Heart disease remains the leading cause of death in women in Australia and the Western world. Women are twice as likely to die from heart disease compared to any other disease.
When women develop heart disease their mortality is higher than that of men. Interestingly, over the last three decades, heart disease mortality has declined for both women and men especially in the over 65 age group. This improved mortality, however, has not been observed in younger women under the age of 65 with heart disease.
Coronary Artery Disease remains the most common form of heart disease. It is a consequence of coronary atherosclerosis and predisposes to cardiac ischaemia and myocardial infarction. For women and men, the traditional risk factors include diabetes, smoking, obesity and overweight, physical inactivity, hypertension, dyslipidaemia, family history/genetic factors and depression. Over recent decades gender specific risk factors for CAD in women have also been identified. These include pregnancy induced hypertension, pre-term delivery, gestational diabetes, autoimmune disease and breast cancer treatment.
Some traditional risk factors pose different risks for ischaemic heart disease in women compared to men. For example, diabetic women have a greater risk of developing heart failure compared to men. Diabetic women are more likely to develop heart failure and other vascular disease such as stroke. There is also a higher prevalence of hypertension in women over the age of 65 than in men.
Whilst women will often display the typical symptoms of angina in acute coronary syndromes such as retrosternal chest tightness and heaviness, women may not uncommonly present with atypical symptoms. Such less-specific symptoms include dyspnoea alone, sweating, nausea, light headedness and abdominal, neck, back and jaw pain.
The treatment of acute coronary syndrome does not differ for women and men. Immediate management with aspirin, hospitalisation and early intervention with coronary angiography is important for accurate diagnosis and timely intervention.
Other syndromes
Coronary microvascular dysfunction (microvascular angina) is defined as limited coronary flow reserve and coronary endothelial dysfunction. It is identified when a patient with typical angina has no significant obstructive coronary disease at angiography. Management of microvascular angina in women includes risk factor modification and lifestyle changes.
Medical therapy for microvascular dysfunction includes the usual anti-ischaemic drugs such as nitrates, beta blockers, ACE inhibitors and statin therapy.
Spontaneous Coronary Artery Dissection (SCAD) is defined as a sudden separation between the layers of the coronary artery wall. An intimal flap is created, and intramural haematoma temporarily obstructs myocardial blood flow. Although this syndrome is rare it is overwhelmingly seen more commonly in younger women who present with an acute coronary syndrome. Diagnosis requires angiography.
Risk factors for SCAD include not only female sex, but fibromuscular dysplasia and the peri-partum period. The classical presentation is a young healthy woman without traditional coronary risk factors presenting with sudden severe chest pain.
The condition is important to diagnose accurately as the treatment and management are often conservative and the use of anti-platelet therapy. Intervention with coronary stents is best avoided.
Stress induced cardiomyopathy (Broken heart syndrome/Takotsubo Cardiomyopathy) has been identified since 1990. It was first described in Japan and named after an octopus trapping pot that has a round base and narrow neck which resembles the left ventriculogram during systole in these patients.
It presents most commonly in post-menopausal women and is often precipitated by extreme physical or emotional triggers. The clinical presentation, electrocardiographic findings and troponin profiles are often similar to those of an acute coronary syndrome. This syndrome is identified by coronary angiography excluding the presence of significant obstructive disease and typical echocardiographic features.
Whilst the underlying cause of this syndrome remains uncertain, treatment is based on medical therapy traditionally used for heart failure such as beta blockers and ACE inhibitors. Recovery is usually seen within six weeks with left ventricular function often returning to normal on echocardiogram.
In summary women are different to men – and their hearts and their symptoms differ too. We should all stay aware of that.
Key messages
- Heart disease is the leading cause of death in women
- Women have the usual, but also other risk factors
- Be alert for different symptoms and syndromes.
Author competing interests – nil