Author: Dr Sergej Cicovic
Ischemic heart disease (IHD) is still sadly the most common cause of death in women. It presents differently in women compared to men, often leading to delays in diagnosis and treatment. Unlike all other demographic groups, mortality from IHD in women between 35-54 is not decreasing.
Atypical Presentation: Why IHD is Often Missed in Women
While men typically experience classic symptoms such as chest pain, women are more likely to present with atypical symptoms like fatigue, shortness of breath, nausea, and pain in the back, jaw, or neck. These subtle signs can be easily overlooked or misattributed to non-cardiac causes. Additionally, women are more prone to non-obstructive coronary artery disease (CAD) such as spontaneous coronary dissection (SCAD) and microvascular angina, conditions that may not show up on traditional diagnostic tests, further complicating timely diagnosis.
Unique Risk Factors: Understanding Women's Cardiovascular Vulnerabilities
Several risk factors uniquely influence the development of IHD in women. While traditional factors such as hypertension, hyperlipidemia, and diabetes are important in both sexes, they often have a greater impact on women. Recently published in the NEJM, a 30-year study showed that CRP, LDL and Lipoprotein measurements are independent risk assessors for IHD in women. Furthermore, female-specific risk factors include hormonal changes, especially post-menopause, which increases cardiovascular risk due to a decline in estrogen’s protective effects. Pregnancy-related complications such as preeclampsia and gestational diabetes also elevate long-term IHD risk, as do autoimmune diseases, which are more prevalent in women.
Psychosocial Factors: The Mind-Heart Connection in Women
Psychosocial factors, including depression and anxiety, which are more common in women, further contribute to cardiovascular risk. Young women are 50% more likely than similar-aged men to present without chest pain when they have an ST-elevation myocardial infarction (STEMI), with 1 in 5 women perceiving their symptoms as being related to anxiety or stress.
Treatment Considerations: Tailoring Approaches for Female Patients
Treatment considerations for women with IHD require careful attention to these gender-specific differences. Diagnostic strategies may need adjustment to identify better microvascular dysfunction or non-obstructive CAD, which are more common in women.
At Ascot Cardiology Group, we can provide a detailed assessment of microvascular disease using state-of-the-art tools. Women may also respond differently to medications like statins and aspirin, and their outcomes after interventions such as angioplasty or coronary artery bypass grafting (CABG) can differ from those of men, often with higher complication rates. Hormone replacement therapy (HRT), once considered protective, is now approached with caution due to its complex effects on cardiovascular health.
For family doctors, it is crucial to maintain a high index of suspicion for IHD in women, especially when faced with atypical symptoms or a history of pregnancy-related complications. Early and accurate diagnosis, coupled with tailored treatment strategies that consider the unique risk factors and presentation of IHD in women, can significantly improve outcomes and reduce the burden of cardiovascular disease in this population.
References and Further Reading
1. Paul M Ridker, M.D. M. Vinayaga Moorthy, Ph.D., Nancy R. Cook, Sc.D. NEJM. Inflammation, Cholesterol, Lipoprotein(a), and 30-Year Cardiovascular Outcomes in Women. Aug, 2024 10.1056/NEJMoa240518
Inflammation, Cholesterol, Lipoprotein(a), and 30-Year Cardiovascular Outcomes in Women | New England Journal of Medicine (nejm.org)
2. Minissian M.B., Mehta P.K., Hayes S.N., et al. "Ischemic heart disease in young women". J Am Coll Cardiol . 2022;80:10: 1014-1022
https://doi.org/10.1016/j.jacc.2022.01.057.
3. Aggarwal NR, Patel HN, Mehta LS, et al. Sex differences in ischemic heart disease: advances, obstacles, and next steps. Circ Cardiovasc Qual Outcomes. 2018;11(2):e004437. doi: 10.1161/CIRCOUTCOMES.117.004437.
Sex Differences in Ischemic Heart Disease | Circulation: Cardiovascular Quality and Outcomes (ahajournals.org)