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Women’s Heart Health Presents Unique Challenges

Identifying women with coronary artery disease can be challenging for a variety of reasons. Primarily, their presentation may be much different compared to men. Rajya Malay, MD, Meritas Health Cardiology’s first female cardiologist and on staff at NKCH, encourages women to be aware of their risks and PCPs to continue to educate their female patients about cardiovascular disease.

Gender-specific Risk Factors

Women with CAD tend to present about 10 years later than men and therefore, have developed more risk factors. While men and women share many of the same risk factors, they impact each gender differently. For example, although diabetes is an important risk factor for both genders, some studies suggest diabetic women’s risk of heart disease is up to 44% higher than men’s. Hypertension has also been shown to impact women differently, with women having a higher prevalence of hypertensive heart disease and congestive heart failure.

Dr. Malay finds that often women neglect their own health while being great caregivers for family and friends. Women are also more reticent to taking blood pressure and other medications than men. “Many women tend to think that high blood pressure or elevated blood sugars do not have long term implications, but we know they do,” she said.

“Patients need to know that uncontrolled hypertension and diabetes may have no clinical signs (and therefore are referred to as silent killers), but affect their bodies at the microvascular level, putting them at higher risk for stroke, kidney, eye and heart disease.”

While lower doses of aspirin are often prescribed to men as a prophylactic for heart attack, there is no evidence of such benefit in women, especially in younger women who do not have a history of heart disease or stroke.

Post Menopause

Estrogen is hypothesized to protect women against heart disease in younger years. The decreased estrogen production after menopause might, to some degree, explain why women present with heart disease later in their lives. Although hormone replacement therapy can relieve postmenopausal symptoms, it does not offer cardiovascular protection and can even elevate a woman’s risk for heart disease.

In the International Takotsubo Registry of 1,750 patients with stress cardiomyopathy, 89.9% were postmenopausal women.

Apical 4 chamber view

Left ventricular apical ballooning - Apical 4 chamber view

Apical 2 chamber view

Left ventricular apical ballooning - Apical 2 chamber view

Apical 4 chamber view with ultrasound contrast showing

Left ventricular apical ballooning - Apical 4 chamber view
with ultrasound contrast showing

Testing and Management

Dr. Malay believes a gender gap in diagnosing CAD still exists. When assessing a female patient and her risk factors, Dr. Malay advises to, “Treat your female patients like you do your male patients; refer them to a cardiologist at the earliest stage of presentation, continue to educate them about their risk factors and the likelihood of non-traditional symptoms and schedule diagnostic testing when clinically indicated.”

She encourages PCPs to continue to aggressively ask heart health questions, keeping in mind that women typically either wait longer to report symptoms or dismiss them entirely. Probing deeper into a patient’s general health habits can increase their awareness and encourage them to communicate small, but potentially significant, changes in their health.

Poorer Prognosis

Women tend to have a lower prevalence of obstructive coronary disease on coronary angiogram but have a higher mortality because of presumably diffuse disease in smaller vessels. More women than men die after a heart attack and women tend to have more complications, such as bleeding, after invasive procedures. Moreover, some conditions, such as Takotsubo cardiomyopathy, occur in more women than men.

Ensuring patients who have had a coronary event or stroke to receive regular follow up care can prevent a reoccurrence. “Encourage patients to follow up with their cardiologist on a regular base, even if they think nothing has changed,” Dr. Malay advised. “We can pick up on changes and symptoms that the patient may not be aware of. Patients need to know that a cardiac event is unlikely to be a solitary occurance. Women are at an even higher risk for second event – even though they tend to mitigate their own risk.”

Approximately 12% of general cardiologists and less than 10% of interventionalists and electrophysiologists in the United States are female. Dr. Malay, who has been practicing for nearly 10 years, believes her gender affords her a different perspective on women’s cardiac care. “Women tend to open up to me,” she said. “My female patients connect with me not only as their physician but as a woman, wife and mother.”

Uncommon Symptoms

PCPs are the first line of defense in preventing heart disease. “Primary care physicians make a difference in identifying women with heart disease. They manage risk factors and refer appropriate patients,” Dr. Malay said.

While chest pain is still the most common symptom of a cardiac event, women can present with:

  • Shortness of breath
  • Sudden fatigue
  • Shoulder or back pain
  • Indigestion
  • Heartburn
  • Jaw pain
  • Dizziness
  • Nausea

Rajya Malay, MD

Rajya Malay, MDDr. Malay earned her medical degree at Osmania Medical College in Hyderabad, India. She completed an internal medicine residency and a cardiovascular medicine fellowship at the University of Connecticut Health Center. Dr. Malay practices invasive, non-interventional cardiovascular medicine and her areas in interest include women’s heart care, management of heart failure disease and echocardiography.