Mars, venus and cardiovascular disease

James Beckerman, M.D., F.A.C.C.
Cardiologist, Providence St. Vincent Medical Center
Providence St. Vincent Heart Clinic-Cardiology

Women and men may hail from Mars and Venus, but Heart Month should serve as a reminder to us and our patients that we have more in common than we might think, particularly where the heart is concerned.

Heart disease remains the leading cause of death in women worldwide. The statistics are eye-opening: One in three women will develop cardiovascular disease, and one in 17 women in the United States will have a major cardiac event before age 60.

Whether in the form of red-dress lapel pins or viral YouTube videos, we need to do a better job of communicating the scope of the problem to patients and their physicians. It will take this realization to place the proper emphasis on prevention, modify treatment when appropriate, and stimulate research in a field long dominated by male physicians and their male patients.

While female hormones do generally delay the onset of cardiovascular disease by about 10 years compared to men, the disease generally carries a worse prognosis for women. Risk factors for heart disease are more common in older women than in men the same age, perhaps because physicians put less of an emphasis on modifying women’s risk factors. Smoking and low HDL may be even stronger predictors of heart disease in women.

Interestingly, marital stress (but not work stress!) has a strong association with poorer prognosis from heart disease. This may say less about heart disease and more about husbands, but it supports the idea that psychosocial stressors must be addressed by cardiologists as well as primary care providers.

Many providers are now aware of the concept that women may present with angina differently than men. The traditional presentation with chest pain may be supplanted by back pain, nausea, indigestion or even palpitations. Exercise stress testing tends to yield more false positives for women than men, and some form of imaging (nuclear versus echo) is generally recommended for more accurate risk stratification and diagnosis.

Once diagnosed, women tend to be managed differently than men. Data suggest that women are less likely to be referred for cardiac catheterization, and are more likely to undergo stenting than surgical revascularization, even when CABG may be associated with better outcomes.

As for medication, there are some interesting gender differences that might surprise a lot of cardiologists. For example, there is less benefit from ACE-inhibitors for heart failure, little data to support the use of aldactone, and an increased risk of death for women taking digoxin. Many providers are not aware of these differences, and tend to prescribe medications based upon randomized studies performed on largely male populations.

As with much of medicine, if you are not thinking of zebras, you will only hear horses. But sometimes we can make a significant difference for our patients from thinking outside our own planetary comfort zones as well as keeping in mind our similarities.