Under Syndrome: Inequities in Women’s Cardiovascular Health

On Feb 10, 2019 the Vancouver Branch held an education session entitled “Under Syndrome: Inequities in Women’s Cardiovascular Health”. Twenty health care professionals, physicians, nurses and pharmacists attended. Dr. Shahin Jaffer, specialist in Internal Medicine with expertise in cardiology, diabetes and weight management, gave an entertaining and enlightening presentation.  Not only did we increase our awareness and understanding of heart and brain health, we also reviewed inequities and challenges facing women on many different fronts.  Heart disease is in fact the leading cause of premature death for women in Canada and women are 5X more likely to die from heart disease than breast cancer.

There are many challenges for women’s cardiovascular health, such as the limited amount of cardiovascular research that has been done including female subjects and especially those of racial and ethnic minorities. What we do know is that women who have a heart attack are more likely to die than their male counterparts and are also more likely to suffer a second heart attack.  We know that a woman in Canada has a stroke every 17 minutes: this equates to 85 women every day, 18 (21%) of whom will die, a mortality rate one third more than men. Women are 60% less likely to regain independence in their daily activities after experiencing a stroke compared to men and have a worse quality of life. Women, for many reasons, are half as likely as men to participate in cardiac rehabilitation and almost twice as many women as men go to long-term care after their stroke. We learned that as with many other health issues, ethnic and indigenous women have higher mortality rates. Time to pause for reflection.

Drs. Kathleen Ross, Shahin Jaffer, Patricia Warshawski, Teresa Clarke, and Charissa Patricelli

As a society of patients and care providers we are “under informed”.  There are knowledge gaps about women’s cardiac health  as women themselves are more likely to attribute symptoms of heart attack to non-cardiac causes.  As many as 78% of women miss their early heart attack warnings and signs! Someone check my blood pressure! Women are less likely to be referred to a cardiologist or internist for investigation and less likely to be referred by a specialist for invasive therapy such as a stent or bypass surgery. Why is that? Do we think women don’t have heart attacks?  We do.  Although women and men present with the “typical” heart attack symptom of retrosternal chest pain, “typical” female heart attack symptoms also include shortness of breath, nausea, dizziness, upper back pain, acid reflux, epigastric pain and profound fatigue.  In those suffering stroke, in addition to the unilateral numbness or weakness which both genders experienced, 50% of women also experienced mental status changes, such as confusion and disorientation. 

Members of the Vancouver Branch and guests enjoyed brunch while learning the latest on women’s heart health.

Gender-related biases in cardiovascular health are prevalent in the psychosocial roles of our society as women strive to be everything to everyone and who "don’t have time to have a heart attack”, dismissing significant symptoms.  Symptoms are also often dismissed by others, including care providers as symptoms of anxiety or stress.  Women have physiologic differences such as smaller hearts and coronary arteries and diagnostic testing such as the angiogram does not capture microvascular disease, i.e. smaller coronary vessel involvement thereby misinterpreting the woman’s angiogram as “normal”. Both stress cardiomyopathy and spontaneous coronary artery dissection are more common in women.  Diagnostic challenges in gender differences such as abnormal CKMB and troponin levels are not specific to women and the modest predictive values of the standard exercise stress test in diagnosing coronary artery disease pose another set of gender specific considerations.  Who knew that diabetes in women increases heart attack risk 7x in women and only 3x in men? (Many of you, possibly, however I did not).

How exciting to think we can now consider the differences of cardiovascular health in women throughout their lives - from gestational diabetes and pre-eclampsia/eclampsia topolycystic ovarian disease, menopause and autoimmune disorders, and... let’s not forget to consider sex-based difference in pharmacokinetic responses to medications.

Thank you Dr. Jaffer for the enlightening cardiovascular talk and highlighting the importance of including women in clinical research, and advocating for a fuller understanding of our cardiovascular system for all genders and ethnicities.

Dr. Charissa Patricelli, MD, CCFP, dipABAM
Honorary Secretary, Director Communications Federation of Medical Women of Canada
Perinatal Services BC Family Medicine Lead
Clinical Assistant Professor, UBC

References:

Heart and Stroke Canada, Ms. Understood, 2018  
https://www.heartandstroke.ca/-/media/pdf-files/canada/2018-heart-month/hs_2018-heart-report_en.ashx

Heart and Stroke - Women #TimeToSeeRed  https://www.heartandstroke.ca/women