Heart disease is a leading cause of death in women, and its incidence is three times as high as breast cancer. Despite this, there is often a lack of awareness of the risk of heart disease in women, leading to underdiagnosis and undertreatment. There are female-specific conditions that increase the risk of heart diseases present during the time of pregnancy, menopause, or sometimes after cardiotoxic breast cancer therapy that can offer a window into a women’s future. Early detection and prevention are crucial to reducing the risk of heart disease in women and improving the morbidity and mortality of patients with ischemic heart disease.
One of the challenges in detecting heart disease in women is that the presentation of ischemic heart disease can be atypical. Women are more likely to experience symptoms such as back pain, jaw pain, epigastric pain, palpitation, and lightheadedness as well as difficulty breathing, nausea, and fatigue, which can be easily overlooked or misinterpreted as other conditions. Registries demonstrated that only 31% of women presented with chest pain in the setting of a myocardial infarction (MI) compared to 42% in men.
Diagnosing heart disease in women is also not easy. The electrocardiogram (ECG) is often nonspecific, and single-photon emission computed tomography (SPECT) imaging has lower sensitivity and specificity in women than in men in part caused by the fact that women have smaller hearts (smaller LV mass). Positron emission tomography (PET) imaging has better accuracy but is less widely available. This makes it essential for healthcare providers to be vigilant in recognizing atypical symptoms and to consider additional diagnostic tests if necessary.
Treatment of heart disease in women can also be more challenging. Women with STEMI (ST-elevation myocardial infarction) tend to present later than men and are often undertreated. When percutaneous coronary intervention (PCI) is performed, women are more prone to complications and have a worse outcome, with an increased risk of mortality. When coronary artery bypass grafting (CABG) is performed, women have more periprocedural complications and increased morbidity and mortality.
Because of these challenges, early detection and prevention remain crucial to reducing the risk of heart disease in women. Women should be encouraged to speak up about their symptoms and concerns, and healthcare providers should be aware of the unique risk factors and symptoms of heart disease in women.
The cardio-ovary risk factors start with the timing of the menarche with women with menarche <12 and >16 years having worst metabolic health in middle age with higher BMI, more hypertension, diabetes, and hyperlipidemia.
Polycystic ovarian syndrome (PCOS), can affect 1 in 10 women and is associated with diabetes mellitus and a two-fold increase in cardiovascular risk. PCOS is defined by polycystic ovaries, rare or no ovulation, and clinical signs of too many male hormones. Women tend to have few, unusual, or very long periods, excessive hair growth, acne, and weight gain. PCOS is a frequent cause of infertility which can be associated with diastolic heart failure (HFpEF) later in life.
Pregnancy offers a window into a women’s future. Hypertensive complications during pregnancy are common and constitute the leading cause of maternal and fetal morbidity and mortality. These complications include gestational hypertension, preeclampsia, and eclampsia. The progression of preeclampsia to chronic hypertension explains the majority of the excess risk of coronary artery disease and HFpEF later in life. In addition, hypertension during pregnancy has been associated with aortic stenosis and mitral regurgitation. Research has also demonstrated some genetic associations between preeclampsia, the risk of hypertension, ischemic heart disease, and heart failure. Preeclampsia could accelerate vascular aging. Spontaneous pregnancy loss has been associated with a >20% increase in cardiovascular disease. Other pregnancy-related factors include multiparity with >5 live births associated with worst metabolic health (obesity, DM, hyperlipidemia, and HTN) as well as fibromuscular dysplasia and spontaneous coronary dissection.
Menopausal transition includes several metabolic changes in body composition with increased visceral adipose tissue and changes in serum lipids that are linked to the development of cardiovascular disease. The lack of estrogen related to menopause does not explain all the adverse changes in metabolic health since the replacement of estrogen does not always protect post-menopausal women, particularly after 60 years of age or after 10 yrs post-menopause. When hormonal therapy is started early post-menopause and in women <60 years of age, the all-cause mortality is reduced by 30% and the risk of coronary disease by 50%. Premature menopause (<40 years), whether it is natural or surgical, has been associated with increased cardiovascular risk. This could be not only related to the loss of estrogen protection but could be associated with other factors such as CHIP (Clonal hematopoiesis of indeterminate potential). Research is being conducted to study factors relating premature menopause to heart disease.
When trying to assess risk in the adult population, there are sex-specific limitations in the 10-year ASCVD risk calculator since it does not identify high-risk women <40 years and does not incorporate risk enhancers such as premature menopause, inflammatory diseases such as Lupus and Rheumatoid arthritis, and pregnancy-related factors. Calcium score can really help identify sub-clinical atherosclerosis and stratify women with an intermediate risk score.
Lifestyle changes such as quitting smoking, eating a heart-healthy diet, maintaining a healthy weight, and staying physically active can all help to reduce the risk of heart disease.
In conclusion, heart disease is a significant threat to women’s health, and early detection and prevention are key to reducing its incidence and improving outcomes. Healthcare providers should be vigilant in recognizing atypical symptoms and consider additional diagnostic tests if necessary. Women should take an active role in their heart health by maintaining a healthy lifestyle, speaking up about their symptoms and concerns, and working with their healthcare providers to reduce their risk of heart disease.
This article was written in collaboration with Dr. Nicole Lohr, Director of the Division of Cardiovascular Disease and Co-Director of the UAB Medicine Cardiovascular Institute.