Myths and Facts: Women and Cardiovascular Disease

IN WESTERN SOCIETY, heart disease is still largely viewed as a male health problem. Even many women’s health advocacy organizations focus more on cancers than on cardiovascular disease (CVD). For instance, pink ribbon campaigns to help raise awareness about the importance of breast cancer detection, treatment and research are hugely popular, and have no trouble gaining celebrity supporters to raise their public profiles. Meanwhile, the “Go Red for Women” campaign to raise awareness of women’s heart disease largely flies under the popular radar. Yet, the facts are plain: CVD kills seven times more women than breast cancer every year. In fact, it kills more women than all cancers combined.¹

CVD isn’t just about heart attacks. Atherosclerosis can lead to strokes and heart attacks, and women are more prone to strokes than men. Hypertension can cause kidney disease if left untreated, and more than half of American adults with high blood pressure are women.² Finally, women are subject to some risk factors for CVD that simply don’t affect men, including eclampsia or preeclampsia during pregnancy, use of birth control pills (which are shown to increase the risk of hypertension) and early onset menopause.³ Of course, women are also vulnerable to all the modern risk factors for CVD that have been shown to afflict men: an unbalanced diet, weight gain, lack of exercise, workplace stress, smoking and too much alcohol.

Despite all of this, polls show many women and their caregivers remain uninformed about the true risk CVD poses to their longterm health, as well as the comparative risk CVD poses versus other diseases and conditions. And, while the information is available, it is often overwhelmed by myths and misconceptions.

Separating Myth from Fact

Myth: Women aren’t as prone to CVD as men.

Fact: CVD is the leading cause of death for women in the United States, and more women than men died of heart disease each year between 1984 and 2012.⁴ And, even though more men than women have died each year from a heart attack since then, the rates are very close, with some 290,000 women dying each year.⁵

And, while men are twice as likely to suffer a heart attack, women are more likely to die from one — and even more likely to die within a few years after suffering their first heart attack.⁶ Women are also more likely than men to suffer a stroke. Every year in the U.S., roughly 425,000 women experience a stroke, compared with only 370,000 men.³ And, about 80,000 of those women will die from the stroke,⁷ which is about twice as many as those who die from breast cancer.⁸ Studies also show female stroke survivors face a tougher rehabilitation than do men, with more mobility challenges and greater pain reported.³

Myth: Women and men display the same symptoms during a heart attack.

Fact: There is conflicting evidence about this issue, likely due to the fact most research about CVD has focused on men, until recently. A 2013 report in JAMA Internal Medicine found earlier research that suggested differing symptoms of a heart attack between the sexes failed to account for age differences (women are on average older when they experience a first heart attack) and overall health differences (diabetes, which is more prevalent in women, can mask some symptoms of a heart attack).⁹ However, this study is still fairly new and not unanimously accepted. There is still much literature based on earlier research that indicates women are statistically less likely to exhibit some of the more typical symptoms associated with a heart attack: pain in the left arm, pain or pressure in the chest, sweating, dizziness and shortness of breath. In fact, both the 2013 study and another with different conclusions agree the original study of chronic heart disease in the mid-20th century was flawed since it was based primarily on middle-aged Caucasian males (typical of most medical research at that time).

The full picture of heart attack symptoms experienced by men and women likely won’t be understood until further research about CVD in women complements the existing body of research on men. Regardless, women and men should both be aware of all the different possible signs of a heart attack and be ready to seek medical assistance if any of them are observed:¹⁰

• Chest pain or pressure
• Increased shortness of breath
• Unusual sweating
• Lightheadedness or dizziness

Other symptoms reported as more common in women include:¹¹

• Nausea
• Extreme fatigue
• Pain in the lower chest or upper abdomen

Myth: Medical research about CVD represents women and men equally.

Fact: As indicated above, most research conducted about heart disease and strokes in the mid- to late-20th century underrepresented women. Indeed, until 2006, studies that were supposed to include both sexes included only 34 percent women — not even close to half.¹² In 1991, cardiologist Bernadine Healy, MD, who was the first woman to head the National Institutes of Health, warned this gender bias in research had “reinforced the myth that coronary heart disease is a uniquely male affliction and generated data sets in which men are the normative standard.”¹³ This has only slowly been rectified by researchers in the decades since.

Myth: Women receive the same quality of CVD care as male patients.

Fact: Female patients who are treated by women physicians in hospital emergency rooms are more likely to survive a heart attack. In fact, numerous studies over the last few decades have shown a consistent statistical difference in women heart attack patients treated by female doctors versus those treated by male doctors. (Among male patients, there is no statistical variance between those treated by male versus female physicians.)¹³

Preventive care also is not equal. An American Heart Association study in 2005 indicated only 8 percent of general practitioners and 17 percent of cardiologists knew CVD killed more women than men.⁴ Other studies have shown public information campaigns about health shape patient perceptions about their risk factors. Men are far more likely to broach the subject of heart disease with their physicians, while most female patients are far more concerned about developing breast cancer than CVD, even though they are at far higher risk of heart disease and stroke.¹⁴ And, many women patients report when they do discuss CVD with their primary physicians, their concerns are not taken seriously, and symptoms are often attributed to other causes with no follow-up.¹⁴ Women patients are also less likely than males to be prescribed beta blockers, statins or ACE inhibitors to treat symptoms of CVD before or even after a heart attack.¹⁵

Myth: Young women do not have to worry about cardiovascular disease.

Fact: Smoking and birth control pills each raise the risk of heart disease or stroke, and the number of heart attacks in women in their 30s and 40s has been increasing in recent years, with sudden cardiac deaths rising 30 percent among women under age 50 over the past decade.¹⁵ In addition, women under age 45 who suffer their first heart attack are more likely than men to die within 12 months. 11 Young women are also more likely to develop hypertension, chronic kidney disease or diabetes — all risk factors for a subsequent heart attack or stroke — than men their same age.¹⁵

Myth: Women who are athletic or physically active don’t develop CVD.

Fact: High cholesterol and hypertension can still manifest even in the most physically fit individuals. A poor diet or unlucky genes (such as hereditary high cholesterol) will not be eliminated by even the most disciplined fitness regimen.¹¹ Therefore, women who are physically active should exercise the same discipline in tracking their CVD risk factors as women who are not.

Myth: If parents and grandparents did not have CVD, an individual is not at risk.

Fact: Lifestyle can trump good genes. According to A. Marc Gillinov, MD, chairman of the Department of Thoracic and Cardiovascular Surgery in the Sydell and Arnold Miller Family Heart and Vascular Institute at Cleveland Clinic, 90 percent of CVD risk comes from a patient’s individual choices, including diet, smoking and exercise.¹⁶ While a family history of CVD is one risk factor, it is not a determinant factor, and a lack of family history should not induce a false sense of complacency.

Myth: If parents and grandparents had CVD, there is nothing a person can do.

Fact: While lifestyle can’t trump bad genes, it can certainly help ameliorate the risk of developing CVD. Researchers and physicians estimate 80 percent of the risk factors for heart disease are preventable through lifestyle choices: Getting regular exercise, avoiding weight gain or losing weight, maintaining a healthy diet, avoiding tobacco usage, moderating alcohol consumption and maintaining a healthy blood pressure.⁴

Dispelling the Myths Now

Many health advocacy organizations are actively educating women and their physicians about the realities of heart disease in women. But, one bit of advice is the same for women and men, and it’s the advice men have been bombarded with for the last half-century: Take control of your health, and if you have any concerns, bring them up with your doctor.

Since many women’s primary healthcare provider is their OB/GYN, they may have to take a more active role in requesting tests and keeping an eye on their cardiovascular system. Or, better yet, they should schedule an annual visit with a general practitioner who is likely to be more familiar with CVD risk factors.¹⁷ Women with multiple risk factors should consider requesting a referral to a cardiologist. In addition, the American Heart Association recommends an annual cholesterol check beginning at age 20. And, blood pressure should be watched in all patients.¹¹

While there is a popular stereotype that women are better communicators than men, one study found only 35 percent told their physician about CVD symptoms they had experienced. And, fewer than one-quarter of women diagnosed with CVD followed up with more questions for their physician.⁴ Therefore, physicians and other healthcare professionals need to be proactive in discussing heart health with their female patients. They should encourage them to share any concerns, and direct them to accurate, up-to-date information that bypasses the myths that can prevent women from effectively preventing and being treated for CVD.