Heart disease in women

Women comprise approximately 40% of all acute coronary syndrome presentations. According to the Heart Disease and Stroke Statistics reported by the American Heart Association, in 2016, there were 661,000 acute coronary syndrome principal diagnosis discharges, of which an estimated 409,000 were men and 252,000 were women. Women present with coronary artery disease up to 10 years later than men. Although the prevalence of coronary artery disease increases with age, prevalence is also on the rise in younger women. Hospitalizations in the United States for people aged 35 to 54 years due to myocardial infarction (MI) increased between 1995 and 2014 and were highest among young women. In addition, recent European data documented an increase in acute coronary syndromes in young women.

Studies have found a high prevalence of diabetes, obesity, and other risk factors in young women experiencing MI. A recent analysis from France associated an increasing smoking prevalence with the greater increase of MI incidence in young women compared with their male counterparts. Although the awareness about cardiovascular disease as the leading cause of mortality globally has increased, cardiovascular risk in young women may still be underestimated. A recent report found that approximately 45% of women are still not aware that cardiovascular disease is the number one killer of women. In addition, physicians reported limited training and use of guidelines in cardiovascular risk assessment for female patients. In a population of young patients with MI, women were less likely than men to be told that they were at risk for heart disease or have a healthcare provider discuss risk modification prior to their index event.

Women in general have greater baseline risk factors than men, including hypertension, diabetes, and chronic kidney disease when they present with cardiovascular disease. In addition to established risk factors for coronary artery disease, under-recognized risk factors are emerging and include female-specific and female-predominant conditions; obstetric and gynecological history including gestational hypertensive disorders and pregnancy-related disturbances in glucose metabolism, polycystic ovary syndrome, premature menopause, inflammatory disease, and depression may confer additional cardiovascular risk in women. Routine cardiovascular evaluation in women should therefore include detailed assessment of established as well as emerging risk factors ( Table 53.1 ).

Depression has been shown to be associated with adverse outcomes following MI in both women and men. More specifically, a 2- to 4-time higher risk of adverse cardiac events independently of other prognostic factors has been documented. Although depression is not a sex-specific risk factor, registry data from patients after MI found higher prevalence of depression in women (28.9%) compared with men (8.8%), with the highest depression scores in younger women. Underlying mechanisms of the association between depression and adverse cardiovascular outcomes may include unhealthy behavior associated with depression including low physical activity, unhealthy diet, and smoking. There is also a robust association between depression and increased levels of inflammatory markers. While scientific evidence on this topic is growing, in routine clinical practice it receives little attention with only 3% of cardiologists reported to be found to screen for depression. A shift toward including depression in cardiovascular risk assessment is urgently warranted.

The Women’s Ischemia Syndrome Evaluation (WISE) study found women with endogenous estrogen deficiency to be at higher risk of angiographic coronary artery disease. Prior observational studies also suggest that women with premature menopause have greater incidence of cardiac events. Endogenous and exogenous reproductive hormone differences may contribute to sex-specific differences in cardiovascular physiology and pathophysiology, but contemporary data question the protective role of estrogens. At present, estrogen replacement therapy is not recommended for the prevention of coronary artery disease.

Yes, sex differences in symptoms associated with acute coronary syndrome presentation have repeatedly been documented. Women compared with men present less often with chest pain and more often with pain between the shoulder blades, nausea, or vomiting. The lower likelihood of presenting with chest pain in addition to other factors including lower awareness of heart disease in women may contribute to the observed higher rates of late hospital presentation in women compared with men.