Women''s Heart Health
According to the World Health Organization (WHO), cardiovascular diseases (CVDs) remain the No. 1 cause of death globally. WHO estimates 19.8 million people died from CVDs in 2022, 85% of those due to a heart attack or stroke. While traditional symptoms of a heart attack - chest pain, sometimes radiating to the arms, neck, jaw or back, shortness of breath, palpitations, nausea and lightheadedness - are frequently used in educational and other materials, those symptoms may not be representative of experiences for both males and females.
Females, with varying symptoms that are often undetected through surface-level testing, could be sent home by a physician with their concerns unaddressed. Or, even worse, sent home questioning the validity of those symptoms in the first place.
At Eisenhower Health, the inequity in identification, treatment and education for women and cardiovascular disease is changing. This issue’s Physicians’ Roundtable explores the nuances of female-centric care, including atypical symptoms and how to integrate that knowledge into timely, thorough patient care.
Read on to learn about the latest developments transforming women’s heart care. It’s life-saving knowledge that makes a difference between emergent and critical care.
Expert Team
- Ehete Bahiru, MD, Board Certified Cardiologist with Eisenhower Desert Cardiology Center, earned her medical degree from Stanford University School of Medicine and completed her residency in internal medicine at McGaw Medical Center of Northwestern University in Chicago. She completed a cardiology fellowship at University of California, Los Angeles David Geffen School of Medicine and completed a Master of Science in Health Policy and Management at UCLA, Fielding School of Public Health. Dr. Bahiru then completed an advanced cardiac imaging fellowship at the University of Washington in Seattle. As a non-invasive cardiologist, Dr. Bahiru specializes in imaging and preventive cardiovascular disease.
- Lisa Fontes, MSN, RN, CV-BC™, Director, Clinical Operations, Eisenhower Desert Cardiology Center, began her career in health care as a registered nurse. Working in cardiology for the last 35 years, she also has experience in primary care and family medicine
- Justin Thomas, MD, Board Certified in Pulmonary Disease, Interventional Pulmonology, Critical Care Medicine and Internal Medicine, moderated the discussion.
Dr. Thomas: Dr. Bahiru, could you begin with the definition of a heart attack?
Dr. Bahiru: The heart supplies blood to itself through the coronary arteries. A heart attack occurs when the blood supply to the heart is blocked - a range from mild or moderate blockage to severe or 100%. As far as the severity of a heart attack, if there is an acute 100% blockage, that could be a medical emergency.
Dr. Thomas: How does the blood become 100% blocked to the heart?
Dr. Bahiru: If plaque buildup in arteries accumulates and is not addressed early on with preventive measures, that plaque could become destabilized and break, essentially blocking the artery up to 100%. Patients who have a blockage of 30%, 40% or 50% are not categorized as critical; however, if the plaque destabilizes and breaks off into the artery, it could lead to a heart attack.
Dr. Thomas: Lisa, what are the typical presenting symptoms of a heart attack?
Fontes: Symptoms include chest pressure, shortness of breath and diaphoresis (sweating). Also, pain and pressure between the shoulder blades and nausea.
Dr. Thomas: What are some of the atypical symptoms that a woman may experience that men don’t typically?
Dr. Bahiru: Many female patients complain of fatigue that may not be associated with activity, which makes it difficult for physicians to pick up on or even for patients to be alarmed. Also, lightheadedness, palpitations, indigestion and back pain.
Dr. Thomas: What is it about women that creates the atypical symptoms?
Dr. Bahiru: It may be tied to physiological changes associated with estrogen, as we know estrogen does have an effect on the blood vessels and microcirculation of women. There might be cellular-level differences that could explain some of these symptoms. For instance, in women there’s a higher risk of having a heart attack without any significant blockage in the large arteries, or coronary arteries. Women have a higher incidence of a heart attack in the smaller blood vessels, which is not diagnosed as easily. The large coronary arteries will look OK on a coronary angiogram but there are signs of a heart attack based on laboratory testing. This is called a non-obstructive heart attack, which is more common in women.
Dr. Thomas: The non-obstructive heart attack is often referred to as a silent heart attack.
Dr. Bahiru: A silent heart attack typically is an event with little or no symptoms; however, a non-obstructive heart attack presents with typical or atypical symptoms and there is evidence of heart muscle damage on laboratory testing but no evidence of major blockage in the large coronary arteries because the disease process is in the small-branch vessels. There may not be obvious findings on electrocardiogram (EKG) or stress testing. There are some advanced diagnostic testing with angiograms to look for small-vessel disease, but that’s usually done in academic centers; it’s not something that’s commonly available.
Dr. Thomas: With silent heart attacks as either asymptomatic or discovered incidentally on an EKG, what’s the procedure for treatment?
Dr. Bahiru: Whenever I see a potential silent heart attack on an EKG, I proceed with getting a comprehensive history, physical exam and risk factor assessment. Usually, diagnostic testing will be ordered to look for evidence of coronary artery disease. Depending on the severity of the disease and symptoms, the patient is treated with medications or interventions.
Dr. Thomas: Do atypical symptoms translate into women being less likely to recognize a cardiac event and does that translate into worse outcomes?
Dr. Bahiru: Yes. Based on observational studies, both the patient and medical providers may not easily recognize atypical heart attack symptoms. If patients don’t recognize symptoms or dismiss them, then they tend to not seek medical care. If the symptoms have been dismissed once, the patient is less likely to come back, even if the symptoms persist. If providers are not picking up on atypical symptoms or signs of a heart attack, they are less likely to provide additional testing or a referral to cardiology promptly - potentially delaying diagnosis.
Delayed presentation and management of a heart attack is one of several factors associated with worse outcomes in women compared to men. Unfortunately, there’s a general societal misunderstanding that heart disease affects men more than women, even with campaigns from the American Heart Association and other organizations to increase awareness that heart disease is the leading cause of death among women in the United States.
Dr. Thomas: Why is it important to recognize early symptoms of a heart attack early?
Dr. Bahiru: Early-symptom recognition of a heart attack could make a big difference between surviving or not surviving the heart attack. The heart is a muscle and every minute it loses oxygen, it could lead to significant muscle damage. Once patients recognize symptoms, promptly seeking care - whether it’s talking to their physician or going to the emergency department - is going to be critical.
Dr. Thomas: Are there any barriers that exist for women in seeking prompt care?
Fontes: In general, women are busy with family as caretakers and they put themselves last. Concerns build and women won’t take the time to investigate causes with their physician.
Dr. Bahiru: Some studies have identified a higher pain threshold in women, which could lead to minimizing of symptoms. And, as discussed earlier, atypical symptoms also could lead to women not seeking prompt care.
Dr. Thomas: How many people would you say per year have a heart attack in the U.S.?
Dr. Bahiru: According to the Centers for Disease Control and Prevention, approximately 800,000 heart attacks occur every year in the United States among men and women.
Dr. Thomas: What are the risk factors that lead to a heart attack and heart disease?
Dr. Bahiru: There are non-modifiable and modifiable risk factors for patients to consider. Non-modifiable risk factors include age, genetic predispositions and gender. Modifiable risk factors are typical traditional risk factors like hypertension, hyperlipidemia (high cholesterol), diabetes, obesity, stress and smoking. Psychosocial stressors like depression have also been found to increase the risk of heart disease.
Dr. Thomas: Are there any risk factors in women that are not necessarily in men?
Dr. Bahiru: Menopause and its hormonal changes is a risk factor unique to women. Out of the traditional risk factors, stress and hypertension seem to have a bigger effect in accelerating heart disease in women compared to men.
Dr. Thomas: What are some of the preventive measures that women can take to reduce their chances of having a heart attack?
Dr. Bahiru: As far as lifestyle, it’s similar for men and women. As I mentioned earlier, know your non-modifiable and modifiable risk factors. There are patients who live a healthy lifestyle, but who are still at a high risk of heart disease because of their family history of heart disease. Understanding how that plays into heart disease progression and a potential heart attack is critical. The American Heart Association has a comprehensive recommendation on its website for a heart healthy lifestyle (see QR code) https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations. The recommendation for physical activity is moderate-intensity exercise at least three times a week for 20 minutes, getting the heart rate above where you’re not able to speak comfortably. I tell my female patients to find a physical activity they enjoy. This process is a marathon; it’s a lifelong commitment. Focusing on changing one habit at a time makes behavioral changes sustainable. A lot of times, I see my patients struggle when adjusting their diet and exercise all at once and they are less likely to stick to it long-term.
Dr. Thomas: What are the first steps in diagnosing a heart attack when a patient arrives at the hospital with typical symptoms?
Dr. Bahiru: The emergency department has a strict protocol to triage patients with signs or symptoms of a heart attack. If possible, we obtain the patient’s medical history and symptoms as we work on diagnostics, including EKG, chest X-ray and laboratory testing. If there’s evidence of a major heart attack (100% blockage is suspected based on the EKG), then the goal is to open up the artery as fast as possible. We mobilize the cardiac catheterization laboratory and the goal is to open up the artery within 90 minutes from the time the patient arrives to the emergency room. Most of the time we are able to open up the artery with a stent; however, in some cases, an emergent or urgent open-heart surgery may be necessary.
Dr. Thomas: If I suspect I’m having a heart attack at home, other than calling 911, is there anything I can do to help myself?
Dr. Bahiru: If patients have a history of coronary disease and they’ve been prescribed nitroglycerin, that’s a medication that they can take. The patient may take it every five minutes for up to three doses. Patients should call for emergency medical services if symptoms persist. Most of our patients who already have a known history of coronary disease are on baby aspirin. They’ll get a higher dose as they are en route to the emergency room or once they’re in the emergency room. I want to make sure that patients are aware that chest pain could be a heart attack or it could be something else. These are medications that could help if they are experiencing a heart attack, but if the pain is severe or not improving, they need to call 911 and get to the hospital right away so that we can do proper diagnosis and treatment.
Patients ask if they should drive themselves or have a family member pick them up. A heart attack could lead to cardiac rhythm instabilities that may cause a patient to pass out or die. And, if they’re driving themselves or they’re having family members drive them with these symptoms, it could be dangerous and may further delay care. Let the EMS handle the care and not put themselves or family members under additional stress.
Dr. Thomas: How has heart attack care changed over time?
Dr. Bahiru: With all of the technological advances in heart attack care, overall outcomes of heart attacks or the ability of patients to survive heart attacks, has tremendously improved over the last few decades. Patients are monitored closely for the first 48 hours after a heart attack because of their risk of a rhythm disturbance. We also have to evaluate for heart failure in all heart attack patients. Patients who present with delayed symptoms are especially at risk for heart failure.
Dr. Thomas: What is heart failure?
Dr. Bahiru: The heart is a pump and in order to pump blood adequately to the rest of the body, it needs its own blood supply to be healthy. If there is significant muscle damage due to a blocked artery from a heart attack, it could lead to failure of the heart to pump blood adequately to the rest of the body. We are able to evaluate potential heart muscle damage after a heart attack using an echocardiogram, which is an ultrasound of the heart.
Dr. Thomas: How does cardiac rehabilitation help patients who have a cardiac event?
Fontes: There are studies that show people who complete a cardiac program can increase their life expectancy by five years. The cardiopulmonary rehabilitation course at the Eisenhower Renker Wellness Center, which requires a physician referral, focuses on building sustainable heart-healthy habits and an individualized prescription for an initial exercise program and its progression. Education is led by professionals, including a team of nurses and registered dietitians. The program focuses on exercise, cardiovascular endurance, muscular strength and flexibility. Also, heart-healthy nutrition, including affordable and satisfying recipes, weight management, label reading and dining out. Lastly, there is a focus on a healthy mindset to decrease anxiety, stress management and smoking cessation, if needed.
Dr. Bahiru: One of the amazing things that a lot of my patients who’ve participated in the cardiac rehab program say is that they walk away with friends. It’s a support group in the community that they look forward to. There’s a lot of times within the first month of a heart attack, or especially open-heart surgery, when patients are overwhelmed and they need the extra support that is provided through cardiac rehabilitation.
Dr. Thomas: What are the medications for heart attack prevention?
Dr. Bahiru: When we talk about heart attack prevention, we focus on modifiable and non-modifiable risk factors. If patients already have evidence of coronary artery disease, we focus on stabilizing the disease process by aggressively identifying and managing their risk factors with the ultimate goal of preventing a heart attack.
Cholesterol management is key, because uncontrolled high cholesterol is one of the major risk factors for atherosclerosis (disease of the arteries with plaque and fatty material on inner walls). Statins (a group of drugs that reduce levels of fats in the blood) are our first-line therapy, but now we have multiple other therapies for patients who have statin intolerance.
Diabetes, hypertension and weight control are also critical. The availability of GLP-1 (glucagon-like peptide-1, a naturally occurring hormone that plays a role in regulating blood sugar levels and appetite) has made a tremendous difference in some of our patients for diabetes and weight management. Also, I see patients needing less blood pressure and cholesterol medications with significant weight loss. There’s a lot of benefits to weight loss, whether it’s through diet and exercise, or using the GLP-1 medications.
We also use aspirin for patients with evidence of significant coronary artery disease to prevent a heart attack; however, aspirin is no longer recommended for primary prevention in patients without evidence of coronary artery disease since the risk for bleeding outweighs the potential small benefit of preventing a heart attack.
Dr. Thomas: What do you recommend as far as lab work to look for any preventive measures?
Dr. Bahiru: Basic cardiac lab testing includes checking for high cholesterol and diabetes. As part of the cholesterol panel, a lipoprotein (a) level could also be an important marker to check for. The lipoprotein (a) is a type of low-density lipoprotein (LDL) molecule that is independently associated with an increased risk of a heart attack. About one in five patients have increased lipoprotein (a) levels and it’s genetic, so even patients who lead a healthy lifestyle may not be able to escape the risk. This is especially relevant for patients with a family history of heart disease.
Dr. Thomas: You had mentioned stress as being one of the primary factors for women. How do you counsel your patients on stress management? And are there medications that can help?
Dr. Bahiru: Stress is an inflammatory process. Your cortisol level is high when you’re stressed, and you don’t take care of yourself. Especially for my female patients, stress is one of the main factors for uncontrolled blood pressure. I encourage patients to reach out to their primary care physician and consider psychological support, whether it be medications and/or cognitive behavioral therapy. A lot of patients feel like it’s a sign of weakness to seek help. I try to emphasize that it’s not.
There’s also a lot of caretaker burden in patients, especially unique to our patient population. Patients who are in their advanced age - 70s or 80s - taking care of their family members and/or spouses. I recommend a holistic approach to manage heart disease including stress management.
Dr. Thomas: What roles do screening and primary care providers play in reducing the risk for a heart attack?
Dr. Bahiru: When patients come to us, they’re usually past the age of 50, and the disease process has already been well underway. The process of atherosclerosis could start as early as age 7 microscopically, so a lot of upstream prevention needs to happen when patients are in their 20s, 30s and 40s. The lifestyle modification needs to be honed in at an earlier age not when patients are already well into their 60s and 70s.
CT coronary calcium scoring is a very helpful tool that primary care physicians can utilize in patients with significant heart disease risk factors in addition to traditional risk scores. As a preventive cardiologist, the use of imaging-based screening of coronary artery disease has been instrumental to diagnose and stage atherosclerosis earlier, and then aggressively manage patients.
Dr. Thomas: What is the age recommended for high cholesterol screening by a primary care provider?
Dr. Bahiru: For those with significant family history, the recommendation could be to screen earlier in childhood. For the average individual, the recommendation is to start screening between ages 20 to 45. Most people are typically screened in their 30s and 40s.
Dr. Thomas: How does hormone replacement therapy relate to cardiac disease?
Dr. Bahiru: Based on guidelines so far, we don’t recommend hormone replacement therapy after a heart attack. A heart attack by itself puts a patient in the high-risk category for potential complications from hormone replacement, including a repeat heart attack, stroke or a blood-clotting issue. Based on the current evidence, there is a potential heart health benefit from hormone replacement therapy if started with the first five years of the onset of menopause, particularly in the 50 to 60 age group. The later that you start it, the less benefit as far as preventing heart disease. The theory behind it, although not very well understood, is that estrogen may have some destabilizing properties for advanced plaque. A woman who’s in her 70s already in menopause for 20 years may have advanced plaque already and starting it at that stage may lead to plaque destabilization from the estrogen and potentially lead to a heart attack.
Dr. Thomas: Are women more affected by depression or anxiety after a heart attack than men?
Dr. Bahiru: There is some observational data that in the first 30 days after a heart attack there is higher prevalence of emotional distress among women than men. Why that is, is not well understood. Maybe it has to do with, again, the caretaking nature of women and the responsibilities and anxiety involving that. Surviving a heart attack is a scary process. When a heart attack is in process, patients are rushed to the emergency room. A lot of the decisions are being made quickly and patients may feel like they are not in control. The loss of control affects patients after a heart attack. Based on my observation, I tend to see my female patients feeling more vulnerable and struggling emotionally more than my male patients, especially after a major heart attack. I use it as an educational tool to emphasize to my patients the importance of prevention.
Dr. Thomas: How can prevention strategies could be better targeted toward women?
Dr. Bahiru: From the patient side, education is going to be critical. Heart disease is the No. 1 killer in women, too, not just men. Education that women could present later in life with atypical symptoms and should seek care and advocate for themselves. If they’re feeling like they’re being dismissed, they need to persist. From the provider side is, again, education. Understanding the nuances between men and women and how to close that gender gap in care.
Dr. Thomas: Looking ahead, what will change in cardiac disease care?
Fontes: Eisenhower Desert Cardiology Center is in the final stages of incorporating an AI-based software into our practice to improve cardiovascular disease diagnosis and outcomes. The platform allows for early detection of heart failure with preserved ejection fraction (the percentage of blood the left ventricle pumps out with each beat), and cardiac amyloidosis (protein buildup in the heart muscle), catching it in the beginning stages so that patients can receive life-saving measures early. An echocardiogram is ordered by a cardiologist, and performed by a sonographer. If applicable, the echo study will be sent to a cloud for analysis. Those images will be processed, and sent to the physician for review. The entire process is completed with approximately 20 minutes turnaround time.
To learn more about the services at Eisenhower Desert Cardiology Center, visit EisenhowerHealth.org/DesertCard.
