Coronary Artery Disease In Women

Although Coronary Artery Disease (CAD) is often thought of as a problem for men, more women than men die of heart disease each year. Women are six times as likely to die of heart disease as of breast cancer. Heart disease kills more women over 65 than do all cancers combined.

The most common symptom in both women and men is chest pain. But for women this may not be the most prominent symptom. “Chest pain” may feel like a burning, tightness, pressure or some other sensation. A better word than “pain” might be “discomfort.” This discomfort may radiate, or seem to originate, in the jaw, back, mid-stomach or either arm.

One of the distinguishing factors between women and men is that women tend to report more associated symptoms. These may include classic symptoms such as shortness of breath, nausea and vomiting – but may also include several less classic symptoms including fatigue, dizziness and palpitations.

While it is most common for both genders to get their symptoms with physical exertion, women may also experience their symptoms at rest, during sleep and with emotional stress. Likewise, women may have an increased frequency of symptoms around the time of their menstrual period.

If you are concerned about your heart, you can try this questionnaire for the Prediction of Coronary Artery Disease (CAD).

A few decades ago heart disease was considered a man’s disease; and even today many physicians are still practicing medicine based on studies mostly performed on white, middle-aged men. A major factor in the lack of heart studies on women in the past was the frequent hormonal changes that women go through each month, which physicians feared would complicate studies. Estrogen is very important to heart function—the heart contains estrogen receptors that bind estrogen and help to release nitric oxide, which regulates blood flow. As women approach menopause, estrogen production slows, reducing nitric oxide.

Risk factors and symptoms:

The most common symptom of a heart attack in both men and women is some type of pain, pressure or discomfort in the chest. But it’s not always severe or even the most prominent symptom, particularly in women. Women are more likely than men to have signs and symptoms unrelated to chest pain, such as:

• Neck, shoulder, upper back or abdominal discomfort
• Shortness of breath
• Nausea or vomiting
• Sweating
• Lightheadedness or dizziness
• Unusual fatigue

These signs and symptoms are often more subtle than the obvious crushing chest pain often associated with heart attacks.

A woman is not just a small man: There are significant differences between men and women in the epidemiology, diagnosis, treatment, and prognosis of CAD that should be taken into account in the care of women with known or suspected disease:

Probability of CAD in patients with chest pain by age, gender, and symptoms
	Non-anginal pain (%)		Atypical angina (%)		Typical angina (%)
		Women		Women		Women
30-39
40-49
50-59
60-69

(From Diamond, et al. N Engl J Med 1979; 300:1350; and from Weiner, et al. N Engl J Med 1979; 301:230).

Furthermore, most available data suggest that women are not referred as often as men for appropriate diagnostic and/or therapeutic procedures, despite similar clinical conditions.

Another factor important in the interpretation of chest pain in women is the greater likelihood of angina being induced by rest, sleep, and mental stress, in addition to or instead of physical exertion. As an example, a previous history of an anxiety disorder is associated with a lower risk of significant angiographic CAD in women. Psychosocial factors are also important, as women drastically underestimate their own risk of CAD, and physicians’ estimates are colored by patient affect.

Women who present to the ER with new onset chest pain are approached and diagnosed less aggressively than men. Compared to men, women are less likely to get:

• EKG, cardiac monitoring, or cardiac enzyme measurements
• See a cardiologist in consultation
• Be admitted to a coronary care or step down unit
• Women are more likely to be treated for psychiatric or psychosomatic complaints.

Many cases of myocardial infarction (MI) in women go unrecognized, particularly at younger ages.

The symptoms of MI in women differ from those in men, which may in part explain the difference in care women receive.

What can differ between women and men is a disease called coronary microvascular disease (MVD). Coronary MVD is heart disease that affects the heart’s smallest arteries. Recently, studies have shown that women are more likely than men to have coronary MVD.

In coronary MVD:

• The walls of the heart’s tiny arteries are damaged or diseased.
• The heart’s tiny arteries don’t relax properly and can spasm (tighten).

Coronary Microvascular Disease

Figure A shows the small coronary artery network (microvasculature), containing a normal artery and an artery with coronary MVD. Figure B shows a large coronary artery with plaque buildup.

Many researchers think that a drop in estrogen levels in women during menopause combined with traditional risk factors for heart disease causes coronary MVD.

Although death rates from heart disease have dropped in the last 30 years, they haven’t improved as much in women as in men. This may be the result of coronary MVD. Standard tests for CHD don’t always detect coronary MVD in women. As a result, women often are thought to be at low risk for heart disease.

Research is ongoing to learn more about coronary MVD and its causes.

Women also are more likely than men to develop a condition called broken heart syndrome. In this recently recognized heart problem, extreme emotional stress can lead to reversible heart muscle failure.

Doctors may misdiagnose broken heart syndrome as a heart attack because it has similar symptoms. However, there’s no evidence of blocked heart arteries in broken heart syndrome, and most people have a full and quick recovery.

Researchers are just beginning to explore what causes this disorder and how to diagnose and treat it. Often, patients who have broken heart syndrome have been previously healthy.

Once recognized, the diagnosis is made the same way as with any other patient.

Treatment however is another matter. Gender bias continues!

A number of studies have documented gender-based differences in rates of catherization and interventions such as PCI  and CABG, even among those with an acute MI. These differences reflect physicians’ failure to refer women with positive exercise tests for subsequent testing, leading to a poorer outcome. In one report, for example, women with a positive exercise test were more likely to have no further cardiac evaluation than men (62 versus 38 percent), a difference that, at three year follow-up, was associated with a higher incidence of MI or death in women (14.3 versus 6 percent per year in men).

Summary

Cardiovascular diseases are the most common cause of death and disability in women in the United States. Important differences between women and men in the presentation of CAD may make it more difficult to establish the diagnosis in women (see ‘Clinical presentation’ above: 

• Women present about 10 years later than men and with a greater risk factor burden.
• Women are less likely than men to have typical angina.
• Women who present to the emergency department with new onset chest pain are approached and diagnosed less aggressively than men.

(From: Heart disease in women, http://www.nhlbi.nih.gov/health/dci/Diseases/hdw/hdw_whatis.html)