Experts say that women are underdiagnosed, undertreated and under-represented in all areas of cardiac care
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Gerry Gajadharsingh writes:
“Women die needlessly as NHS treats heart trouble as a man’s disease. I added but it’s not straightforward.
The media have a habit of sensationalising a headline, stoking the culture wars and are sometimes a bit binary.
Cardiovascular disease and in particular heart attack or myocardial infarction (MI) is obviously a serious acute medical emergency, especially if it has caused a cardiac arrest (which is when the heart stops).
The big one that carries a high mortality if not treated rapidly is an anterior STEMI and is usually from acute thrombotic occlusion of the left anterior descending (LAD) coronary artery — also historically known as the “widow maker” but also affects women. The classic ECG changes in the ST wave are known as Tombstoning, because of the shape the curve forms.
STEMI heart attacks tend to be more common in men than in women.
According to research, men have a significantly higher risk of experiencing STEMI, with estimates indicating that approximately 60-70% of STEMI cases occur in men, while 30-40% occur in women.
In the UK, the overall incidence of heart attacks, including STEMI, is higher in men than women, particularly in younger and middle-aged groups. However, the incidence gap narrows with age, especially after women reach menopause.
Of around 85,000 heart attacks in the UK in 2022, 36 % were STEMI.
Mortality caused by ST elevation myocardial infarction (STEMI) has declined because of greater use of primary percutaneous coronary intervention (PCI), such as fitting a stent to improve coronary artery blood flow.
In a study in 2020 in Spain, “Observed and Expected Survival in Men and Women after Suffering a STEMI” Pascual et al, included 450 consecutive patients >75 years of age with a STEMI, treated with primary PCI. A total of 438 patients out of 450 were Caucasian (97.3%) and 263 (58.4%) patients were male, reflecting that the incidence gap narrows with age, especially after women reach menopause.
The data was interesting in that common risk factors such as hypertension (high blood pressure) was not present in 40% of men and 30% of women, and high cholesterol was not present in 55% of men and 60% of women (it doesn’t state how many people were already taking cholesterol lowering drugs such as statins.
They concluded that life expectancy of both men and women suffering a STEMI and treated with primary PCI is intimately linked to survival during the first period of time. Women who survive the first 30 days after the STEMI still have an excess of mortality due to the STEMI or its consequences during the first year of follow-up, they don’t yet know why, this excess of mortality is not shown in men who survive the first 30 days. After one year, the risk of death for both men and women seems similar to that of the general population of the same age, sex, and geographical region and importantly Sex is not a risk factor for long-term mortality in this group of patients, this obviously goes against the grain of the headline in The Times recently.
In general (i.e. not just in patients >75 years of age), while elevated cholesterol is a key risk factor, approximately 20-25% of people who experience a STEMI may have cholesterol levels within normal ranges. However, other underlying conditions or risk factors usually play a role in such cases and some studies also indicate that approximately 25-30% of people who suffer from a heart attack, including STEMI, may have normal or controlled blood pressure.
Women can also sometimes present with atypical features of a heart attack and I think this is something that clinicians need to be made more aware of.
These can differ from the classic chest pain typically associated with heart attacks in men. These atypical symptoms may include:
- Shortness of breath – This may occur with or without chest discomfort.
- Fatigue – Unusual or unexplained fatigue, even if there has been no physical exertion.
- Nausea or vomiting – Some women experience gastrointestinal distress, including nausea, indigestion, or vomiting.
- Pain in the neck, jaw, shoulder, upper back, or abdomen – This pain may feel like pressure, squeezing, or an aching sensation.
- Dizziness or light headedness – Women may feel faint or dizzy.
- Sweating – Women often experience cold sweats, which may resemble symptoms of stress or anxiety.
- Sleep disturbances – Some women report difficulty sleeping or waking up feeling short of breath in the days leading up to the heart attack.
These symptoms can be subtle, making it harder to recognize that they might indicate a heart attack. If a woman experiences any combination of these symptoms, especially if they are new or unexplained, the recommendation is to seek medical attention right away.
To complicate matters it’s thought that approximately 40% of patients presenting to accident & emergency with suspected heart attack symptoms have not actually had a heart attack.
In the absence of known risk factors such as high cholesterol or hypertension, and CVS calculators such as QRISK3 showing low risk, it is unlikely that many patients would have received preventative treatment and so the first sign of having cardiovascular disease may well have been a heart attack.
Other suspected causes of heart attack can occur via a variety of mechanisms
Increased adrenaline, and other stress hormones as a consequence to stress both prolonged and acute leading to plaque rupture.
Coronary artery spasm caused by Endothelial Dysfunction: The endothelium (inner lining) of the coronary arteries may become dysfunctional, reducing its ability to produce substances like nitric oxide that help relax the artery walls. By the way a natural way of increasing Nitric Oxide is to Nose breathe not mouth breath. Autonomic Nervous System Imbalance: An imbalance between the sympathetic and parasympathetic nervous systems can cause excessive constriction of the coronary arteries. Increased Activity of Smooth Muscle: The smooth muscle cells in the artery walls can become more reactive, leading to spasms. This hyperactivity may be due to inflammation, stress, or other triggers. Smoking: Nicotine and other chemicals in cigarettes can irritate the arteries and cause them to spasm. Cold Exposure: Cold weather/water can lead to constriction of blood vessels, including coronary arteries, which may trigger spasms in susceptible individuals. Drug Use: Certain drugs, such as cocaine, amphetamines, and other stimulants, can lead to coronary artery spasms by increasing sympathetic nervous system activity and causing intense vasoconstriction. Emotional Stress: Acute stress or anxiety can provoke a release of stress hormones, leading to arterial constriction and triggering spasms. Hyperventilation: Breathing too quickly or deeply can alter the balance of oxygen and carbon dioxide in the blood, which may trigger spasms. Medications: Certain medications, particularly those that constrict blood vessels (like some migraine medications), can increase the risk of coronary artery spasm. Magnesium Deficiency: A deficiency in magnesium, which helps regulate muscle function, including that of blood vessels, can make the arteries more prone to spasms. Allergic Reactions: In rare cases, allergic reactions (like anaphylaxis) may trigger coronary artery spasms, a condition known as Kounis syndrome.
Spasms are typically temporary, but if they persist long enough, they can reduce the blood supply to the heart muscle and may cause chest pain (angina) or, in severe cases, lead to a heart attack.
Strenuous exercise, it’s always useful to know your maximum exercise heart rate which is usually given by a calculation of 220-age and then multiplied by 50-75%. So, if you’re 60 years of age this would lead to 220-60*75% = 120 maximum, which would be the suggested maximum exercise heart rate, especially after a heart attack. If the patient is on medication such as beta blockers, the rate is usually set lower.
Whilst exercise is an important part of recovery and general health it is normally suggested that six months after a heart attack strenuous exercise is not undertaken.”
The Times
Eleanor Haywood
Women having a heart attack are more likely to be misdiagnosed and told they have indigestion, muscle pain or are even having a “funny turn”
Thousands of women are dying unnecessarily from heart attacks because sexist attitudes mean they are “underdiagnosed and undertreated”, say cardiologists.
More than 3.6 million women in the country have heart disease, and it is the biggest killer of women, but academics say there remains a perception that it is a man’s disease.
This means women are not involved in enough clinical trials or research, often do not get the same access to lifesaving treatment and have symptoms such as high blood pressure ignored by doctors.
A group of heart experts from the UK have written a report, published in the journal Heart, demanding action from the NHS to improve care for women.
They have called for more education for GPs and doctors to highlight that “heart disease does not discriminate by sex”, as well as more research into how sex-specific factors such as the menopause affect heart disease risk.
The statement was drawn up by 33 experts affiliated with the British Cardiovascular Society, including medics at Imperial College London and Cambridge University.
They said there is a “discrepancy” between men and women when it comes to diagnosis and treatment, with women less likely to receive certain treatments or diagnostic tests.
The group also says that women are “under-represented” in clinical research about heart disease. “Many treatments are mainly investigated in men and then applied to women,” the statement said. “Unfortunately, women are underdiagnosed, undertreated and under-represented in all areas.”
The report said that women with traditional risk factors such as high blood pressure and high cholesterol, are often not treated as quickly as men. Meanwhile, women also face specific risk factors due to changing hormone levels, including falling oestrogen after the menopause which increases the risk of heart disease.
The lead author, Professor Vijay Kunadian, from Newcastle University, said: “heart disease, in particular coronary artery disease, is the number one killer for women in the UK and worldwide.
“And yet, even to this day, we see that their symptoms are being ignored or told there is nothing wrong with them, or treated for something else, when all along they might be suffering from a heart problem.”
She said national databases are showing “year after year” that women are being undertreated and “unfortunately that leads to higher death rates following heart attacks. We can’t ignore that anymore; it is about time that we do something about it”.
Lives were being lost because “if women received the correct treatment, then their lives could be saved”, Kunadian said.
“People assume it is a men’s disease. When a man complains he is more likely to get the attention from the ambulance or the doctors for example. So, we need to change the perspective of people and make people think this is also a woman’s condition.”
About 100,000 people are admitted to hospital each year with heart attacks, when the supply of blood to the heart is suddenly blocked.
Previous studies have shown that women having heart attacks are 50 per cent more likely than men to receive a wrong initial diagnosis.
This has been blamed on a perception that most heart attack victims are overweight middle-aged men, meaning women are more likely to be dismissed as having indigestion, a “funny turn” or muscle pain.
Dr Sonya Babu-Narayan, associate medical director the British Heart Foundation and a consultant cardiologist, said: “heart disease kills more women than breast cancer every year, yet robust evidence from across the globe shows the odds are stacked against you if you are a woman, in part due to entrenched biases in society including health and care.
“This shocking state of affairs show inequalities negatively affect women’s heart health at all stages in the patient journey.”
A Department of Health and Social Care spokesman said: “In the broken NHS we inherited it is clear women’s health has been neglected. This government will prioritise women’s health as we reform the NHS and ensure their voices are heard.
“Cardiovascular disease is one of this country’s biggest killers of women and men, which is why this government will deliver up to 130,000 extra health checks at workplaces across the country to catch this and other diseases earlier.”