of developing high blood pressure after delivery.

8 Should Women Be Concerned About "Broken Heart Syndrome"?

Broken heart syndrome is a short-term, acute disease that looks like a heart attack. Chest pain, shortness of breath, and heart muscle failure are common symptoms of this condition, which arises in response to significant mental or physical stress. According to a report published in the Journal of the American Heart Association in October 2021, the diagnosis of broken heart syndrome has risen, particularly among women over 50. It's actually 6 to 12 times more common among women aged 50 to 74 than it is among younger women or men.

The good news is that most patients who suffer from broken heart syndrome will recover quickly and completely, with no long-term consequences. However, scientists are still investigating the syndrome's long-term implications and why it is more common among these women.

9 What Should Women Expect From Their Doctor Visit?

Women should expect and accept nothing less than a personalized approach. Personalized medicine entails taking the time to learn about the patient and how their biology and background may affect their cardiovascular health. We have calculators that can estimate a person's chance of having a heart attack in the next ten years, which is an excellent place to start.

However, more information is usually required—what is their nutrition, activity level, daily stressors, depression and trauma experience, and general well-being? It's crucial to understand women's pregnancy experiences, particularly conditions like diabetes, preeclampsia, high blood pressure, or pre-term delivery, all of which are risk factors for heart disease. What is their family's background? Is advanced cholesterol testing, a calcium score, or genetic testing necessary? Finally, we must collaborate with our patients to put it all together in order to determine their personalized risk and the potential to reduce it as accurately as possible, as well as to take into account their preferences, values, and goals in order to determine the best strategies for promoting cardiovascular health.

I encourage women to take any troubling symptoms seriously and to speak up if they don't receive a clear diagnosis after a cardiac episode. When something is wrong with a woman, we now know that the initial line of testing may not show the answer. In my practice, I encourage women to seek a second opinion or a second line of testing.

10 What Should Women be Doing to Prevent Heart Disease?

Women should discuss about heart disease more among themselves and with their doctors as a beginning point. One of the most significant things they can discuss is their family history, which is especially essential for young and middle-aged women because there are several possibilities to determine whether they, too, are at risk and to reduce that risk. It's also vital to talk about your pregnancy and menopausal experiences, as well as your nutrition, exercise, and stress levels.

'Knowing what you know about me, what is my risk, and what can I do to mitigate my risk?' I want women to feel safe asking. Then we may collaborate to create a plan that is unique to you. Also, don't go to any of these 35 Places You're Most Likely to Catch COVID to safeguard your life and the lives of others.