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From OHSU Knight Cardiovascular Institute
Nandita Gupta, M.D., FACC
Dr. Gupta is the medical director of the Cardiovascular Service Line at OHSU Health Hillsboro Medical Center, formerly Tuality Healthcare, and she also leads the OHSU Women’s Heart Program at the Center for Women’s Health on Marquam Hill. She is a board member of the American Heart Association of Oregon and an advocate for sex‑specific differences in cardiovascular care.
The field of cardiology has come a long way in recent years to establish and recognize gender-based differences in cardiovascular disease.
We’ve also uncovered some hard truths about how women with cardiovascular disease often receive less aggressive therapy or less preventive counseling than their male counterparts.
Since we know women have higher death rates and rehospitalizations from cardiovascular disease, we need to shift our approach to heart disease in women. The OHSU Women’s Heart Program is a comprehensive, multidisciplinary effort to focus on how women experience cardiovascular disease risk factors, symptoms, presentation and treatment.
Uniquely female risk factors
Pregnancy is nature’s free stress test for women’s risk of cardiovascular disease. In a rising number of cases, it’s a test not all women pass.
Cardiovascular disease is the no. 1 cause of death during pregnancy.
Factors such as advanced maternal age, obesity, social determinants of health and less aggressive treatment may all contribute to this trend.
The complex hemodynamic changes during pregnancy show a window into the future cardiovascular health of a patient and provide an opportunity for early intervention.
Eighty percent of women will have at least one pregnancy, and about 30 percent develop a complication, such as preterm delivery, gestational diabetes or preeclampsia. Women who have these adverse pregnancy outcomes have a four- to fivefold higher risk of cardiovascular disease in the five to 10 years following the pregnancy.
Among your female patients with these histories, a discussion of this risk is useful, so that together you can aggressively follow guidelines for controlling blood pressure, reducing blood sugar, maintaining a healthy weight and improving diet and exercise. You may also consider referring these patients to a preventive cardiologist or women’s heart program.
Gender differences in traditional risk factors
The current method of calculating cardiovascular risk is not gender specific. Among shared high-impact risk factors in both genders, the results can be different.
For example, women who smoke are at a 25 percent higher risk of cardiovascular disease than men who smoke. Women above age 60 have a higher prevalence of hypertension than men, but studies show only 30 percent of those women have blood pressure adequately controlled. Inactivity and sedentary lifestyles are also more common in women than men.
Presentation often differs in women
A 2018 study of men and women under age 55 with acute heart attack showed that 90 percent of women and men had identical symptoms. But women were less likely to be told their symptoms were heart related.
Other studies have shown women are less likely to receive early medical therapy and invasive procedures.
Part of the challenge for providers is that cardiovascular disease is often anatomically different in women.
Men often have a focal stenosis, but women often have diffused blockages.
Women are also more susceptible to other causes of cardiovascular disease. As examples, the highest prevalence of cardiac syndrome X — microvascular angina — is in post-menopausal women, and spontaneous coronary artery dissection (SCAD) is uncommon but occurs overwhelmingly in women.
Unlike men, women do not always have the crushing chest pain that clearly signals the cause. The less specific symptoms of dizziness, fatigue or diffuse pain in the limbs can delay diagnosis.
As providers, we need to be aware of women’s experiences of cardiovascular disease so we can be more proactive in modifying risk factors and providing treatment.
When to refer
- Patients who experienced preterm delivery, gestational diabetes or preeclampsia during pregnancy.
- Patients with heart failure with preserved ejection fraction.
- Patients with sex-specific or sex-predominant cardiovascular conditions, such as SCAD, myocardial ischemia with normal coronary arteries (MINOCA) or ischemia with normal coronary arteries (INOCA).
- Any women with heart disease or risk for heart disease who wish to be seen at the OHSU Women’s Heart Program.