Why don't we know more about women's heart health?

Heart disease is the most preventable cause of death, but women are 50 percent more likely to die following their first attack than are men. Why?

Running has always been my father’s favorite pastime. He enjoyed staying fit and being active. But one sunny morning in May 2016, while on the treadmill, he experienced sudden cardiac arrest. His heart began to beat incredibly fast. The electrical workings of his heart malfunctioned, throwing the heart’s rhythm off course. Blood stopped flowing to the rest of his body, and he eventually collapsed and loss consciousness.

Fear consumed everyone at the gym. My dad’s lifeless body lay face down on a moving treadmill. The gym’s employees struggled to work the defibrillator.

Fortunately, by some twist of fate, a medical resident working out on a nearby treadmill rushed over, took control of the situation, and revived my dad after nearly four minutes of unresponsiveness. The only thing my father can remember from the accident is waking up in the back of an ambulance surrounded by paramedics.

Following my dad’s accident, I took initiative to become more informed about my own heart health. I hired a personal trainer, received nutritional counseling, and set out to lead a healthier life. In the course of this journey, I discovered that heart disease manifests itself differently in women than in men.

Heart disease affects approximately 44 million women in the United States. Cardiovascular disease and stroke cost one in three women their lives every year. That is about one person every 80 seconds. Approximately 90 percent of women have at least one of the risk factors for heart disease or stroke.

Despite these figures, there’s an overwhelmingly common public perception that heart disease is a male issue. Media coverage only amplifies the gender gap. Women’s heart health is rarely covered in research. Thus, news organizations mainly report on what is being studied: male heart health.

Consequently, there is a substantial gap in our understanding of heart disease as women. “There is not one specific factor that’s at play here,” says Rachel Dreyer, an associate researcher focusing on women’s cardiovascular health in the Department of Emergency Medicine at Yale School of Medicine. Many of the findings about heart health are based on studies conducted on men. Women’s heart disease is far from thoroughly explored in research. The American Heart Association didn’t make its first scientific statement on women’s heart attacks until early 2016. A few key reasons are: lack of research, underestimation of the problem and difficulty in detecting symptoms.

But there’s something more alarming. More women have died from heart disease than men since 1984 says the Heart Foundation. A 2017 report by the George Institute for Global Health and University of Sydney found that women aren’t as likely to be screened by their doctors for cardiovascular disease. Men were much more likely to be evaluated for heart disease risks. Women, the report found, were less likely to receive appropriate medications. “A long time ago there was a historical concept that it was a man’s disease. That I think really just got ingrained in a lot of older physician’s minds. But I think what’s going on in younger physicians is I think the word is out that this is a men’s and women’s disease. It’s an everybody disease,” says Dr. Karol Watson, a cardiologist and director of the University of California Los Angeles Barbra Streisand Women’s Heart Health Program.

Ultimately, lack of understanding about sex and gender contribute to this under-treatment and less than ideal care of women patients. Some experts are taking note of this and are calling for better focus on women’s care. A 2017 article in Circulation explores how sex specific differences relate to heart health and research outcomes. And even when such research is performed, the results might not be accurate. “When investigators are doing studies, it is tremendously difficult because you are asking men or women right after a heart attack about their symptoms and they might remember certain things, more than other things,” says Dr. Elizabeth Jackson, a cardiologist and director of the Women’s Heart Program at University of Michigan. These gaps in information make it hard to decipher which research findings affect men and women specifically.

Amongst the problems, research indicates women have a different form of heart disease then men, says Dreyer. Women are more likely to suffer from a form of heart disease that restricts the blood flow in small vessels of the heart, known as microvessels. Women rarely have blockages in the large vessels of the heart. Instead, the blockages take place in smaller vessels—making the blockages harder to detect. “We now know that the little tiny, tiny, tiny minuscule vessels that supply about 60 percent of blood to the heart are just as important. And you don’t see those on an angiogram, but in women it appears that these little, what are called microvessels actually probably are more important in woman then men in determining how much blood flow gets to the heart and how much of a heart attack risk they have,” says Watson. In fact, more research has to be done in order to come up with effective techniques for catching blockages in these small vessels.

Healthcare professionals—and female patients themselves—often underestimate women’s heart disease risks. For instance, many people incorrectly think that women are less likely to have heart attacks than their male counterparts. Only 54 percent of women realize that heart disease is our leading cause of death. In fact, Women in Innovation Initiatives (WIN), a group of cardiologists that aims to improve female heart health care, issued a 2010 consensus statement which stated, “Lack of awareness of the prevalence of [cardiovascular disease] in women, on the part of both patients and healthcare providers, is in our opinion the main reason why it often goes underdiagnosed and undertreated.”

The symptoms of a heart attack also differ in women, according to an American Heart Association statement. Dreyer agrees. “Chest pain is the most common presenting symptom, but young women are more likely to have atypical symptoms, which is a challenge to healthcare providers in terms of diagnosing the heart attack,” she says. Women experience symptoms such as nausea and vomiting, both of which could easily be tied to pregnancy or something much less severe like the flu. Men and women both experience chest pain. However, women experience less common symptoms like fatigue, nausea, or back pain. These symptoms are associated with a number of other less serious health-related conditions, causing them to go unnoticed and making them less likely to be reported by patients promptly. “Any symptom that you have any where between your nose and your navel that comes on with exertion either physical and emotional and goes away with rest, you have to consider your heart,” says Dr. Watson. But one major concern is that because these indications are so subtle, women suffer heart attacks but fail to report them, not realizing these heart attacks have happened. “So heart attacks are almost never silent killers, but they are sometimes clinically not apparent. Most people have symptoms, but they don’t recognize them as heart attack, so if someone says ‘Oh my God! I feel I’m exhausted! I’m sweating! I’m short of breath!’ They may think they caught a virus, but it might have been a heart attack,” explains Dr. Watson.

Back at the hospital with my father, doctors ran some tests and discovered that several of the major arteries in my dad’s heart were 85 percent or more blocked. He had coronary artery disease and was completely unaware of it. Initially, cardiologists came up with a plan to alleviate his problem with stents, catheters, and balloons. But after two unsuccessful procedures and discovering more blockages than anticipated, doctors turned to bypass.

On May 27, 2016, my dad underwent sextuple bypass surgery. Doctors informed us that the first year following my dad’s surgery would be the most critical. And now that one-year has passed my dad says, “I feel so great. I’m back to running an hour a day. I forget about my surgery. Until, I take a shower and look down at the scar in the middle of my chest.”