Women's Hearts

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Only about one-third of women know that heart disease is the leading cause of death for women, according to an AHA-sponsored survey in 2000, while almost two-thirds of female respondents thought cancer was their chief health threat. Cardiovascular disease (CVD) kills nearly half a million women each year, with over 240,000 women dying of heart attacks, twice the number of all female cancer deaths combined.

While CVD kills more women (51.9%) than men (48.1%), current diagnostic and treatment protocols are based largely on research and clinical trials limited to men. Part of the reason for this discrepancy is that CVD strikes men at a younger age than women, by about a decade on average. For decades, women were excluded from medical research and it wasn't until 1986 that the National Institutes of Health required women to be included in clinical studies. Dr. Nanette Wenger, chief of cardiology at Grady Memorial Hospital and professor at Emory School of Medicine, commented: "Before that, they would take the research from the middle-aged men and apply it to the universe, the elderly and women." Subsequently, inaccurate presumptions were made about how diseases such as CVD affected women.

Women need to be aware that gender differences exist. Most likely, their perception of what constitutes a symptom of disease is based on a "male model." For example, the original Centers for Disease Control and Prevention (CDC) definition of AIDS was based on the presence of pneumocystis pneumonia. Women were misdiagnosed or underdiagnosed as having an AIDS-related condition because rather than exhibiting pneumonia, they were presenting symptoms such as vaginal infection and were therefore not included in the AIDS statistics.

The same is true for heart disease: For years, heart disease was studied, stereotyped, and considered a "man's disease." Picture a patient in the emergency room complaining of chest pain and most likely, you will picture a man. Women are less likely than men to believe they are having a heart attack because they don't believe that they are at risk, even in cases when their risk is clearer. For example, family history of heart disease is a stronger predictor of heart disease for women than it is for men. Also, women with diabetes are roughly five times more likely to develop heart disease than women without diabetics, while men are only two to three times more likely if they have diabetes. Finally, women are more likely to develop hypertension after the age of 45 than men. Over half of all women over age sixty-four have high blood pressure. Heart attacks cause more death and disability in women than in men, and women are also more likely to die after their first heart attack.

Why are women less likely to recover? Dr. Jean McSweeney, associate professor of the University of Arkansas for Medical Sciences in Little Rock, provided an explanation for this health outcome difference at the National Heart, Lung and Blood Institute's (NHLBI) conference, "Cardiovascular Health for All Meeting the Challenges of Healthy People" in Washington, D.C. on April 11-13. She believes the answer lies in the failure to identify women's heart attack symptoms, which tend to differ from men's. Dr. McSweeney reported findings about those symptoms from a recent study of nearly 650 women who were interviewed after having a heart attack.

While the male model of heart disease gives the classic example of angina, or chest pain, around the breastbone with the pain radiating to the throat or either arm as a signal of a heart attack, the early signs of heart disease are exhibited very differently in women. She found that some women experience undiagnosed warning signs up to two years before having a heart attack, with the five most-frequent symptoms being fatigue, sleep disturbance, shortness of breath, indigestion, and anxiety. Women tend to report a "bewildering array of symptoms," which also include severe pain in the stomach, back, neck, teeth, and ears; swelling in the legs; burning in the chest; nausea/vomiting; and depression. Physicians might not treat women's wide-ranging heart disease symptoms with the same concern as they might a man's; forty-five percent of women present their doctors with "no recognizable symptom or no symptom at all" of cardiovascular disease. Since doctors expect chest pain and numbness in the arms, women are unaware that their symptoms may be different. The same 2000 AHA survey cited earlier found that only 9% of women knew that nausea was a symptom and 5% knew that fatigue was a symptom of a heart attack. These two signals are very common in women.

While the NHLBI recommends that those experiencing heart attack symptoms should call 911 within the first five minutes of symptoms, most women put off receiving medical care. Studies have shown that women tend to wait two or more hours before seeking treatment (up to one hour later than a man will), although they are more likely to have other conditions, such as diabetes, high blood pressure, and congestive heart failure, which make it all the more pertinent that they seek proper treatment quickly.

There are also differences in diagnostic testing between the sexes. While women get mammograms and pap smears, men get electrocardiograms and a variety of lab tests. Even tests used to detect heart disease are not as accurate for women: The treadmill stress test is only about 42% accurate in women versus 90% accurate in men.

Finally, there are differences in treatment. While more women than men die of heart disease, women undergo fewer cardiac surgical procedures. In 1998, angioplasty was performed on 594,000 men and 332,000 women, and bypass was performed on 396,000 men and 158,000 women. Only recently has it been discovered that women's hearts and capillaries tend to be smaller than men's, leading to the redesigning of catheters and devices used in angioplasty and other procedures, which were made to suit men. There has been debate about the efficacy of such procedures for women, but new findings from the NHLBI-supported Bypass Angioplasty Revascularization Intervention suggest that women undergoing coronary artery bypass graft surgery or balloon angioplasty procedures survive just as well as men do.

If "men are from Mars and women are from Venus," it's not surprising they have different reactions to disease and different health needs. We are finally starting to take notice of these gender differences and move away from the dominant "male-model." The moral of the story is: While in the past women were disregarded when it came to the diagnosis, detection, and treatment of heart disease, resulting in negative health outcomes, we no longer have to accept these inequalities. We should educate ourselves about the prevalence of heart disease in women, understand our risk factors (increasing age, family history, diabetes, lipid levels, tobacco use, etc.), and modify our lifestyle or dietary habits accordingly. We need to discuss heart disease, symptoms, detection, and treatments with our doctors, and we need to be aware of our bodies. We cannot ignore the symptoms or simply pass them off as "indigestion" or "nerves." If women demand more knowledge and more appropriate detection and treatment, the medical community should respond by paying more attention to gender differences.

Karen L. Schneider is a research intern at the American Council on Science and Health.