Coronary artery disease (CAD) is the leading cause of mortality for men and women in the United States. Historically, CAD has been thought to be a “man’s disease,” perhaps because the average age at first myocardial infarction (MI) is 64.5 years for men, compared with 70.3 years for women. However, data show that mortality rates for CAD are higher among women than men.
Recent research suggests that CAD-related mortality rates have increased in young women in recent years, despite a significant decline among all Americans. “When stroke is included as a commonality, the lifetime risk of developing heart disease for women is approaching one in two,” says Martha Gulati, MD, MS, FACC, FAHA. “To put that in perspective, the lifetime risk of women developing breast cancer is one in eight. The risks for breast cancer have been well documented in clinical research. That same level of awareness, however, seems to have escaped patients and providers when it comes to CAD in women.”
According to Dr. Gulati, co-author of an update on CAD in women that was published in Global Heart, the presentation of the disease is often similar to that among men. Two-thirds of women present with the classic symptoms—chest pain, chest pressure, shortness of breath, and sweating—that are described and seen quite often in both men and women, she says. The remaining one-third, however, can present with symptoms that are vaguer. These include:
• Diffuse body ache.
• Shortness of breath not accompanied by
chest pain or pressure.
• Pain that is present in only the arms,
neck, or back.
“The traditional risk factors for CAD should be screened for in all patients,” says Dr. Gulati (Table 1). “These include diabetes, tobacco use, family history of CAD, poor functional capacity for age, poor heart rate response to exercise, high cholesterol, and high blood pressure. However, there are some unique risk factors to consider in women, such as preeclampsia and gestational diabetes. Coronary disease equivalents put women at high risk for CAD. These include diabetes, peripheral vascular disease, aortic aneurysms, and chronic kidney disease.” Disease states such as lupus and rheumatoid arthritis also disproportionately affect women and are risk factors for CAD.
Various stress testing modalities have been useful in women and have historically helped physicians make a diagnosis of CAD, according to Dr. Gulati (Table 2). “However,” she says, “physicians tend to rely heavily on imaging and less so on the simple information that can be obtained from various types of stress testing, particularly exercise testing. Even when exercise testing is performed with imaging, the exercise part of the testing tends to be ignored. The exercise portion of stress testing can provide important diagnostic information as well as prognostic value. It can provide data on functional capacity, fitness level, heart rate response, and blood pressure response. This information shouldn’t be lost when physicians translate test results to patients.”
Closing Treatment Gaps
Evidence suggests that the traditional treatments used in men with CAD are equally effective for women. Dr. Gulati says that despite this knowledge, research indicates that women are not treated as aggressively as men. “Physicians are less likely, for example, to give women an aspirin, b-blocker, or ACE inhibitor after a heart attack,” she says. “We’re also less likely to perform a diagnostic catheterization, implant a stent, or perform bypass surgery. As a result, women have a higher mortality rate than men after being diagnosed with an MI. The treatment gap doesn’t refer to how women should be treated. Rather, it is embodied by how we actually treat them.” Dr. Gulati says more research is needed to determine why there are gender-specific differences with regard to treatment of CAD, but says learning more about the rationale for these differences may eventually bridge gaps in care.
Heightened awareness among providers that CAD is not gender specific is critical, Dr. Gulati says. “Just as women tend to know when to get mammograms or Pap smears, they also need to be educated on screening for CAD and whether they’re at high risk. Talking to women about their risk for CAD will heighten their awareness. In turn, this can empower women to be more responsive and react to symptoms of CAD by getting themselves to the
ED for the urgent care they need.”
Readings & Resources (click to view)
Sharma K, Gulati M. Coronary artery disease in women: a 2013 update. Global Heart. 2013;8:105-112. Available at http://globalheart-journal.com/article/S2211-8160(13)00038-0/fulltext.
Mosca L, Mochari-Greenberger H, Dolor R, et al. Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health. Circ Cardiovasc Qual Outcomes. 2010;3:120-127.
Roger V, Go A, Lloyd-Jones D, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
Dickerson J, Nagaraja H, Raman S. Gender-related differences in coronary artery dimensions: a volumetric analysis. Clin Cardiol. 2010;33:E44-E49.