America needs a wake up call: Coronary artery disease is the number one killer of women, but many people, including doctors, are unaware of the seriousness of the problem. According to two studies, between 80 and 92% of women do not know the facts about the female mortality rate and heart disease. As alarming, one of the studies found that 32% of primary care physicians did not know that heart disease was the number one cause of death in American women.
This lack of knowledge about cardiac risk leads to the double problem of women not seeking medical evaluation for potential cardiac symptoms and physicians not pursuing appropriate diagnostic testing.

Heart to Heart
The gender gap in understanding cardiovascular disease

The Incidence of Cardiovascular Disease
Gender Bias in Diagnosis
Gender-Specific Symptoms
Understanding Coronary Artery Disease
Profile of a High-Risk Woman

The Incidence of Cardiovascular Disease

Cardiovascular disease is by far the leading cause of death among men and women in the United States. There are significant differences between the sexes in respect to heart and vascular disease, however.

Men are at higher risk for cardiovascular disease below age 45.
Women have a higher incidence as they enter menopause.
Approximately 25,000 more women than men die of cardiovascular disease each year.
Overall, there are 1.6 million more women with heart disease than men.
Almost as many women (30 million) as men (32 million) have hypertension. However, the implications of hypertension in men and women are different, although for both it is the most important risk factor for stroke.
Women smokers are slightly more at risk for stroke than male smokers.
Aortic aneurysms are five times more common in men than in women.
The incidence of peripheral vascular disease in women, severe enough to require surgical intervention, is a third that of men.
Women complain of heart palpitations more frequently than do men; and they have a higher heart rate than men both during sleep and while awake.Diabetes is twice as important as a risk factor for coronary artery disease (CAD) in women as it is for men. Diabetic women have a much greater risk of developing congestive heart failure, some kinds of strokes and intermittent claudication (cramplike pains, aching or muscle fatigue in the lower legs and calves caused by blockages in and narrowing of the arteries in the legs and feet) than do diabetic men.
When women have their first heart attack, they have a much higher mortality rate than men. In a recent study, 44% of women died within a year of their first heart attack, compared with 27% of men.

Gender Bias in Diagnosis

Diagnostic tests and evaluation of symptoms of CAD are skewed to favor males’ experience of heart disease. Only recently have researchers discovered that there are significant gender-based differences in symptoms and in how to test for CAD. The exercise ECG (or stress) test—long the cornerstone of diagnostic techniques for assessing CAD in men—provides a less accurate analysis for women. Studies show as much as a 40% false-positive evaluation for women.

Assessing blood cholesterol levels using male-oriented criteria is inaccurate for evaluating heart disease risks in women. Traditionally, when doctors measure cholesterol they are most concerned with elevated levels of LDL (bad cholesterol). This measure is of primary importance for diagnosis in men. For women, on the other hand, LDL is not as significant in determining risk of heart disease or need for treatment. Instead, doctors should look at HDL and triglyceride levels. Unfortunately, they are often overlooked or ignored.

Chest pain—long a sign of male heart disease—is not a reliable indicator in women. In fact, in the Framingham Study--a long-term look at tens of thousands of people over several decades--at 6 years' follow-up, none of the women who had originally reported chest pain had had a heart attack. At 12 years’ follow up, 70% of the men who initially had chest pain had died of cardiac disease, while only 31% of the women who initially had chest pain died of cardiac disease.

The Coronary Artery Surgery Study (CASS) Registry revealed that 50% of women with chest pain showed little or no coronary artery disease when evaluated with an angiogram; only 17% of men with chest pain proved to have little or no CAD. This gender difference was seen regardless of which coronary risk factors were present.

Gender-Specific Symptoms

So what are the reliable symptoms of CAD in women?

15 to 20% of women suffering a heart attack have upper abdominal pain, nausea and sweating.
Shortness of breath
Rarely, pain in the upper back
Chest pain, particularly in conjunction with other symptomsBecause the first three of these signs are not typical of men's symptoms, doctors often do not follow up the woman's complaints with appropriate diagnostic testing.

Post-heart attack symptoms

Not all women with chest pain have CAD--but all women who have had myocardial infarctions (heart attacks) have chest pain.

This is an important distinction since we know there are similar symptoms for both men and women who have already experienced heart attacks--the number one symptom being chest pain. Fatigue, shortness of breath and weakness are also symptoms that both genders experience. Yet, according to a study of heart attack patients at United Hospital and St. Paul Heart Clinic in St. Paul, Minnesota, "significantly more women than men reported loss of appetite, sudden difficulty in breathing at night, and back pain."

Further complicating the search for tell tale symptoms, the woman with cardiac disease is likely to be 10 years older than the typical man. This comes at an age when the woman may also have other medical problems such as diabetes or hypertension. Hypertension can raise the risk of heart attack. Diabetes can blunt the woman's ability to feel the classic warning sign of constricted blood flow--pain.

Source: The Partnership for Women's Health at Columbia; The Female Heart, Marianne J. Legato, M.D., and Carol Colman (Simon & Schuster, 1993); A Woman's Place Is in the Know: Ask Your Doctor about Coronary Heart Disease in Women (Partnership for Women's Health at Columbia, 1997).