Physicians Roundtable: Gender Matters - Women and Heart Disease

CARDIOVASCULAR DISEASE REMAINS THE LEADING CAUSE OF DEATH IN WOMEN. According to United States statistics, 398,086 female deaths occurred in 2013 from cardiovascular disease. As noted in a 2016 study, Cardiovascular Disease in Women: Clinical Perspectives, although there have been, “dramatic declines in heart disease mortality for both men and women in the past three decades…recent data suggest stagnation in the improvements in incidence and mortality of coronary heart disease, specifically among younger women.” Also, “women are less likely to receive preventive treatment or guidance, such as lipid-lowering therapy, aspirin and therapeutic lifestyle changes, than are men at similar atherosclerotic cardiovascular disease risk. When medications are prescribed, treatment is less likely to be aggressive or to achieve optimal effects. Also, cardiac rehabilitation is underused with women 55 percent less likely to participate than men…partly as a result of lack of referral by their treating physician.”

In 2017, the Journal of the American College of Cardiology released a study of women and heart disease which was conducted to explore opportunities to improve awareness of cardiovascular disease in women. The results indicated that 45 percent of all women surveyed were unaware of cardiovascular disease as the leading cause of death for women and 71 percent of women in the study said their heart health wasn’t even mentioned during their visit with their physician. The study found that both physicians and patients put insufficient emphasis on cardiovascular disease, and the stigma of the disease and body weight prevent women from seeking treatment. In this Physicians Roundtable, experts discuss women and heart disease. The discussion includes Board Certified Cardiologists Leon Feldman, MD, James Fitts, MD, and Eric Sontz, MD. The panel was moderated by Board Certified Cardiologist Philip Shaver, MD.

"I think it raises this queswtion - can you die of a broken heart?" - Philip Shaver, MD
]Dr. Shaver: Between 45 and 64 years of age, one in nine women develops symptoms of some form of cardiovascular disease. after 65 years of age this ratio climbs to one in three. Usually, the women present 10 years older than men. They catch up after 55 years of age with risk.

Our risk estimate tools often underestimate the risk in women. I am interested in the thoughts of my colleagues in seeing just how many diseases actually are more prevalent in women than men that involve the cardiovascular system. For instance, we see predominantly in women a condition known by several names — stress-induced cardiomyopathy, broken heart syndrome or takotsubo syndrome [characterized by ballooning of the left ventricle]. Patients present like they’re having an acute heart attack. We take them to the catheterization lab and do an angiogram [an X-ray procedure to evaluate blockages in the arterial system] and they have normal coronaries. Dr. Feldman, what’s your experience with this entity?

Dr. Feldman: We see it all the time. I suspect I may have seen it in a patient last night who is struggling with advanced metastatic renal cell carcinoma and came in with what was appearing like an acute heart attack.

Dr. Sontz: I think the data says 80 to 90 percent of those diagnosed with Takotsubo syndrome are women. I actually saw a woman today with it.

Dr. Shaver: The syndrome refers to an octopus-catching trap in Japan called the tako-tsubo [when stressful events cause the heart to balloon and distort, it can resemble this traditional Japanese fishing trap . Dr. FITTS: In the past 10 years I can’t think of one male that I’ve seen with this condition. In terms of differences between men and women with cardiac diseases, this syndrome is probably number one where there’s a high prevalence in women and not in men.Dr. Shaver: I think it raises this question — can you die of a broken heart? at least half of these patients have had some kind of occurrence preceding the event that’s been stressful.Dr. Sontz: In the case I had today, the patient’s daughter-in-law died suddenly three months ago, so I think it has a lot to do with stress.Dr. Fitts: There is probably a genetic explanation. It wouldn't’t surprise me if there’s a similar set of genes related to these conditions but I don’t think there is a known mechanism right now.Dr. Shaver: We are also seeing more heart failure with preserved ejection fraction [congestive heart failure where the heart contracts normally but is stiff and relaxes poorly]. It has been termed, "a disease of grandmothers." Forty years ago, we thought if your heart contracted normally you couldn’t have heart failure because we thought all heart failure was due to the pump. In order for your heart to pump it has to fill, and it has to fill at a normal pressure. We now realize this is as prevalent as heart failure with someone who has a diminished pump function.Dr. Feldman: This heart failure preserved ejection fraction phenomenon is certainly a condition of advanced age, and women are more likely to get to an advanced age than men. It’s quite possible that the higher prevalence that we see may reflect the fact that more women live long enough to get this disorder and men will die younger.I think the challenge that comes up with heart failure preserved ejection fraction is that our therapies are limited. It’s been a particularly hard disorder to treat. Mostly we treat symptomatically — when people get short of breath we give them medications to relieve the extra fluid in their body and that’s about all we’ve had to offer them. Then we see deterioration and frequent hospitalizations. We’re starting to find that closer monitoring of these patients can lead to less hospitalization and overall better quality of life and maybe even a longer life. There are tools that we’re coming up with now — one of which is an in-dwelling pressure monitor that can offer patients the ability to see what the pressure in their body is and be able to treat that effectively, perhaps even extend their quality of life and length of life with them.Dr. Shaver: You’re referring to the CardiomemS™ hF system?Dr. Feldman: Yes.Dr. Shaver: You also deal with atrial fibrillation and thromboembolism [formation of a blood clot that breaks loose and travels by the blood stream to plug another vessel]. Studies have demonstrated that women are at a higher risk than men for stroke in the setting of atrial fibrillation. has that been your experience?Dr. Feldman: One of the risk factors for strokes in atrial fibrillation which has not yet been fully clarified is gender. Women are at higher risk for having strokes when atrial fibrillation occurs and we don’t have a clear understanding of why that is, but it raises my expectation to start anticoagulation on women sooner than in men because they already have one risk point coming into me the first time they have atrial fibrillation.Dr. Shaver: That risk point being female gender?Dr. Feldman: Yes, and adding in any other risk factors such as being over age 65 or having hypertension and diabetes. I would have the patient start on anticoagulation to prevent blood clot, particularly the worst effect which would be a stroke.Dr. Shaver: Something that is very specific to women is if they’ve had breast cancer and gotten chemotherapy or radiation — we’re now seeing some cardiac problems from this prior treatment. although these drugs and radiation therapy have improved a great deal over the years, it may be associated with future cardiac problems. When a woman has had radiation, especially to the left breast, I’m immediately on alert. Could there be something in the valves, the arteries, even the heart muscle itself that has been damaged from that therapy? The sac around the heart, for example, the pericardium, may also be involved.

"What I've been doing for people who are at intermediate risk is a coronary calcium score...a very low radiation CT scan of the chest." - Eric Sontz, MD
Dr. Sontz: Yes. Either the chemotherapy induces cardiomyopathy [chronic disease of the heart muscle] — either diastolic dysfunction or reduced ejection fraction — or radiation can hurt the heart valves or accelerate atherosclerosis in coronary arteries. These women need to be followed up fairly closely and watched.Dr. Shaver: I’d like to discuss the difference between sex and gender. Sex is basically what your chromosomes give you. But gender is a social construct and men and women are often socially very different individuals. I think cultural norms, values, perceptions, social characteristics and behaviors are different in women than men. Years ago, Dr. Bernadine Healy called it the Yentl syndrome — if a woman presents with typical symptoms like a man, she is treated similarly to a man, but if they are atypical symptoms, she isn’t. I recall in the early part of my career, that if we saw a young woman with chest pain, even if it was typical, she was considered to have a fairly low-risk for having real coronary disease. We thought if the stress test was positive, it was probably a false-positive.Dr. Feldman: One of the ways where gender may be more powerful than sex difference is in the presentation of syncope.Dr. Shaver: Fainting?Dr. Feldman: Yes. For example, we can go back to the old stereotype where the Beatles would show up and then women would faint, or they’d see Elvis and faint. Women developed a reputation for fainting, also known as vasovagal syncope, where there is actually lowering of the blood pressure and the heart rate is lowering — it really is a true medical condition.And it was more socially acceptable for women to faint than for men to faint. But it turns out that men faint at about the same rate as women. It’s just that men wouldn’t see a doctor for fainting but women would. It’s interesting that there are certain disorders that are more socially acceptable for women to have than men, and I guess it works in both directions.Dr. Sontz: In terms of angina [severe chest pain], in terms of how women and men present, they both typically present with chest pain, although some don’t. It’s been documented that women probably present a little less typically but for the most part, they also present with symptoms of chest pain. They may also have more shoulder pain, neck pain, shortness of breath and nausea but the most common symptom for women is chest pain — described as a tightness or pressure.Dr. Shaver: heart disease is the number one killer of women, more than all cancers combined. But early studies didn’t reflect women. There was the Multiple risk Factor Intervention Trial published in 1982. It had 12,866 subjects — all men, not a single woman. The Physician’s health Study in 1995 had 22,071 subjects — all men, not a single woman.A lot of our data on risk with heart disease, coronary disease specifically, date to these two studies. Many doctors thought women were like men but with slightly smaller hearts, slightly smaller arteries. Some physicians said we shouldn’t be as aggressive because we didn’t have as many tools, and I think we were reluctant to treat women more aggressively. Based on that, I think their care has suffered. What are your thoughts, Dr. Fitts?Dr. Fitts: I think there was a time when there was a lack of access or delayed presentation but I’m not seeing that as much anymore. In my experience with all the high-tech tools that are out there for interventions in cardiology, I think that women are being treated with good care.I was involved in research as a cardiology fellow at Dartmouth. I presented a poster on the differences in women and men with heart attacks in the 1990s and the earlier 2000s, and there weren’t really any differences in door-to-balloon time and things that we measure in terms of how aggressively someone gets care. But there were differences in complications after stents were put in. Women had higher vascular complications, they had higher bleeding rates, and that was with control for size and age, and they still had higher bleeding rates and higher complication after the procedures. So, there were some notable differences but I’m not sure that was related to care.Dr. Sontz: I think that perceptions have changed a bit. However, the data shows there is still a difference between the way women and men are treated, perhaps delayed presentation, and women’s symptoms may be discounted more often. Certainly in the past, this was the case and now, not as much. We’re still not as aggressive as we should be with taking women to the catheterization lab. There’s some disparity in women’s symptoms that still are discounted, even by women themselves. Fortunately, there is a greater awareness with the American Heart Association’s® Go Red for Women® campaign. I think things are changing and improving.Dr. Shaver: Go red for Women launched in 2004 and in fact it has a very good website: There are a number of initiatives that have been in place since about 1990. Women are being incorporated in the studies now, so researchers are not just extrapolating data from male studies to females.Let’s talk about aspirin and heart disease prevention. For years, we followed the theory that if aspirin works for men, it must work for women. however, the Women’s health Study, comprised of 40,000 healthy women, discovered aspirin doesn’t always work for women. It didn’t work across the board, but it did appear to benefit older women.I’d like to clarify the difference between primary prevention and secondary prevention. Secondary prevention means you already have the disease, and if you have coronary disease, you need aspirin unless there’s a contraindication [an indication where it should not be used]. But, we’re talking about preventing heart disease — and based on current studies, aspirin is probably better for stroke prevention in women and heart attacks in men. However, the United States Task Preventive Services Force made their recommendations recently, and it is without reference to gender. They do a risk score, and if someone has a 10 percent, 10-year risk — a low risk of bleeding and expected to live 10 years — then aspirin at a low dose makes sense, gender independent.There’s very firm data that aspirin is appropriate also in prophylaxis for colon cancer. I like the idea of taking a low dose aspirin for that. But I don’t think a lot of women understand that the data for preventing heart disease is not as firm as it is in men. I get this question very frequently, "Should I be on an aspirin, doctor?" How do you answer that?Dr. Sontz: If you look at the Women’s Health Study, these were young women, 40,000 total, over the age of 45. How much benefit would they get taking aspirin? But they did have the benefit in stroke reductions by 17 percent. That’s important to think about. Overall, they had a reduction in ischemic heart disease.Dr. Shaver: Did that include older women?Dr. Sontz: No, overall they only had a nine percent reduction which wasn’t significant. But over the age of 65, it was significant. I think there’s no question that women over the age of 65 should be getting a baby aspirin for primary prevention [of coronary disease].Dr. Fitts: In cardiology we’re seeing a selection bias when it comes to patients. We’re seeing higher risk patients as soon as they walk in the door. There are always exceptions to that but most of the time, if a primary care physician is concerned about a patient enough to send them to a cardiologist, there’s more risk involved. And post-menopausal women who have significant risk factors for coronary disease should be taking a baby aspirin every day unless there is a contraindication.
"Women are at higher risk for having strokes when atrial fibrillation occurs and we don't have a clear understanding of why thatis..."Leon Feldman, MD
Dr. Feldman: While aspirin may help prevent strokes in women, it does not help prevent strokes in women or men with atrial fibrillation. Aspirin is not effective therapy for stroke prevention in atrial fibrillation — that has to be done with an anticoagulant.Dr. Shaver: One thing that’s a non-traditional risk factor is if a woman had hypertension during pregnancy — gestational diabetes — she will have an increased risk of long-term cardiovascular disease. I wonder how many cardiologists really do a pregnancy history when a 60-year-old patient comes in to be treated for hypertension or high cholesterol — how often do we actually take that history?Dr. Sontz: As cardiologists, we are always assessing what the risk is, and we plug it into our risk calculators. That may sway us one way or another. But what I’ve been doing for people who are at intermediate risk is a coronary calcium score. It’s a CT scan, a very low radiation CT scan of the chest. It shows the density of arteries and if there’s calcium, it’s reported in something called Hounsfield units. That really helps to risk stratify these patients, and I think it makes a lot more sense to do it that way. When we see atherosclerosis, we can diagnose the disease and try to prevent it from getting worse.Dr. Shaver: To explain that a bit, it can be calculated as a score. Some people actually may have zero and that’s quite favorable prognostically. I’ve had people with zero calcium scores, and I can count on one hand who among them have had heart attacks. We think that in women, maybe more than men, rather than plaque rupturing, sometimes, it erodes. It goes downstream and blocks an artery in very high cholesterol patients.Dr. Feldman: The point that has to be made, though, in addition to that, is that if you are diagnosed with gestational diabetes, or hypertension in pregnancy, that you probably need to be screened post-pregnancy, perhaps even more carefully than you otherwise would be. That isn’t just a benign disorder that disappears when the pregnancy comes to completion. You might say, now I’ll look for high blood sugar, or high blood pressure, in their 30s, 40s, and 50s, and not wait until later in life to screen those more thoroughly.Dr. Sontz: Another big factor is women who get pregnant and don’t lose their pregnancy weight after a year. Those women also are at high risk for developing cardiovascular disease.Dr. Shaver: If we’re talking about women in their 30s and 40s with these risk factors, unfortunately, they can be developing plaque, and maybe at that age you wouldn’t see a lot of calcium in their arteries. It’s the soft plaque that ruptures in the bloodstream and causes heart attacks. If you really calcify plaque and make it fibrotic, maybe it’ll never rupture. Calcified plaque raises my suspicion and I talk to the patient about taking a statin.It seems like there’s always someone telling patients statins are bad for them. Statins actually do increase the blood sugar slightly and the risk of progressing to diabetes. This is most common in patients who are at most risk of developing diabetes. When you look at the recommendations of the american Diabetes association®, they are very firm that people with diabetes should take a statin — as well as people who already are on their way to diabetes. They’re overweight, they may have some element of hypertension, they fall into this dysmetabolic syndrome [having several metabolic abnormalities], and then they take a statin and their glucose moves up a few points — now they move into diabetic range and that concerns them a great deal.I try to assuage those fears and say, "You’re already at risk, you already have a number of risk factors and a statin should reduce your risk of developing heart disease." It is important to stress lifestyle modifications such as weight loss and diet to these patients.Dr. Sontz: You’re right. Eighty percent of the people who develop diabetes while on statins had glucose intolerance to begin with. They’re on their way to getting diabetes anyway and they need to be protected with the statin.Dr. Feldman: This class of drugs has probably saved millions of lives. No one says, "I didn’t have a heart attack because I’m taking a statin drug." Instead, they focus on aches and pains, thinking it must be the statin and the toxin misattributed. So, the statin drugs have gotten a bad rap. They’re not appreciated for the great success that they’ve had in keeping people healthy.Dr. FItts: There’s no question statins have changed the face of cardiology.Dr. Shaver: Coronary disease is still the biggest killer of women, and we know that sometimes when women show up in emergency rooms after heart damage that they’ve been told, "oh it’s not your heart, you’re a woman, so it can’t be." We’re still seeing this theme that women’s symptoms are often downplayed. they may even have been told to come to the hospital by taxi or private vehicle, rather than calling 9-1-1, since they’re women.There have been some papers published, including a study from 2005 that showed that high risk women with acute coronary syndrome had the benefit of angiography, angioplasty or bypass surgery less often.Women may have atypical symptoms, but they may not. I recently saw a woman whose pain was all in her neck and jaw and nothing in her chest. There are a number of symptoms, but the problem is that some of them are so non-specific, such as shortness of breath or nausea or sweating or fatigue. Could you imagine if we did a stress test on everyone who said they were fatigued? That’s one of the major complaints from my older patients.A physician has to take into account the risk factors and the patient’s history, and experience is sometimes a great teacher.Dr. Feldman, have you seen this?Dr. Feldman: I actually see it fairly frequently. It brings to mind an example of a woman who had undergone several angiograms and had been reassured that it wasn’t her heart but there was no explanation of what was causing her symptoms. I finally started her on a medication called Ranexa® as a trial and for the first time in a great many months, she had relief and went on with that therapy for the indefinite future. It was very gratifying to see her get relief and for her to actually have a diagnosis and to know that her syndrome was real.Dr. Shaver: let’s discuss hormone replacement therapy and heart disease. These hormones don’t prevent heart disease. The herS trial, the women’s health initiative, came out and failed to demonstrate protection. In 2016, the elIte trial came out in the New England Journal of Medicine and it said in early post-menopausal women, it seemed to be protective. Then the editorial of the New England Journal of Medicine said no, we should follow the same guidelines. I’m interested to know if a postmenopausal woman comes to see you and she’s recently postmenopausal, do you treat her differently, based on what you know from recent studies?Dr. Sontz: I don’t start them on hormone therapy, but I think the data suggests that if you treat them earlier with hormone therapy, postmenopausal within six years, they may do better in the long run. If you treat them after ten years, then, no.Dr. Shaver: But our governing body says these drugs should not be used to prevent ischemic heart disease in women.Dr. Sontz: I think that the data is always changing a bit, and it may be a bit blown out of proportion in terms of the risk of taking it. If somebody has a lot of symptoms related to postmenopausal symptoms, it’s not unreasonable to treat them with hormone therapy.Dr. Shaver: Absolutely. That is the indication for postmenopausal symptoms. We have data that says that early on, it is protective. But we have these guidelines. Now, in the editorial, they make the point that it was a surrogate that they were looking at. They were looking at thickening of the carotid intima media lining, which is a surrogate for development. But no one can show outcomes, and that seems to be the only way anyone will say these drugs are protective.Dr. Sontz: That’s right. But the coronary calcium did not improve in any way. I think that if it helps someone when they take it early after menopause, the benefit is going to be minimal. Any time a woman takes hormone therapy, there’s always the risk of blood clot, pulmonary embolism. I don’t think it’s going to be a big cardiovascular benefit in the future.
"...there's a clear difference between men and women...we need to create awareness for our patients, our readers and the physicians taking care of the patients that there are differences."James Fitts, MD
Dr. Fitts: A lot of my research, and my PhD work, were in endocrinology. It’s not so simple as to just replace a hormone and think it’s all going to be better. I think that’s what we’re seeing in the postmenopausal population. The hope was to give estrogen and have it solve everything, but clearly that’s not the case. The other evidence with that is birth control pills have led to some strokes in young women. It’s hard to get it right when it comes to replacing hormones — it’s not as easy as it seems.

Dr. Shaver: When a woman comes to see you who is not having hot flashes, and who went through menopause six months ago, asks, “Should I take hormone replacement therapy to prevent heart disease?” What do you tell them?

Dr. FItts: There’s no literature, at least to my knowledge, that really supports treating a women with hormone replacement therapy to prevent heart attacks.

Dr. Feldman:My perspective is that this is a very charged issue. If this was a strong useful therapy for prevention of heart disease, you wouldn’t have so much conflicting data. The fact that we’re still trying to tease apart some subtle differences shows that this is really not a therapy for prevention of heart disease. That’s my perspective. We have better therapy for prevention of coronary artery disease, including the statin drugs, good diet and exercise, maintaining weight, treating your blood sugars, and all the things that are way more powerful than whether you should replace estrogen or not.

If you replace estrogen, it’s on the basis of quality of life and symptom improvement. As a cardiology community here in the valley, I think that’s the way we practice. As we speak to our colleagues, both within the group and without, it does not come up as a major issue as to whether we should be treating our patients with hormones or not.

Dr. Shaver: I think it’s important that we keep talking to our patients, having a discussion with them, and reminding them that ischemic heart disease, coronary disease, is a leading killer of women. We have to have these discussions. less than half of our colleagues in cardiology and almost 80 percent of primary care doctors are uncomfortable with the guidelines and knowing what exactly to tell our patients.

Dr. Sontz: For every one of the risk factors — smoking, diabetes, being overweight — women are actually more at risk than men for all of those problems. They have a higher risk of having heart disease and heart attacks because of those risks. For women in particular, these are really important issues.

Dr. Shaver: Heart disease is the leading killer of women. I think everyone knows that now. Cardiologists certainly have to have the discussion with patients and teach our primary care physicians how important this is for lectures and consults and not to downplay this among women.

There is still a prejudice that if a woman presents with certain symptoms, it’s probably not her heart. I would say, take a good history, look at the risk factors, and realize that it probably is her heart — prove that it isn’t. When we see a 55-year-old man with chest pain, we say, “I bet that’s his heart,” because we’ve been trained to think that way. Maybe we should turn that around and regard women in the same way.

Dr. Fitts: I think we talked about a few cardiac conditions today where there’s a clear difference between women and men. There are also differences in symptoms and we need to create awareness for patients, our readers and the physicians taking care of the patients that there are differences.

Dr. Feldman: Over the last few years, I’m finally seeing that there’s a higher representation of women in studies for both the newer agents and implants that we’re doing. It’s refreshing to see that they are looking at women to see whether they have the same risk and benefits as men with the tools that we have.

For more information, or to find a cardiologist with Eisenhower Desert Cardiology Center, call 760.346.0642.