Cardiac disease kills more women than all cancers combined. But many women believe they are most likely to die of cancer, or breast cancer alone, according to surveys.

That’s not too surprising. Women’s heart health has long been overlooked and understudied. As a result, doctors sometimes struggle to diagnose heart problems that are more common in women. Researchers aren’t clear on what causes some conditions, making them harder to prevent. And many patients don’t know that heart attack symptoms can present differently in women, or what to look out for. But despite the challenges, there’s a lot that women can do to reduce their risk.

Risk factors

Hypertension, high cholesterol, diabetes, smoking, inactivity and a family history of heart disease increase risk for both men and women. But women have to consider a longer list.

Those who have pregnancy complications such as pre-eclampsia or gestational diabetes are likelier to have heart problems later. But patients “don’t necessarily think to tell their doctor that they had a pregnancy 20 years ago that was affected by pre-eclampsia, and a lot of doctors won’t ask,” said Dr Anais Hausvater, a co-director of the Cardio-Obstetrics Program at NYU Langone Health, US.

Polycystic ovary syndrome or PCOS is also associated with higher risk of heart disease. So are lupus and rheumatoid arthritis, autoimmune diseases that are much more common in women. And women who go through menopause before age 45 are especially vulnerable.

Menopause impact

Largely because oestrogen helps protect the heart and blood vessels, women tend to develop heart disease about 10 years later than men. Menopause is the key transition — as oestrogen falls, blood pressure and cholesterol tend to increase and arteries tend to become less elastic, a surprise to many women.

“They’re like: ‘My cholesterol wasn’t that bad in my 30s. Why is it all of a sudden so bad? I’m still exercising. I’m eating the same things’,” said Dr Tala Al-Talib, the medical director of Johns Hopkins’ Green Spring Station cardiovascular clinic, US.

Your doctor can help you find the best strategy for your situation, whether it’s lifestyle changes, medication or a combination of the two. While premenopausal women’s risk is lower, it’s not zero. And the impact of high blood pressure and cholesterol is cumulative over decades, so what you do in your 20s and 30s can affect you later.

Symptoms

Doctors and patients alike frequently dismiss women’s heart attack symptoms because they don’t always present as crushing pain and pressure.

Chest pain is still the most common symptom. But many women describe it differently, as “a pressure or a heaviness, as opposed to men, who will sometimes just say ‘it hurts’,” said Dr Natalie Bello, an associate professor of cardiology at Cedars-Sinai and director of women’s cardiovascular health and cardiology at Atria Health and Research Institute, US. And women are likelier than men to have multiple symptoms, such as shortness of breath, nausea, dizziness, jaw pain, upper back pain, cold sweat or unusual fatigue. Women may be more inclined to minimise their symptoms. Those managing family obligations often “put their own health on the back burner or find other reasons to explain symptoms”, said Dr Erica Spatz, director of the Preventive Cardiovascular Health Program at the Yale School of Medicine, US.

Different causes

Heart attacks in men are typically caused by a blockage in a major artery as a result of obstructive coronary artery disease. Plaque breaks off or a blood clot forms, stopping blood from reaching the heart, which damages the heart muscle.

Many women too experience such blockages. But women also have heart attacks unrelated to that disease more frequently than men do, and they can be tricky to diagnose and require different treatment.

For example, women are likelier than men to have coronary microvascular disease, which affects small blood vessels, and they are also prone to coronary artery spasms, in which an artery periodically squeezes, said Dr Nupoor Narula, the director of the Women’s Heart Program at Weill Cornell Medicine, US. Both conditions cause heart attacks.

Women are also disproportionately susceptible to spontaneous coronary artery dissection, a tear in an artery’s wall that is especially common after childbirth. It can lead to a heart attack and its symptoms are similar. And takotsubo cardiomyopathy, or broken-heart syndrome, is a reversible form of heart failure in response to severe stress that happens mostly in postmenopausal women.

Test variety

Emergency room doctors sometimes wrongly conclude that a woman’s symptoms are unrelated to the heart because atypical heart attacks don’t always show up on standard tests. Take an ordinary angiogram, in which a provider injects dye into blood vessels and takes X-rays. It may not show artery spasms or a blocked minor blood vessel.

If you go to the ER with heart-attack-like symptoms and your angiogram is normal, it’s a good idea to see a cardiologist afterward. The doctor may recommend assessments such as a PET scan, a heart MRI or coronary function testing.

Research gaps

The history of gender bias in medical research still profoundly affects healthcare, even though women’s health research has increased in recent decades. Women have historically been underrepresented in studies of drugs, treatments and medical devices. Doctors don’t fully understand the effects of hormones on cardiovascular health or the long-term impacts of certain pregnancy complications.

Standard treatment guidelines for heart disease are based largely on decades-old studies in which few participants were women, said Dr Sonia Tolani, a co-director of the Columbia Women’s Heart Center, US.

Even medical devices are designed for men.

Attitude delay

Many women who could benefit from medications for high blood pressure and cholesterol start taking them later than they should. Sometimes, the reason is that their own doctors worry about prescribing medications to women of reproductive age.

Some of these medications are unsafe during pregnancy, but that doesn’t mean no woman of reproductive age should take them. Even for women who want children, it can be safe — with a doctor’s guidance — to stop a medication temporarily during pregnancy, Dr Spatz said.

Women also sometimes avoid discussing heart health because they fear doctors’ judgment. “I turn that back on us as the medical system,” Dr Bello said. “We need to be more accommodating of our patients and explain how we can help them.”

NYTNS