How to detect heart disease in women

Dr Ross Walker

For many years there was this false notion that heart disease was typically a disorder of males. Thankfully, there has been increasing publicity over the past decade. Work has gone into educating both the public and the medical profession about the importance of the variety of ways cardiovascular disease may affect women.

Firstly, the most common form of cardiovascular disease is atherosclerosis. This is the progressive build-up of fat, inflammatory tissue and calcification in the walls of arteries. This is the most common cause of heart attack and stroke. In this condition, a fatty plaque reaches a critical mass in the wall of the artery involved. It suddenly ruptures with a subsequent clot forming leading to a blockage in the artery.

This condition is typical in people with major risk factors for heart disease. These factors are hypertension, high cholesterol, cigarette smoking, pre-or frank diabetes and a strong family history of vascular disease. The only difference between men and women in this situation is that typically women are protected by their hormones until menopause. They may, on average, experience a typical atherosclerosis related heart attack 10 years later in the female compared with a male with similar risk factors.

But, there is now increasing evidence that lesser well known forms of cardiovascular disease are more common in women than men. In some cases, for obvious reasons, these factors only affect women.

Uniquely female risk factors

MINOCA or Myocardial Infarction in Non-Obstructive Coronary Arteries

This condition is being increasingly recognised in typically younger women. They may experience, at times, atypical symptoms but still evidence of heart attack. When they are investigated with a coronary angiogram there is minimal to no blockages in the arteries. What is happening here is that a lesser fatty plaque in the wall becomes acutely inflamed and erodes the lining of the artery. A large clot then forms to acutely blocked the artery. By the time the angiogram is performed, the clot has dissolved and the artery looks normal or has only minor blockages. These types of cases need more aggressive anti-inflammatory and blood thinning. It is not enough to focus on standard risk factors.

Peri-partum cardiomyopathy

Obviously, this condition only affects women and can cause varying degrees of heart failure either during or after a pregnancy. This requires ongoing cardiologic management, typically indefinitely.

IVF associated heart disease.

Women who fail IVF have double the risk of cardiovascular disease when followed for 10 years after the procedure. The reasons for this are unclear.

SCAD or Sudden Coronary Artery Dissection.

This is not related to atherosclerosis and most commonly occurs in younger women often but not always around the time of pregnancy. If diagnosed, it can be effectively treated with coronary stenting but again, this is not an atherosclerotic condition so does not require aggressive risk factor modification such as cholesterol-lowering therapy. This condition is not exclusive to women but certainly more common in the female gender

Takotsubo’s Cardiomyopathy

This is stress induced constriction of the coronary arteries. It often leads to symptoms very similar to a heart attack. It was felt until recently that this was a one off phenomenon. However, work from the UK has suggested the potential for recurrence and ongoing cardiac damage. Again, this needs to be recognised and managed appropriately.

Pre-eclampsia

This is a relatively common condition associated with a significant rise in BP during pregnancy. This is very well managed at the time but recent work has shown that women who suffer pre-eclampsia during pregnancy have up to a 4 times are at an increased cardiovascular risk. These include an increased risk of high blood pressure in later life twice the risk of stroke or heart attack and 1.5 times the risk of death. Also, it appears that women who suffer these issues following an episode of pre-eclampsia tend to experience the cardiovascular complications 10 years earlier than other women. Thus, anyone with a history of pre-eclampsia should have regular cardiac assessments.

Coronary artery spasm

This condition can affect men and women but tends to be more common in women. It may or may not be associated with the lesser degrees of blockages in the arteries. There is also an association between coronary spasm, migraine and a condition of the micro-circulation in the hands and feet known as Raynaud’s phenomena.

Clearly, cardiovascular disease is not just in the domain of men. Any symptoms referable to the heart in men and women need to be assessed immediately. A person doesn’t need to have the Hollywood heart attack i.e. crushing central chest pain radiating to the throat and down the left arm to justify a cardiovascular workup. The earlier these conditions are recognised, more effective treatments can be offered.