Dr. Sherryn Rambihar is a Toronto cardiologist and researcher. We asked her why women are under-diagnosed and under-aware, and what needs to change to close the research gap.
How are women’s hearts different from men’s?
That’s a simple and complex question at the same time. From a distance, women’s and men’s hearts look the same, but when we drill down, we see differences in heart disease and how it develops and how it presents.
We know women have smaller arteries. They also lay down heart cholesterol in smaller vessels. This has implications when we diagnose and treat heart disease.
How do risk factors for heart disease differ between women and men?
We are all familiar with usual suspects that are associated with heart disease in both men and women. These include lifestyle risk factors such as physical inactivity, unhealthy diet and stress, plus conditions including high blood pressure.
But in women, certain factors — including depression, smoking and diabetes — can be more important and more strongly linked to heart attack.
And then there are women-specific risk factors.
First are complications that can occur during pregnancy, including gestational diabetes, pre-eclampsia and pregnancy induced hypertension (high blood pressure). We now understand that these conditions can be linked to future risk of cardiovascular illness.
Finally, some conditions that are experienced by more women than men, such as autoimmune disease, are strongly linked to cardiovascular disease. People may not be aware of that.
How do heart attacks differ in women and men?
When women present with a heart attack, it's important to know that the most commonly experienced symptom is chest pain. The same is true for men.
But women also describe more symptoms. We know that for 53% of women who experience heart attack symptoms, it is not recognized as a heart attack.
Maybe it was epigastric pain (pain in the upper abdomen, below the ribs). Maybe they described their pain differently. Maybe they felt they wanted to get the kids to school and downplayed their symptoms.
We know in cardiology that “time is heart.” When you have a heart attack you need to get an artery open, you have to seek medical attention. So if women — and some healthcare professionals — are not recognizing a heart attack, this is a big problem.
Finally we have to be aware that there are vulnerabilities in our system. There are socioeconomic gaps and there are high risk ethnicity gaps that put some people — some women — at higher risk.
These gaps affect Indigenous people, but also people of South Asians and African origin. We need to be aware of that and understand the causes that can amplify risk in an exponential way.
Why are women being under-diagnosed?
The tools we use to evaluate someone’s cardiovascular risk were from before women were enrolled in clinical trials. These are old data based on a largely white male population. They are not reflective of the patients that are in our offices, in our emergency rooms, and in our society.
These tools neglect high risk modifiers like pregnancy, autoimmune disease, things that are affecting young women and are increasing their risk.
The non-invasive diagnostic tests are less sensitive to the type of heart disease many women have in their small vessels.
And even when women go to the cardiac catheterization lab for invasive treatment or management of a heart attack, 25% of young women with heart attacks have tears on their coronary arteries that are often underdiagnosed because the technology is not there.
How are we going to change this?
There are things coming down the pipeline, some very promising directions. But we need more research to develop them.
For example, there are new algorithms to help practitioners, nurses and doctors on the ground diagnose women more accurately. These incorporate women-specific risk factors, and address younger women as well as ethnic factors and vulnerabilities.
Looking at non-invasive diagnostic testing, we have advances coming in MRI, PET scans and new technology in the cath lab suites.
These are all coming but they are largely experimental now. We need more research; we need funding and we need support to make these a reality.
So research is critical. How will it save women’s lives?
We need to translate this research to the healthcare professional on the ground, in the emergency room and in the clinic. They’re the ones talking to women; we need to better equip them to understand women’s unique and different risks and symptoms, and what to do about them.
The more we talk about heart disease in women, the more it becomes part of common conversation. It’s not something to be embarrassed or ashamed about, it's something that needs to come to the forefront.
- Learn more about women, heart disease and stroke
This article is adapted from a Heart & Stroke #SeeRedTalk in April, 2018.