Stay Informed: Update on Heart Disease in Women

Do you know the most common cause of mortality in women? Breast cancer? Cardiovascular disease? Lung disease?

The answer is cardiovascular disease. We know that one of every three women dies of some form of cardiovascular disease. Studies show that serious heart disease and stroke combined are responsible for claiming a woman’s life every 80 seconds. There is a myth that heart disease is for old people, but it affects women across all age groups. An AHA/ACOG Presidential Advisory published in 2018 reveals that women who take birth control pills and smoke have a 20% increased risk for sudden cardiac death.

Signs and Symptoms

About 64% of women who died suddenly of coronary artery disease did not experience any symptoms prior to their death. Women who have coronary artery disease frequently experience atypical signs and symptoms such as shortness of breath, fatigue or lack of energy.

They may also have:

• Nausea and vomiting
• Persistent indigestion
• Back pain or jaw pain
• Dizzy spells
• Syncopal episodes

Because of these vague symptoms, a woman may not realize she is having a myocardial infarction (MI) and take longer to arrive at an emergency department, resulting in far more heart damage than if she had sought help sooner. Additionally, the provider may not consider that the woman is having an MI, further delaying appropriate clinical interventions.

A study found that young women experiencing an ST-segment elevation MI (STEMI) were less likely than men and older women to receive reperfusion therapy (thrombolytic or percutaneous coronary intervention [PCI]) and more likely to have delayed treatment. The researchers found disparities among patients who were transferred to PCI facilities or who received fibrinolytic therapy.

Common Risk Factors for Heart Disease in Women

• Diabetes
• Mental stress, depression
• Smoking
• Lack of physical activity
• Menopause
• Complications associated with pregnancy
• Family history of early onset heart disease (prior to 4th decade) is a greater risk for females than it is for males.
• Inflammatory diseases, including rheumatoid arthritis, lupus, etc.

Some Facts to Keep in Mind

• Older women with a history of heart disease and related issues are likely to experience a reduction in their thinking and memory skills.
• About 49% of African American women 20 years and older have heart disease. Cardiovascular disease accounts for 50,000 deaths of African American women annually. Some individuals may have had a genetic predisposition causing them to be more sensitive to salt, which may lead to hypertension.
• Hispanic women have been shown to develop heart disease 10 years earlier than non-Hispanic women. Many Hispanic women are unaware they have an increased risk to develop heart disease.
• Insomnia increases a woman’s risk of stroke by 54% over a four-year time period. The risk is eight times higher in women who are 18 to 34 years old.
• Peripheral vascular disease (PVD) is a marker of systemic atherosclerosis and is associated with a three- to six-fold increased risk of death from any cardiovascular cause. PVD is considered an independent risk factor for cardiovascular disease.
• In 2020, there continued to be a smaller number (38%) of women participating in clinical trials investigating various aspects of cardiovascular disease.

Management of Patients With Ischemic Heart Disease

Medical therapy for a woman diagnosed with ischemic heart disease is frequently delayed. Studies indicate that women are less likely to receive goal-directed therapy for lipid lowering or aspirin therapy, or recommendations for lifestyle changes for prevention when compared to men with similar risk factors. When medications are prescribed, the treatment is usually not aggressive, or optimal effects such as lower blood pressure or lipid levels are not achieved. Women with diabetes are less likely to have a statin prescribed to reduce their low-density lipoprotein (LDL) cholesterol level.

A woman who is diagnosed with acute coronary syndrome (ACS) may have unstable angina, or either a non ST-segment elevation MI (NSTEMI) or a STEMI. For these diagnoses, studies have demonstrated that women are treated less aggressively with fewer cardiac catheterizations, PCI procedures, fibrinolytics and coronary bypass procedures. The result is worse outcomes, higher mortality rates and reduced quality of life for survivors. When women have a cardiac catheterization or PCI, they have a higher incidence of bleeding events compared with men undergoing the same procedures. When cardiac catheterization is performed, women often have less obstructive coronary disease.

Following an MI, women have a higher incidence of dysrhythmias compared with men. Antithrombotic and antiarrhythmic medications are metabolized differently in women, resulting in higher blood levels of the drug and more adverse effects. It is important that the dosages of these medications are adjusted appropriately. Following an MI, their prognosis is worse than that of their male counterparts.

Women are 55% less likely to have referrals to out-patient cardiac rehabilitation (rehab). This situation has been attributed to providers failing to refer women, but it is also impacted by program structure and patient preference. Cardiac rehab reduces cardiovascular-related deaths by 18% to 26% compared with usual care. Referrals to attend a cardiac rehab program should be consistently offered to all women and reinforced by all members of the healthcare team.

Other Forms of Ischemic Heart Disease in Women

• Takotsubo/Broken Heart Syndrome
  • Often referred to as a stress MI
  • Most common in post-menopausal women ages 58 to 75 years
  • Often preceded by extreme stress or emotional triggers
  • Stress hormones may “stun” the heart, triggering changes in the myocardium, and reducing myocardial contractility.
  • The clinical presentation, ECG findings and cardiac biomarkers are congruent with an ACS or STEMI.
  • Cardiac catheterization reveals normal coronary arteries without obstructive disease. The left ventricle is often dilated.
  • Many recover without long-term damage.
• Coronary Microvascular Dysfunction (MVD)
  • Affects women of all ages but younger women are more likely to develop MVD
  • Cardiac catheterization reveals large coronary arteries are clear without obstructive disease, but smaller arteries have impaired blood flow.
  • Primarily diagnosed via positron emission tomography (PET) or magnetic resonance imaging
  • Treatment is focused on risk factor modification and referral to cardiac rehab for exercise training and traditional medications, including statins and beta blockers.
• INOCA: Ischemia With No Obstructive Coronary Arteries
  • Previously called Syndrome X
  • Associated with coronary spasm, which can lead to an MI
  • Signs/symptoms include chest discomfort or pain, shortness of breath, fatigue
  • Associated with slightly better outcomes, but experts recommend further evaluation to identify potential underlying causes

Heart Failure in Women

Heart failure in women usually occurs later in life and usually is not associated with ischemic etiologies. Notably, women are two times more likely to develop heart failure with a preserved ejection fraction (HFpEF) than men. Women experience poorer quality of life after their heart failure diagnosis and often experience depression.

Women and Stroke

Women have a higher incidence of initial and recurrent strokes than men, which can be attributed to a sharp increase in the risk for stroke following menopause. Factors contributing to the increased stroke risk include hypertension, abdominal obesity and metabolic syndrome, especially in older women. There is a lower incidence of atrial fibrillation in women; however, they have a higher incidence of stroke and a greater mortality risk associated with atrial fibrillation than men.

What can our nursing community do?

• Don’t be misled by vague signs and symptoms. Always have a high index of suspicion for cardiac events.
• Always advocate for your patient, particularly if you are caring for a woman who may be reporting vague signs or symptoms despite having a normal ECG.
• Patient/Family Education: Provide specific content related to the type of heart disease a female patient may have. Engage the family if possible. Using written handouts is helpful, but they should be written clearly and easy to understand. Keep in mind that small amounts of information is better than too much.
• If your patient has had an MI, start discussing participation in a cardiac rehab program as soon as possible. Do not wait until discharge. At discharge, follow up to ensure there is a cardiac rehab referral. Patients are more likely to attend if the cardiac rehab facility is near where they live. Many cardiac rehab programs at large metropolitan facilities have the ability to connect the patient with a program near where they live.

I encourage you to think about opportunities to become engaged in educating the public about women and heart disease. Specific examples might be during a book club meeting, a women’s meeting at your church or a community health-screening event. A resource that is always kept current is the American Heart Association’s initiative Go Red for Women website. The 2021 issue of Circulation Go Red includes a compilation of the latest studies addressing prevention and treatment of cardiovascular disease in women.

What actions will you take to educate others about women and heart disease?