Heart Disease Heart Disease in Women Presents Differently than in Men Heart disease is the leading killer of women in the United States, with important and often overlooked physiological and clinical differences that distinguish it from the disease in men. While most risk factors for heart disease affect both genders, some more actively promote the disease in women, says Karol Watson, MD, director of the UCLA Women’s Cardiovascular Center. “As physicians, we need to be aware of the risk factors that are especially important in women and be especially aggressive in identifying and addressing them,” Dr. Watson says. In particular, metabolic risk factors, which are risk factors often linked to overweight and obesity — including insulin resistance, overweight/obesity and high triglycerides — appear to be much more harmful to women’s hearts than men’s. Traditional risk factors such as smoking, high blood pressure and high blood cholesterol can increase a woman’s risk of cardiovascular disease by at least 10-fold, notes Marcella Calfon Press, MD, PhD, co-director of the center. Studies also suggest that physical activity and healthful eating are particularly important for women. “The good news is that basic lifestyle changes can have dramatic impacts on a woman’s risk,” Dr. Calfon Press says. Studies also have indicated that mental stress, anxiety and depression play a greater role in development of heart disease in women and are more likely to contribute to worsened cardiovascular-disease outcomes. “We need to take a holistic approach to counseling women on implementing lifestyle changes that will reduce stress levels and improve mood,” says Tamara Horwich, MD, co-director. The presentation of coronary artery disease also tends to be different; a heart attack for a woman can be very different from what a man experiences. For men, “It’s like a bomb going off — you get a dramatic chest pain that sends you to your knees,” Dr. Watson says. “But for women, it tends to be more of a plaque erosion, which produces more subtle types of symptoms.” Because women’s symptoms are likely to be more atypical and vague — such as pain in the jaw, arm or neck, or simply nausea and fatigue — they are underreported and under-recognized, and consequently many women don’t receive a diagnosis that could bring them lifesaving therapies. Because of this more subtle presentation — and the fact that tests for detecting heart disease have been based on studies done in men — diagnosis in women can be more challenging, Dr. Watson says. Stress tests tend to be less accurate in women, and an angiogram also is less reliable. A standard angiogram doesn’t show the microvessels that arise from the inside of the heart, supplying about one-third of the blood flow, and microvascular dysfunction is more common in women. In men, an angiogram tends to show discrete blockages in the coronary arteries. “That’s the way we’ve traditionally thought about heart disease, but that’s really male coronary artery disease,” Dr. Horwich says. “Women tend to have more diffuse disease in their coronary arteries, as well as diseases of their smaller vessels that aren’t visible on an angiogram.” Advanced imaging techniques, including specialized PET scans and cardiac MRI, are able to detect microvascular disease, she notes. There are differences, too, in the realm of therapies. Risk, not gender, dictates the value of statin therapy, but low-dose aspirin is recommended in women only after the age of 65, according to American Heart Association guidelines. Women are more likely than men to have trouble tolerating statins and other medications, which doesn’t mean they shouldn’t receive the therapy if they are at the appropriate level of risk, but it may require adjusting doses. Traditional risk factors such as smoking, high blood pressure and high blood cholesterol can increase a woman’s risk of cardiovascular disease by at least 10-fold. “As physicians, we need to be aware of the risk factors that are especially important in women and be especially aggressive in identifying and addressing them.” 3 UCLA Physicians Update