Women and Heart Disease – Part 2

In the second of two blogs, Enable Law lawyerLaurence Vick looks at medical risk factors in women’s heart medicine, and how they support accusations of a gender bias.

 In my last blog I showed how, compared to men, women are less likely to be believed when they’re having a heart attack, less well-treated during and after a heart attack and more likely to die from one.

In this blog I would like to describe specific medical conditions which place women at a higher risk of heart complications.

NSTEMI

Women who had a NSTEMI (Non-ST-elevation myocardial infarction – a form of heart attack) are 34% less likely than men to receive timely coronary angiography within 72 hours of their first symptoms.

Coronary angiography uses dye to reveal narrowing and blockages in arteries and is a crucial step in heart attack care. Research shows patients who receive early angiography for NSTEMI have better outcomes. Women were less likely to be prescribed statins and beta blockers when leaving hospital – medication which helps to lower the risk of a second heart attack.

Women who had a STEMI, a heart attack where the coronary artery is completely blocked, were less likely than men to receive emergency procedures including drugs and stents to restore blood flow to the heart.

In a 2016 study “Impact of initial hospital diagnosis on mortality for acute myocardial infarction”, a team at the University of Leeds headed by Professor Chris Gale considered the difference in survival rate that early diagnosis of STEMI or NSTEMI can make. Their research found that women who suffer a heart attack are 50% less likely than men to be correctly diagnosed.

SCAD

SCAD (Spontaneous Coronary Artery Dissection) is a rare emergency cardiac condition which predominantly affects women in late pregnancy or soon after giving birth. Although SCAD causes a small percentage of heart attacks overall it is the most common cause of heart attack in women under 50.

It is a good example of the challenge of arriving at a correct diagnosis by traditional techniques, because a woman may suffer a SCAD heart attack without any heart arteries being blocked. Instead, an artery of the heart suddenly closes upon itself.

Women may appear healthy and have no obvious risk factors. SCAD can only be diagnosed with an angiogram demonstrating blood flow in the heart’s blood supply. There is a risk that SCAD patients can be discharged from hospital in the middle of a heart attack that may remain undiscovered for days. Further, SCAD is often misdiagnosed, leading to treatment which can cause more damage to the affected artery.

BeatSCAD is a UK charity doing an excellent job of raising awareness of the condition and working with the BHF and the research team at Leicester University, Glenfield Hospital.

Heart Failure

A 2019 University of Oxford study found GPs were 9% more likely to miss the signs of heart failure in women.

The symptoms of heart failure don’t vary between the sexes, but the causes do.

In men, the most common cause is heart disease or having had a heart attack. In women, the chief cause is uncontrolled high blood pressure which, over the years, puts a strain on the heart. The extent of the underdiagnoses of heart failure was observed to be so great – especially among women – that the true figure affected could run into the millions.

AN AAA

A 2013 study showed women have long been under-represented in clinical trials for treatments to a condition which has worse outcomes for them.

Abdominal aortic aneurysms (AAAs) are a bulge or swelling in the main blood vessel that runs from the heart down through the chest and abdomen. AAAs are more likely to rupture in women, and women over 65 who develop an AAA face a higher risk of death. Women’s outcomes following surgical procedures for AAA are also reported to be significantly worse when compared to men.

Maternal health implications

Issues arising in pregnancy which have heart-related risk factors include:

• gestational diabetes
• persistent high blood pressure and pre-eclampsia
• pre-term delivery
• polycystic ovarian syndrome

Maternal heart disease has emerged as a major threat to safe motherhood and women’s long-term heart health. In the US disease and dysfunction of the heart and vascular system is now the leading cause of death in pregnant women and women after childbirth – accounting for around a quarter of pregnancy-related deaths. The figure for the UK is around half of that.

Diabetes

Type 2 diabetes increases the risk of heart disease in everyone with the condition but, it is thought, more so in women. Women with diabetes frequently have added risk factors such as obesity, high blood pressure and high cholesterol.

US studies show that although women tend to develop cardiovascular disease around ten years later than men, diabetes removes that advantage. In women who have already had a heart attack, diabetes can double the risk of suffering a second heart attack and increases the risk for heart failure.

Type 1 diabetes is associated with a 47% excess relative risk of heart failure in women compared to men. For women with Type 2 diabetes the excess risk is 9% higher. Around four million people in Britain are living with diabetes, with the majority (92%) suffering from Type 2. Around 44% of all cases are women.

Cancer Treatments

The chemotherapy used to treat breast cancer may increase the risk of cardiovascular disease which remains a lasting threat for breast cancer survivors. Heart problems can appear more than five years after treatment.

In The Sports Arena

Historically female athletes have also been under-represented in the research relevant to sports cardiology but in recent years studies have been carried out into gender differences as an important biological variable. Heart conditions including Athlete’s Heart in women can present in a very different way from men. This is reflected in guidelines for the interpretation of ECGs. I will be covering cardiac testing in sport and the medico-legal implications of gender on key issues within sports cardiology in a future article.

CONCLUSION

Progress has been made in raising awareness of heart disease and the threat it presents for women’s health. Ways must be found though, and still more needs to be done to redress the imbalance and close the gap in treatment and health outcomes for women and expand gender-focused research and the development of gender-based guidelines.

This September the British Heart Foundation will launch their Women and Heart Disease campaign, aiming to narrow the gender inequality in cardiac medicine, and I hope this will be a significant step towards the provision of equal heart care for all.