Written by: Meesha Dogan, PhD
Women make up one-half of the population in the United States and according to the US Department of Labor, are responsible for about 80% of health care decisions. Yet, for the longest time, women’s health has merely been about reproductive health. Now that the tides are changing and the women’s health sector is gaining more momentum, it is paramount to expand the definition of women’s health.
Women’s health includes more than just reproductive health. Despite being largely preventable, heart disease remains the number one killer of women, killing 1 in 5 women in the United States. However, according to a survey of more than 1,500 women over the age of 25 in the United States on heart disease awareness trends over 10 years, in 2019 merely 44% of women recognized that heart disease is their number one killer, down from 65% in 2009. The largest declines in awareness after adjusting for factors such as income and education level were among younger women ages 25-34 years old, Hispanic women, and non-Hispanic Black women. The survey also found a decline in awareness of nearly every warning sign and symptom of a heart attack from 2009 to 2019. Even though heart disease kills more women than all cancers combined, many women still erroneously identify cancer as their leading cause of death. The awareness gap is unsettling as it could drive women to delay otherwise life-saving preventive screening and interventions until it is too late. Therefore, raising awareness of heart disease among women from all walks of life should continue to be a priority. While initiatives such as American Heart Association’s Go Red for Women are dedicated to this cause, it is up to each of us to help close the awareness gap that continues to persist by sharing information on heart disease that is rooted in facts.
Understanding heart disease in women cannot be an afterthought as heart disease is not just a man’s disease. Not only because it is the leading cause of death for women, but also because risk factors can differ, and heart disease can present quite different between men and women. Heart attack symptoms that women experience can be different from that experienced by men. While the most common symptom for both men and women is chest pain, women may also experience other non-typical, less known symptoms such as upper back pain, fainting, indigestion, and extreme fatigue. In a 2018 study of 2,009 women and 976 men aged 18 to 55 years, researchers found that about 62% of women reported at least three non-chest pain-related symptoms compared to about 55% of men. Under-recognition of less obvious, non-chest pain-related symptoms can mean that women may have trouble recognizing that they are having a life-threatening heart attack and as a result, delay seeking timely care.
While the risk for heart disease does increase with age for both men and women, biological differences between men and women also play a role in the risk for heart disease. Conditions specific to women and their reproductive histories such as endometriosis, preeclampsia, and gestational diabetes that develop during pregnancy, and menopause can increase a woman’s future risk of heart disease.[3,4,5] In a study of more than 116,000 women, after 20 years of follow-up, researchers found that women with endometriosis were 62% more likely than those without endometriosis to have a heart attack, chest pain or require intervention for blocked arteries. It should not come as a surprise that our understanding of heart disease in women and how these conditions affect heart disease risk in women is relatively recent and is continuing to evolve considering that until the late 1990s, research studies and clinical trials predominantly consisted of men. Prioritizing the representation of women of different backgrounds in research studies and clinical trials is critical to further mapping out gender-related differences to inform more personalized and effective diagnostic and preventive interventions.
Addressing the awareness gap and funding studies to improve our understanding of gender-specific differences alone would not be sufficient to change the narrative around heart health in women. It requires clinicians, who are major stakeholders in healthcare, to acknowledge and bridge the care gap that exists. It is not uncommon for clinicians to misread heart attack symptoms in women. In the same 2018 study of 2,009 women and 976 men aged 18 to 55 years, compared to 37% of men, 53% of women reported that their clinician did not think that their symptoms were cardiac-related. Numerous studies have also shown that women are less likely to receive the proper treatment and care for heart disease compared to men. This includes secondary prevention medications such as statins and procedures such as coronary angiography that could help prevent a cardiac event before it is too late.[6,7] Missed diagnosis, under-treatment, and lack of care for heart disease in women can lead to fatal consequences and further exacerbate disparities in health outcomes between men and women.
Improving heart care for women means knowing the tools and interventions that work well for women. Diagnostic tools for heart disease that work well for men may not always work equally well for women. Commonly used heart disease risk calculators such as the Framingham Risk Score and ASCVD Pooled Cohort Equation that aggregate traditional risk factors for heart disease such as cholesterol and blood pressure do not include women-specific risk factors. Such risk calculators have shown to not perform as well for women.[8,9,10,11] Healthcare decisions that clinicians make are only as good as the tools and data that they have at their disposal. Therefore, clinicians can help address the disparity in care by ensuring that their practices can better care for their female patients by offering patient-centered, personalized care for the diagnosis and treatment of heart disease. A primary way to do that is to move away from a one-size-fits-all approach to a precision medicine approach by embracing evidence-based, innovative solutions that work well for women and can help improve their outcomes.
The awareness, gender, and care gaps are intertwined. While considerable progress has been made to address them, there is still work to be done to further address the disparity in heart health care for women. Yet, it is important for us women to be more proactive about our heart health by finding the right healthcare provider and getting tested to better prevent heart disease. As the chief health decision-maker of our family, prioritizing the health of our loved ones cannot come at the expense of our own. So let’s take charge of our heart health, get the care that we deserve, and make it known that heart disease is a women’s health problem.
- Cushman, M et al. Ten-Year Differences in Women’s Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association. 2020. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000907
- Lichtman, J et al. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction. 2018. https://www.ahajournals.org/doi/10.1161/circulationaha.117.031650#d3e3621
- Mu, F et al. Endometriosis and Risk of Coronary Heart Disease. 2016. https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.115.002224
- Mosca, L et al. Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women – 2011 Update. 2011. https://www.ahajournals.org/doi/pdf/10.1161/cir.0b013e31820faaf8
- Vallahajosyula, S et al. Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young. 2020. https://www.ahajournals.org/doi/full/10.1161/CIRCHEARTFAILURE.120.007154
- Isiadinso, I et al. Do We Need a Different Approach to Address Cardiovascular Risk in Women? 2017. https://www.uscjournal.com/articles/do-we-need-different-approach-assess-cardiovascular-risk-women
- Dogan, M et al. External Validation of Integrated Genetic-Epigenetic Biomarkers for Predicting Incident Coronary Heart Disease. 2021. https://www.futuremedicine.com/doi/epub/10.2217/epi-2021-0123
- Park, K et al. Assessing Cardiovascular Risk in Women: Looking Beyond Traditional Risk Factors. 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664450/