Women and Heart Disease
William A. Crafford, Jr., M.D., F.A.C.C.

For years, women have failed to recognize the risks of cardiovascular disease in the female population. The American Heart Association statistics from 2001 showed that over 361,000 women died from heart disease, which exceeded the next 4 causes combined. The other causes included stroke (100,000), lung cancer (66,000), chronic obstructive lung disease (63,000), and breast cancer (41,000). It was also noted in a 2000 national women's survey that only 34% recognized heart disease as the leading female health problem, while only 8% appreciated heart disease as their primary killer, which takes 1 in 3 American females (greater than 500,000) per year. Physicians themselves have also been ignorant of this fact predominantly because of the earlier male dominated studies. They are now becoming educated also in the seriousness of female cardiovascular disease.

It is with the onset of menopause that women catch up to the incidence and severity of male cardiac disease. This usually is delayed 10 years after their male counterparts and arrives in the female population in their 60s. Incidence is increased 2 to 3 times higher for postmenopausal compared to non-menopausal women of the same age. Women at this juncture are more likely to have severe complications such as death and congestive heart failure and poor results from intervention such as coronary bypass surgery and catheter based procedures such as coronary angioplasty and stent deployment.

Current trends also indicate that women are "nurturing" future incapacitating risk factors at an early age. These include obesity, cigarette smoking, increased physical inactivity, earlier diabetes, as well as hypertension. With the exception of depression, women display the same risk factors as men and similarly, if not more so, benefit from control of these risk factors. Women are more sensitive to the deleterious effects of cigarette smoking, and as little as 4 cigarettes a day in a female triples her risk for coronary disease. Remarkably, women can lower their risk by as much as 82% by altering their lifestyle and dealing aggressively with these risk factors. It is estimated that 22.6 million women smoke, and 25% of all women suffer from significant hypertension. As many as 55.6 million women are estimated to suffer from hyperlipidemia, and 82% are overweight, with 33% demonstrating frank obesity. Physical inactivity is said to be present in 25% of women, while minimal exercise activity of 30 minutes a day is not achieved by 60% of women. Diabetes is rampant and is estimated to be present in 6 to 8.8 million females.

Once cardiac disease is manifest, women tend not to fair as well as males. They are twice as likely to have recurrent heart attacks within 6 years after their initial event and also twice as likely to develop subsequent congestive heart failure. They tend to have more bleeding problems with coronary bypass surgery and catheter based intervention such as angioplasty, as well as higher morbidity and mortality rates with these procedures. Contributing to this may be the fact that women are more likely to require urgent or emergent intervention and surgery. Subsequently, females are less likely to participate in cardiac rehab programs and, in general, tend to be less compliant with medications and followup. The diagnosis of heart disease in females is further compromised by "atypical" symptoms. They tend to have less frontal or typical angina-like chest pain but complain more of shortness of breath, nausea, vomiting, fatigue, jaw/neck/arm/shoulder pain, and tend to have more referred pain to the back and between the shoulder blades. This further delays prompt diagnosis and treatment. The threshold for female intervention and assessment hopefully will be lowered with this new knowledge of what is the "typical" female presentation.

It was also previously felt that hormone replacement therapy with estrogen and progesterone were cardioprotective for females. However, with recent studies in the past 5 years, it is now evident that hormone therapy is not beneficial for postmenopausal women for the purpose of treatment or prevention of ischemic heart disease. These studies have shown an increased incidence of deep venous blood clots, pulmonary blood clots (emboli), strokes, breast cancer, and gallbladder surgery. Hormone intervention, in fact, seems to enhance cardiovascular risk and therefore is no longer recommended for primary treatment in postmenopausal females.

With this newfound awareness of cardiovascular risk and its precipitating factors, women will hopefully be able now to approach their "number 1 killer" aggressively with lifestyle changes, medicinal therapy with agents such as cholesterol lowering "statins," earlier diagnostic evaluation, and resultant earlier intervention and therapy. It is certainly evident that the female "typical" symptoms are "atypical" only by comparison to the age-old established "typical" male symptomatology. The present "Red Dress" initiative should therefore be a "red flag" to women as well as physicians in their efforts toward prevention and therapy of female heart disease.

Dictated by: William A. Crafford Jr., M.D., F.A.C.C.