Women and Heart Disease: An Update

For years medical professionals have presumed that heart disease affected men and women similarly. Research studies frequently included only male participants, but the medical community then applied these findings to their female patients as well.

In the past few decades, we have come to recognize that heart disease can be very different in men and women.

So it is essential to educate our female patients on these differences and how they can best advocate for themselves and their health.

I recently saw my patient Sheila. She is a lovely 66 year old woman who I have been treating for hypertension and rheumatoid arthritis for several years. She has been having shortness of breath on her usual morning walk for several months. Her initial evaluation did not suggest that her lungs were the culprit since her lung exam and chest x-ray were both normal.  

We know that women with heart disease don’t always present with classic symptoms of left sided chest pain and can often have shortness of breath, dizziness, jaw pain or indigestion instead. We also now know that rheumatoid arthritis is associated with an increased risk of heart disease. Individuals with rheumatoid arthritis have a higher likelihood of developing cardiovascular conditions such as coronary artery disease, heart attack, heart failure and stroke compared to the general population. The inflammation that occurs in rheumatoid arthritis can affect the blood vessels and heart muscle, leading to accelerated atherosclerosis (hardening of the arteries) and increased risk of cardiovascular disease. This is also the case with many other inflammatory autoimmune conditions, and these conditions more often occur in women (80% of cases are women).

Sheila went on to have a stress test which was normal. Stress tests are good tests when looking for blockages in the larger coronary arteries. Sheila initially felt reassured, but her symptoms persisted. Is it possible that the stress test results were wrong?

It turns out Sheila has what is known as coronary microvascular disease. This is a term that many patients haven’t heard of, but it’s important for women to familiarize themselves with this subset of heart disease! In some cases, women with heart disease may have coronary microvascular dysfunction which affects the smaller blood vessels in the heart. This condition may NOT always be detected by traditional stress tests or coronary angiograms that evaluate our larger coronary vessels primarily.  And this condition is much more common in women who have smaller blood vessels compared to men. Often a cardiac MRI or other advanced imaging is required to make this diagnosis, as these imaging techniques can provide detailed images of the heart and coronary arteries, allowing for assessment of both the large and small blood vessels.

Sheila’s blood pressure medication was changed to a medication known to help relax and widen the blood vessels, and she started a statin (cholesterol-lowering medication) and a daily aspirin. She is also doing a much better job of eating a heart healthy diet low in saturated fats and sodium, and high in fruits, vegetables, whole grains and lean proteins, often referred to as a Mediterranean diet. She is also working on stress reduction through meditation and slowly getting back to regular walks - we know that 150 minutes/week of aerobic activity like walking can reduce cardiovascular risk. And thankfully for Sheila, she is feeling much better!