Most women I know, friends and patients, fear breast cancer. It makes sense because one in eight of us will develop breast cancer over our lifetime, which translates to a lifetime risk of 12.5 percent, and higher for those of us with a high-risk gene mutation. However, our fear of breast cancer may come at the expense of an even greater killer: cardiovascular disease (CVD). One in five women in the U.S. die of cardiovascular disease.1 The number of women who die of cardiovascular disease is seven to ten times more than the number who die from breast cancer, according to the CDC.2 Earlier breast cancer detection and better breast cancer survival rates, together with only modest gains when it comes to CVD mortality, are the explanation for this difference. However, there are other, very important reasons why heart disease is killing more women than breast cancer.

What is Behind the Rise in Heart Disease Mortality in Women?

Women are developing cardiovascular disease at much younger ages than ever before. I wanted to share with you an alarming statistic. Despite an overall reduction in cardiovascular mortality, in the U.S. hospital admission with acute myocardial infarction (a heart attack) is on the rise in women aged 35 to 54.3

Risk Factors for Cardiovascular Disease

The major risk factors are high blood pressure, unhealthy blood cholesterol levels, diabetes and obesity. Behaviors that increase risk include smoking, eating a diet high in saturated fats, trans fat, and cholesterol, drinking too much alcohol and not enough exercise.

Aside from these standard risk factors there are more than 400 risk factors now for cardiovascular disease. It’s important for all of us to be aware of our personal risk of cardiovascular disease. There are so many markers that show up early when you have the greatest opportunity to reverse them.

Sex Difference in Symptoms of Heart Disease

Sex differences in symptoms is a factor in the high mortality rate in women for heart disease.

The classic symptoms of a heart attack that is taught in medical schools is crushing chest pain, like an elephant sitting on your chest, with pain that often radiates down the left arm from the shoulder to the elbow.

Symptoms of heart disease in women, however, tend to be atypical and nonspecific. For coronary heart disease, prodromal symptoms include the following.

  • Nausea
  • Dyspnea (shortness of breath)
  • Fatigue
  • Unexplained weakness
  • Feeling “unwell,”
  • Pain in upper back and/or neck
  • Sense of foreboding (like something bad is about to happen)
  • Difficulty with exercise
  • Syncope (fainting)

Other signs of heart disease include blood pressure > 120/80, abnormal lipids, and changes on noninvasive tests like ENDOPAT and others. Mechanisms are often different for women versus men, which is why the symptoms are different and tests may not pick them up.

Another major sex difference is pregnancy. I was never taught in medical school that pregnancy is a stress test of the heart. Pregnancy can unmask future risk of cardiovascular disease (CVD).

A 2013 systematic review and meta-analysis showed that “there is increasing evidence that pre-eclampsia, a principal cause of maternal morbidity, may also be a risk factor for future cardiovascular and cerebrovascular events.”4

The literature also shows that a history of gestational diabetes mellitus (GDM), in other words pregnancy-induced diabetes, can “increase the risk of developing not only type 2 diabetes mellitus but also cardiovascular disease (CVD) independent of a diagnosis of type 2 diabetes later in life.”5

Preterm birth or having a low birth weight baby for gestational age can also be a marker of cardiovascular disease.6 Certain pregnancy complications that develop either during the gestation period or postpartum can expose CVD risk factors in women. This 2019 review states that pregnancy and the postpartum period afford clinicians “the opportunity to reliably identify women with underlying, often unrecognized, CVD risk factors.”7 These women should be referred for regular follow-up and “undergo CVD risk screening at a younger age.”

Gender Differences in Cardiovascular Disease

One of the gender differences that affect heart disease mortality rate in women is that women are less likely to get early medical care when they have symptoms of cardiovascular disease. It’s not by a small amount, it’s actually 10 to 25 percent lower chance of early medical care.8

Another study showed that amongst patients treated by men, female patients survive their treatment less often than do male patients.9 In this study done in Florida, they looked at ER patients who were admitted with a heart attack between the years 1991 to 2010. They found that women who came in with a heart attack, if they saw a female physician in the emergency room they had a two to threefold greater survival than if they saw a male physician. There was no difference in survival rate for men depending on whether they saw a male versus a female physician.

We Must Raise Awareness of Heart Disease in Women

We need to raise awareness about cardiovascular disease. We don’t want to study it or pay attention to it at the expense of breast cancer. We want to keep our eyes on both of them. One of the reasons why only about half of women recognize that heart disease is their number 1 killer and are more concerned about breast cancer is because of what’s known as an availability bias. This means we see our breasts every day and it leads us to question what is going on with them. When it comes to the heart and the cardiovascular system and the vascular tree of your body, we don’t see it and so it’s a little more abstract. I think that plays a role here.

We have made great strides recently with raising awareness of heart disease and the differences in men and women.The American Heart Association and their campaign #GoRedforWomen has done a great job in doing this. Yet, we need more research on women. We need a different approach to the healthcare team that takes care of women. We need more women-focused care and we certainly need more women cardiologists. Beyond that we need a much more collaborative and team-based approach to address these deficiencies that we have with taking care of women when it comes to cardiovascular disease and to address this gap in terms of survival.

Reduce Your Risk of Cardiovascular Disease

Heart disease is primarily a lifestyle problem which means that there is so much hope and capacity to turn this crisis around with precision lifestyle medicine. You can reduce your risk of CVD with dietary tweaks, changing your exercise, and adding targeted nutraceuticals. Some patients will require prescription medications when these are insufficient to improve health. It takes understanding your own quantified health, together with self empowerment and collaboration with a knowledgeable clinician, to prevent or reverse cardiovascular disease.

Follow me on Instagram, Facebook or YouTube to learn more about how to reduce your risk factors and reclaim your health.

Endnotes

  1. Centers for Disease Control and Prevention. https://www.cdc.gov/heartdisease/women.htm accessed November 20, 2019
  2. Centers for Disease Control and Prevention. https://www.cdc.gov/heartdisease/women.htm accessed November 20, 2019
  3. Arora S et al. Circulation. 2019 139 1047 1056
  4. Brown MC et al. Eur J Epidemiol. 2013;28(1):1‐19.
  5. Vrachnis N et al. Int J Endocrinol. 2012;2012:458610.
  6. Smith GN et al. Obstet Gynecol. 2019;134(4):851‐862.
  7. Smith GN et al. Obstet Gynecol. 2019;134(4):851‐862.
  8. Jneid H et al. Circulation. 2008;118(25):2803‐2810.
  9. Greenwood et al. Proc. Natl. Acad. Sci. USA. 2018;115:8569–8574.





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