Gaps persist in knowledge about women and heart disease

Physicians are being reminded of women's high rate of heart disease and some possible gender differences in symptoms and diagnosis.

By Susan J. Landers, amednews staff. April 16, 2001.

Washington -- The saga of Julia Carson's quest for relief from her chest discomfort could serve as a case study in what can go wrong in diagnosing and treating heart disease in women.

First, her primary care physician attributed her complaints that something was wrong with her heart to the stress of a recent election campaign -- Carson, a Democrat, is a U.S. representative from Indiana. Then she underwent a battery of tests -- but none on her heart.

Masked signals
Links

When the pain got too bad, Carson called the emergency department of her local hospital and said she would be coming in. But, rather than head straight over, she detoured to keep a previous appointment.

Not only did Carson wind up having a double-bypass operation at the hospital, but she also had to replace her front door, which had been removed by emergency personnel who feared she had been too ill to leave her home.

Although this example may seem extreme, much of what Carson experienced is fairly common. Too often, physicians miss properly diagnosing heart disease or heart attacks in women, attributing symptoms to hot flashes or indigestion. And just as frequently, women decide to finish cooking dinner or wait until someone can drive them to the hospital rather than calling 911 right away.

Women are thought to be at less risk of heart disease and heart attacks than men. However, cardiovascular disease, both coronary heart disease and stroke, are the leading causes of death in women in this country, according to the American Heart Assn. Both claim more female lives than the next 16 causes of death combined, including all forms of cancer, chronic lung disease, pneumonia, diabetes, unintentional injuries and AIDS.

"This is a crisis," said Sharonne N. Hayes, MD, director of the Women's Heart Clinic at the Mayo Clinic in Rochester, Minn. She addressed a seminar on women and heart disease held March 28 by the Jacobs Institute of Women's Health.

On the preceding two days, the National Heart, Lung and Blood Institute held a workshop to lay groundwork for a new heart health education campaign aimed at women and doctors.

"There were concerns about a knowledge gap," said Gregory Morosco, PhD, associate director for prevention education and control at NHLBI. "We have a lot of information that isn't getting out there," he said.

Gender differences

While men's risk of dying from a heart attack has declined in recent years, women's risk has increased. Women's cardiovascular death rate was higher in 1998, the most recent year for which statistics are available, than it was in 1979, according to the Centers for Disease Control and Prevention and the American Heart Assn. But the death rate among men declined during those same years.

Study results show that men are more likely than women to be referred for angiograms following abnormal stress tests, said Dr. Hayes. Women, on the other hand, were more likely to be given a psychiatric diagnosis for their pain.

Women are unaware of their risk. Only 8% of women surveyed recently by the American Heart Assn. identified heart disease as their greatest health threat. Many more, or 61%, incorrectly said they believed they faced a greater risk from cancer.

Primary care physicians are in a good position to educate female patients about their risk of heart disease and to counsel them on diet, exercise, smoking and lowering high blood pressure, said Dr. Hayes. Physicians could use the occasion of a woman's mammogram to ask about her health habits and to check her lipid levels, she said.

Controlling high blood pressure alone would help many women. "More than half of women over age 45 are hypertensive," noted Nieca Goldberg, MD, chief of the Women's Heart Program at Lenox Hill Hospital in New York and a spokesperson for the American Heart Assn.

Women also achieve better results than men when prescribed lipid-lowering drugs, said Noel Bairey-Merz, MD, director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles. The only problem is, they aren't prescribed for women as often as they are for men, she said.

In addition, when women do seek medical care for a possible heart attack, they may exhibit different symptoms than do men, according to several studies.

"Women can have discomfort in the lower portion of the chest, so it can be easily mistaken for abdominal symptoms or gall bladder disease," said Dr. Goldberg. "Sometimes women's symptoms are less specific and may lead a physician to look somewhere else for the cause," she said.

Exercise stress tests paired with electrocardiograms may be less accurate in properly diagnosing heart disease in women than are newer tools such as the use of ultrasound plus an exercise stress test, said Dr. Goldberg.

Women who are having heart attacks are also less likely to call for an ambulance than are men; this may delay their care to such an extent that normally effective treatments may be of no use.

Clot busters and angioplasty are aimed at opening arteries and reestablishing blood flow to the heart and must be administered quickly to be effective, noted Mary Hand, coordinator of the National Heart Attack Alert Program at NHLBI.

Although men and women share many risk factors -- cigarette smoking, high blood cholesterol, high blood pressure, physical inactivity and excess weight -- diabetes is thought to be more prevalent among women who have heart attacks than among men.

"Diabetes takes away any gender advantage that a woman may have had," noted Dr. Goldberg.

Estrogen does protect women from heart disease, but after menopause women's risk increases, said Hand. Women tend to have heart attacks, on average, 10 to 15 years later than men.

However, the possibility of younger women experiencing heart attacks must also be considered, say researchers.

Gender differences linger in the aftermath of a heart attack, said Dr. Hayes. Levels of anxiety and depression are higher for women than for men. Also, social supports are generally lacking for women, who are more likely to be widowed and poor than are men.

ADDITIONAL INFORMATION:

Masked signals

Women and men experience many of the same warning signs of a heart attack, but some less common symptoms may signal a heart attack in women. In addition to the classic warning signs -- pressure, fullness, squeezing or pain in the center of the chest -- some of these alerts include:

Pain in the neck, back, stomach or abdomen.
Nausea or dizziness.
Shortness of breath and difficulty breathing.
Unexplained anxiety, weakness or fatigue.
Palpitations, cold sweats or paleness.

Weblink

Cardiovascular Gateway, part of the National Heart, Lung and Blood Institute's Healthy People 2010 initiative (http://hin.nhlbi.nih.gov/cvd_frameset.htm)

American Heart Assn. (http://www.americanheart.org/)