"Men explode, but women erode."
That's how Carolyn Thomas, who blogs under the moniker Heart Sisters, sums up how heart attacks can differ between men and women.
In men, arterial plaque breaks off, causing a clot and crushing chest pain – a Hollywood-style, chest-clutching heart attack. In women, plaque tends to erode, gradually blocking the artery, so they suffer fatigue and pain around the shoulders, back and arm.
But even when women present with classic heart attack symptoms – chest pain, nausea, sweating, and pain radiating down the left arm – like Ms. Thomas did in May, 2008, they are often misdiagnosed. Women's heart attacks are misdiagnosed between 26 and 54 per cent of the time, according the published research.
Ms. Thomas was told she had acid reflux and sent home, but not before apologizing to the emergency room doctor for being a bother. Days later, she suffered a classic "widowmaker" (99-per-cent arterial blockage) and nearly died.
She has since dedicated herself to raising awareness that cardiovascular is not strictly a man's disease and that there are significant gender differences in how heart disease occurs and should be treated.
In 2012, the most recent year for which detailed data are available, 66,178 Canadians died of cardiovascular disease – 33,196 women and 32,982 men.
That's more women than men, in case you didn't notice. In fact, cardiovascular disease is the top cause of death, disability and hospitalization for women over the age of 35.
Yet, the public and even health-care practitioners often labour under the belief that heart disease is a man's disease and cancer is a woman's disease.
As Dr. Noel Bairey Merz, director of the Barbra Streisand Women's Heart Health Center at Cedars-Sinai Heart Institute in Los Angeles, said in a recent TED talk: "Breast cancer … kills women, but heart disease kills a whole bunch more."
There is also a growing recognition that cardiovascular disease needs to be treated differently in women. That's the motivation for the creation of the new Canadian Women's Heart Health Centre – the first of its kind in Canada – at the University of Ottawa Heart Institute.
"The landscape of women and heart disease has evolved greatly over the years, but efforts still need to be made in addressing the lack of public and professional awareness of women's coronary risk," said Dr. Michele Turek, the centre's medical adviser. "We must address this important challenge and correct misperceptions concerning the incidence, prevalence and significance of cardiovascular disease."
There are some biological differences between the sexes. For example, women develop cardiovascular disease, on average, seven to 10 years later than men. They also have specific risks related to pregnancy: Women who suffer pre-eclampsia or gestational diabetes have significantly higher risks of heart disease later in life. We know, too, that a woman's risk of heart attack or stroke soars after menopause – because blood pressure, cholesterol and diabetes rates all increase.
But most risk factors are common to women and men. The main reason women with heart disease have worse outcomes is not physically because of gender, but because prevention is lacking and treatment is delayed.
That's why the new centre in Ottawa will focus on prevention and providing strategies and resources. Because the issue is not on the radar for health providers or women themselves, there tends to be less prevention work done and significant differences in treatment – and not in a good way. Until a generation ago, cardiovascular research focused almost exclusively on men.
Despite efforts to raise awareness, the treatment gap remains notable. Women get fewer angiograms, less surgery (either revascularization or bypass) and fewer stents. They are less likely to be prescribed daily ASA and ACE inhibitors for prevention, and less likely to get statins, beta blockers and ACE inhibitors as treatment. It wasn't until 2004 that the first gender-specific treatment guidelines for cardiovascular disease were published.
Given all this, it's not surprising that women have higher death rates – 38 per cent of women die within a year of having a heart attack, compared to 25 per cent of men.
And, while heart-related deaths are falling overall – due largely to the decrease in smoking rates – they are falling much more quickly for men than for women. In the past 35 years, cardiovascular mortality has dropped 17 per cent in men, but just 2 per cent in women.
There is still a lot of catching up to be done, but it starts with awareness.
André Picard