Women and heart disease

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in North America.(1) Five times as many women die from heart disease as they do from breast cancer. However, women are often unaware of their risks and how CVD can differ from men in both symptom presentation and location of disease in the heart vessels. Women are also under-represented in the research that is used for the development of diagnostic and clinical management guidelines.(2) These factors have led to delays in obtaining accurate diagnosis and appropriate evidence-based clinical management for women presenting with symptoms of ischemic heart disease. 

Signs and symptoms of a heart attack in women
Many of us are aware of the signs and symptoms of a heart attack (also known as a myocardial infarction or MI). These include chest pain (described as squeezing pressure or heaviness) that can radiate to the jaw, arms, abdomen or back. Symptoms can also include shortness of breath and/or heart palpitations. 

Though women often do present with chest pain, many women describe this experience differently than these classic symptoms, such as dullness, discomfort or burning, rather than overt pain. Women can also present with symptoms that may seem vague and don’t necessarily point to a cardiovascular origin.(1) 

Women’s symptoms of an MI can include:(1) 

• Extreme fatigue 
• Shortness of breath with, or with without, chest pain 
• Light-headedness 
• Cold-sweats 
• Nausea and vomiting 
• Indigestion and/or heartburn

Why do these symptoms present so differently?
The heart muscle requires a continuous supply of oxygenated blood via the coronary arteries. Ischemic heart disease (IHD) occurs when there is inadequate blood flow to the heart either from plaque obstruction in the coronary arteries (atherosclerosis), spontaneous plaque rupture, or other causes of microvascular dysfunction.(3) Women have less anatomical obstructive coronary artery disease (CAD) than men, and more often present with other causes of IHD. 

Historically, heart disease was synonymous with obstructive CAD. This involves a build-up of plaque in the coronaries, which can, over time, lead to ischemia and/or a complete obstruction of blood flow causing a MI. 

However, recent evidence has shown that this obstructive CAD is less common than other forms of ischemic heart disease and more than half of women with ischemia presented with no obstructive CAD. (4,5) Women are more likely to have disease in the smaller vessels of the heart (6) (microvasculature) that branch out from the main coronaries. This different physiology can present instead as plaque erosion, coronary microvascular dysfunction, coronary vasopasm, microbemboli, or spontaneous coronary artery dissection (SCAD; 90 percent of all SCAD cases are women).(7) These differences pose challenges in obtaining the correct choice of imaging and diagnostic studies for an accurate diagnosis and origin of ischemic disease. 

Another physiological difference between men and women is the hormonal changes throughout life during pregnancy and/or menopause. Due to estrogen’s cardiovascular-protective effects, the decline in estrogen during menopause increases the risk of cardiovascular disease. Women are encouraged to speak with their health care provider about the safety and options for hormone replacement therapy, including bioidentical hormones. 

Understanding the risk factors
“Ninety percent of Canadians have at least one risk factor for cardiovascular disease,” says Dr. Sonia Anand, MD, a Professor of Medicine at McMaster University and a researcher at the Heart and Stroke Foundation.(8) This highlights the importance of educating both ourselves as healthcare practitioners, as well as our patients about these known risk factors so CVD onset or progression can be limited.  The most common modifiable risk factors of heart disease include:(6) 

• Hypertension 
• Diabetes 
• Physical inactivity 
• Smoking 
• Obesity 
• Mental health inlcuding depression and anxiety

Naturopathic doctors have the unique ability to spend more time with their patients and focus on prevention and management of potential risk factors. 

Prevention, management and ongoing empowerment
Jennifer Mieres, M.D., a cardiologist and professor of cardiology and population health in New York, noted that “eighty percent of heart disease is preventable.”(9) Ongoing education and inclusion in research is important so women are able to recognize the symptoms as well as when to seek appropriate medical attention. 

Though the inclusion of women in research has come a long way, there is still an under representation of women in research trials important for the creation of guidelines for CVD diagnosis and management. Two thirds of the clinical research on heart disease and stroke use male subjects.(10) In 2018, Heart & Stroke began investing in the inclusion of women in heart and brain research, and have since seen great results. For more information, visit The Heart and Stroke Foundation website. 

Another important aspect of prevention and management is the inclusion of women in cardiac rehabilitation programs, where only half of women are likely to attend compared to men. These programs are offered to individuals for either primary prevention of heart disease (in the presence of risk factors) or recovery from and management of disease. Included is a visit with a cardiologist for screening and risk stratification, ongoing support from nurses, dietitians and four months of supervised exercise rehabilitation classes with qualified exercise professionals. They are paramount for education, restoring cardiovascular function, improving quality of life and prevention of a second event. 

Naturopathic medicine can play a role as well. In addition to a thorough assessment, pertinent physical exams and diagnostic testing, naturopathic doctors provide guidance for the following lifestyle factors to reduce any existing risk factors: 

• Nutrient-dense food
• Physical activity 
• Quality sleep 
• Stress management and nourishing relationships 
• Smoking and other substance cessation

These lifestyle factors, or “pillars of health,” are vital for helping individuals build a resilient foundation for prevention and management of illness, including CVD. 

An individualized approach with the patient’s medical care team can help target and support these areas. This approach can also ensure women are aware of the signs and symptoms of ischemic heart disease and feel empowered to seek proper medical care. 

REFERENCES:

1. (2020), Heart and Stroke Foundation of Canada. 
2. Chrysohoou, C., et al. (2020). Cardiovascular Disease in Women: Executive Summary of the Expert Panel Statement of Women in Cardiology of the Hellenic Cardiological Society. Hellenic journal of cardiology : HJC = Hellenike kardiologike epitheorese, S1109-9666(20)30215-3. Advance online publication.
3. Taqueti V. R. (2018). Sex Differences in the Coronary System. Advances in experimental medicine and
   biology, 1065, 257–278. https://doi.org/10.1007/978-3-319-77932-4_17
4. Mehta, P. K., Bess, C., Elias-Smale, S., Vaccarino, V., Quyyumi, A., Pepine, C. J., & Bairey Merz, C. N.
   (2019). Gender in Cardiovascular Medicine: Chest Pain and Coronary Artery Disease. European Heart Journal. 0, 1– 8. doi:10.1093 
5. Shaw, L. Bugiardini, R. and Merz, C.N.B. (2009). Women and Ischemic Heart Disease: Evolving Knowledge. Journal of the American College of Cardiology. 54 (17) 1561-1575. 
6. Brewer, L.C. Svatikova, A., & Mulvagh, S.L. (2015). The Challenges of Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women. Cardiovascular Drugs and Therapy, 29(4), 355-368.
7. Saw, J., et al.(2019). Canadian spontaneous coronary artery dissection cohort study: in-hospital and 30-day outcomes. European Heart Journal, 40(15), 1188-1197.
8. McMaster University. (2019). Simple cardiac risk score can predict problems with blood flow in the
   brain. ScienceDaily; Anand, S. et al. (2019). Cardiovascular risk scoring and magnetic resonance imaging detected subclinical cerebrovascular disease. European Heart Journal. 
9. (2015). Angina in Women Can Be Different Than Men. American Heart Association.
10. (2020). A Fighting Chance, 2020 Spotlight on Women. Heart and Stroke Foundation of Canada.

Dr. Whitney Baxter is a naturopathic doctor in Victoria, BC. Prior to becoming a naturopathic doctor, she worked as an exercise physiologist in cardiac rehab. It was here that she witnessed the value of a holistic approach to health care and understood that each individual’s physical, mental, and emotional health are interconnected. She has a general practice and enjoys working with mental wellness, digestive health and cardiovascular disease management and prevention.