Well-dressed, well-groomed women are going undiagnosed with heart disease because they look healthy, as Victoria Lambert reports
Over a lifetime, women are just as likely to die from cardiovascular disease as men, yet there are surprising differences in causes and treatment between the sexes.
While it’s tempting to ascribe these to natural declines in oestrogen levels after menopause and its potentially protective effects pre-50, the picture is more complicated, says Adam Fitzpatrick, consultant cardiologist at BMI Healthcare and the Manchester Royal Infirmary.
“Although only 20 per cent of 60 year olds who have angina or a heart attack are women,” says Dr Fitzpatrick, “they are almost all smokers and difficult to treat. Women’s coronary arteries are much finer and bypass grafting or stenting is technically less successful.
“Among women aged 70-plus, heart disease is due to a mixture of factors, such as air pollution, hard water, diet and ageing of the lining of arteries – the same reasons that men get heart disease at this point.”
High levels of cholesterol, high blood pressure, smoking and obesity are all risk factors at any age, but among younger women, says Dr Fitzpatrick, cardiovascular disease (CVD) may be due to rare inherited conditions or an embolism in the coronary artery, coronary spasms and even as a result of a small tear to the lining of an artery, when the coronary arteries otherwise look normal.
No wonder so few women understand whether they are at risk. Self-employed Priscilla Chandro, 42, of Ottershaw, Surrey, suffered a heart attack five years ago “out of the blue”.
She recalls: “My head was aching and I felt pain radiating into my arms. A wave of heat rushed through me. Then I passed out. When I came round I was chilled and feverish.”
Women’s coronary arteries are much finer and bypass grafting or stenting is technically less successful
Paramedics, called by her father, failed to suggest an ECG as a heart attack was not suspected. But left with a dull ache in her chest, Priscilla went to her GP the next day who insisted on an ECG. Even so, the local hospital refused to act, and Priscilla, whose daughter Anusha is nine, was sent home.
Two days later, back in A&E, Priscilla was admitted straightaway. “You had a massive heart attack,” she was told. Her left artery was 100 per cent blocked; doctors admitted they don’t know how she survived. “It was surreal,” she says.
Priscilla was given a stent, and put on to a cocktail of drugs including aspirin, beta blockers and a statin.
When she attended an NHS six-week cardiac rehab programme, she walked into a room full of elderly men and women. “People were shocked at me being there,” she says. “But the emotional support was unbelievable.”
Dr Fitzpatrick is concerned that many women may go through an experience like Priscilla’s where, due to gender, heart disease is not diagnosed.
“A particular cause of CVD in both sexes is atrial fibrillation (AF), a heart rhythm disorder, which can be hard to detect,” he says. “The most common symptom is palpitations, but 60 per cent of women report those around the menopause and, if they visit the GP, it’s unlikely to get a diagnostic ECG.”
Even when diagnosed, figures show women receive only 50 per cent of the support given to men with AF.
And women respond less well to treatment. According to Global Heart, journal of the World Heart Foundation, women have been shown to have narrower coronary arteries than men. Even stents, used to unblock and keep arteries open, are less effective in women, says Dr Fitzpatrick, although we don’t know why.
It’s not just practical problems that recur. Many women feel lost emotionally as the diagnosis can be so unexpected. Patients and survivors can share experiences on the British Heart Foundation Women’s Room online forum.
QUESTIONS TO ASK YOUR PARTNER
1. Do you get a tight chest during exercise?
Just because you’ve taken up jogging or go to the gym doesn’t mean you are not at risk of heart disease. Twinges when out running or climbing the stairs, breathlessness when exercising, and pain or discomfort in the chest that subsides with rest could all be early-warning signs, says British Heart Foundation specialist nurse Amy Thompson. But getting fit is important for everyone and the BHF recommends we all do about 150 minutes a week of exercise, which increases the heart rate, to stay heart healthy. A weekly activity diary helps you stay motivated and track progress.
2. Have you seen the GP recently?
Unlike other aspects of their health, men do often go to the GP when they have chest pain, says Ms Thompson. “Men are more conscious than women of the risk of a heart attack,” she says. “Women tend to shrug pain off, claiming they don’t have time to go to the doctor.” Other warning signs to speak up about are light-headedness and heart palpitations or an abnormal heart beat. Fifty is the typical age when some men can develop coronary heart disease. Prescription? An exercise stress test. Sometimes called a treadmill test, this monitors how well your heart handles work.
3. Are you too tired for sex?
Symptoms of testosterone deficiency tend to be sexual – low libido or lack of morning erections. But men may notice mood swings and lack of energy. And if you have type 2 diabetes, you are at increased risk of falling testosterone levels. Diagnosis is by blood test, but needs to be repeated and monitored for accuracy. Investigation is required to identify an underlying cause; however, obesity may be the cause of a contributory factor. Testosterone replacement therapy, if indicated, is either by gel or injection, although new modes of administration are in development.