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Heart disease in women: Unsuspected? Overlooked? Ignored?

©MFMER

Joy O’Neal was diagnosed with advanced heart failure — two years after she first started telling doctors that she was fatigued, gaining weight and just didn’t feel like herself.

“In 2014 I was pushed aside and told my complaints were just because I was getting older,” she recalls. Her doctor said it also might be an emotional reaction to becoming an empty nester, or to menopause. “By 2015, it was worse and I was telling the doctor I was out of breath. Because I pushed and pushed, I got tested for diabetes and had a scan for cancer.”

The result? Diabetes and cancer were ruled out, so the doctor suggested that Joy had a mental health issue and completely ignored her signs of the No. 1 killer of women — heart disease.

Luckily, she had to go through another medical exam to purchase a life insurance plan. “I went to get an ECG,” Joy recalls. “Afterward I got a letter in the mail that said the insurance company would have to change my rates since I hadn’t disclosed my heart disease!

“It was because of the ECG that I finally saw a cardiologist and found out I had advanced heart failure. For two years I was misdiagnosed. If I had known heart disease was the No. 1 killer of women, I would have insisted on having my heart checked and I could have started treatment earlier.

“Our responsibility as women is to stand up for ourselves,” says Joy, a WomenHeart Champion who volunteers for that organization helping empower women to take charge of their heart health. “We wouldn’t hesitate to advocate for a parent or child or husband, but we have to advocate for ourselves as well. If the doctor won’t listen, get a second opinion — rule out or identify a heart issue. Do not put it off.”

Joy’s story of being unaware of women’s risk of heart disease and encountering her doctor’s lack of understanding of the symptoms of cardiovascular issues in women is repeated thousands and thousands of times a year in women of all ages. This five-part series on women’s heart health is designed to help keep it from happening to you.

 

►Heart attack

Cardiovascular disease is the leading cause of death in women — 16 times more frequent than breast cancer. Around 445,000 women each year have a first-time or a recurrent heart attack and fatal coronary heart disease. Yet despite the danger that heart attack and other cardiovascular diseases pose, only about half of women realize that heart disease is their No. 1 killer. To save lives, it is essential that women understand their risk of, and the symptoms of, heart attack.

News flash! Chest pain is the primary symptom of heart attack for women — and men. No symptom is exclusive to either sex, however. While it’s true that women may report more symptoms than men and may experience nausea and vomiting and shortness of breath more frequently, the vast majority of women experience chest pain or pressure as the most prominent symptom of a heart attack.

“I had a patient in her 70s who was having chest and arm pain and never thought it signaled a heart attack,” says Sharonne N. Hayes, M.D., a cardiologist with over 25 years of experience in treating complex heart and blood vessel conditions in Mayo Clinic’s Women’s Heart Clinic. “She told me, ‘that’s not a symptom women are supposed to have’

“The messaging on women and heart attacks has been twisted because early on, women’s symptoms weren’t being recognized — not because they were so different, but because women and their issues are generally not valued in our society. Or at least, they have not been valued as much as men’s.

“Chest discomfort also gets ignored because when it strikes, it’s not like a ‘Hollywood heart attack’,” cautions Dr. Hayes. “Those chest-clutching, writhing-in-agony symptoms you see in films don’t happen to most women — or most men.”

Disparity in symptom recognition is even more pronounced in women of color. One preliminary study found that compared with white women, postmenopausal Black women were 28% less likely to receive guideline-based treatment, such as a stent to open a blocked artery when having a heart attack.

  • Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes — or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness or pain.
  • Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, the neck, the jaw or the stomach.
  • Shortness of breath. This can occur with or without chest discomfort.
  • Other symptoms. They can include breaking out in a cold sweat, nausea or lightheadedness.

Beyond Heart Attacks

Heart attacks are not the only cardiovascular problem that women need to become more aware of. Add to the list heart failure, high blood pressure (HBP, also called hypertension), atrial fibrillation and spontaneous coronary artery dissection (SCAD).

►Heart Failure

By the age of 40, the overall lifetime risk of developing heart failure for both men and women is 1 in 5. However, the age-adjusted rate for Black women is more than double that of white women. “And all women, on average, have different types of heart failure from those in men,” says Dr. Hayes.

That means women tend to develop heart failure a few years later than men do, and it often shows up as a stiff, inflexible heart muscle as opposed to a weakened muscle. High blood pressure, coronary artery disease, heart valve disease and diabetes are common underlying causes of heart failure for women. In addition, women very rarely can develop peripartum cardiomyopathy — heart failure that happens sometime between the last month of pregnancy and five months after delivery.

Early symptoms of heart failure can be fairly mild, but don’t put off seeking care or discussing your concern with a health care provider. Make a medical appointment right away for symptoms that include:

  • Shortness of breath with activity or when lying down
  • Fatigue and weakness
  • Swelling in the legs, ankles and feet or rapid weight gain from fluid retention
  • Reduced ability to exercise
  • Persistent cough or wheezing
  • Swelling of the belly area (abdomen)
  • Rapid weight gain from fluid buildup
  • Nausea and lack of appetite

Some symptoms of acute heart failure can mimic other life-threatening conditions and indicate a need to get immediate medical help. They include:

  • Sudden, severe shortness of breath
  • Chest pain
  • Fainting or severe weakness
  • Rapid or irregular heartbeat associated with shortness of breath
  • Coughing up foamy white or pink mucus

For more on avoiding a missed diagnosis of heart failure, watch Glenda’s story below from WomenHeart:

►High blood pressure

If you have high blood pressure, it means that the force of the blood flow against your artery walls is increased. Over time, this can damage the lining of your arteries and your heart muscle, and it may eventually lead to heart attack, stroke, or restricted blood flow to the brain, kidneys and other organs.

Almost 50% of adults with high blood pressure are women. And while high blood pressure isn’t directly related to being female, pregnancy, pregnancy prevention (hormonal birth control) and menopause can increase the risk of developing it. In addition, women who are 20 or more pounds overweight or have a family history of high blood pressure are at an increased risk. Other causes may include sleep apnea, diabetes, kidney disease, thyroid problems, and some medications, such as birth control pills, decongestants and nonprescription pain relievers.

More than 56% of African American women have high blood pressure, while around 37% of white women do. For African Americans, high blood pressure also develops earlier in life and is usually more severe than for white people. Higher rates of obesity and diabetes in African American women than in other populations may be a contributing factor. However, according to LaPrincess Brewer, M.D., M.P.H, a Mayo Clinic cardiologist, “African American women are faced with an overwhelmingly high burden of negative social determinants of health, and these include chronic stress related to factors such as food insecurity, systemic racism, the wealth gap and socioeconomic disenfranchisement within communities. These challenges really prevent African American women from following a healthy lifestyle and controlling many of the heart disease risk factors.”

What Is a Healthy Blood Pressure Reading?

On a blood pressure reading, the top or first number is a measurement of pressure in the arteries when the heart beats (systolic pressure). The lower or second number measures pressure in the arteries between heart beats (diastolic pressure). Blood pressure measurements fall into several categories:

  • Normal blood pressure: Less than 120 millimeters of mercury (mm Hg) systolic and 80 mm Hg diastolic.
  • Elevated blood pressure: 120 to 129 mm Hg systolic and less than 80 mm Hg diastolic. Elevated blood pressure tends to get worse over time unless steps are taken to control it. Elevated blood pressure may also be called pre-hypertension.
  • Stage 1 hypertension: 130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic.
  • Stage 2 hypertension: 140 mm Hg or higher systolic or 90 mm Hg or higher diastolic.

Checkups to keep it in check: High blood pressure usually causes no symptoms. That’s why you should have your blood pressure checked regularly. Have your health care provider perform a blood pressure test:

  • At least once every 2 to 5 years if you are between 18 and 39 with blood pressure that’s not elevated and no risk factors for heart disease
  • Every year if you are age 40 and older — or 18 and older with an increased risk of high blood pressure or heart disease

Treatment of high blood pressure: Across major demographic groups, about 55% to 75% of women with hypertension are aware that they have the condition. In addition, a high percentage of those women are receiving some kind of treatment for it. However, the percentage of women who have effective control of diagnosed hypertension is only 29% in white women and is 2% to 14% lower in other races and ethnicities. This is true despite the fact that there are more than 50 Food and Drug Administration (FDA)-approved drugs that can help lower blood pressure. If one doesn’t work or causes side effects, there are many others to try.

Lifestyle changes also can help lower blood pressure. They include weight loss, regular physical activity, the heart-healthy DASH diet (which stands for Dietary Approaches to Stop Hypertension), and stress-reducing techniques such as meditation and yoga.

The good news: Research shows if women can prevent or completely reverse hypertension, whether through lifestyle changes, with a medication or both, they can reduce their risk of dying of cardiovascular disease by 38%.

Atrial fibrillation

Atrial fibrillation — a heart rhythm problem in which the upper chambers (atria) of the heart beat irregularly or very rapidly — is more common in men than in women. However, since women tend to live longer than men, there are more women living with the condition. Atrial fibrillation is a major risk factor for stroke, so diagnosis and proper treatment are critical. Black people have lower rates of clinically apparent atrial fibrillation, but according to a 2019 study published in the Journal of the American Heart Association, it is not known whether Black people ” truly have less atrial fibrillation or simply more undiagnosed atrial fibrillation.”

Risk factors for women: In women, high blood pressure and heart valve disease are the most frequent risk factors for atrial fibrillation. In men, the most common causes are coronary artery disease and heart attack. Obesity and untreated sleep apnea are risk factors for both men and women.

Could you have atrial fibrillation? For many people, atrial fibrillation may have no symptoms. But when symptoms do occur, they can include a racing heart, palpitations, shortness of breath and chest pain. Women can also have symptoms of fatigue and weakness. Also, episodes of atrial fibrillation may be more frequent and longer lasting for women than for men. And women with atrial fibrillation may have a higher stroke risk than that of men, and the strokes in women may be more severe than those in men.

Women may also respond to and receive standard treatments differently from men.

  • Newer blood clot-reducing medications are equally effective in men and women, but traditional clot reducers, such as warfarin (Coumadin, Jantoven), are less effective in preventing stroke and have more bleeding complications in women than in men.
  •  Some medications that suppress atrial fibrillation are more likely to trigger life-threatening arrythmias in women than in men.
  • Women are treated with atrial fibrillation ablation procedures less often than are men. Ablation has the potential to cure atrial fibrillation. It’s performed by guiding surgical tools encased in narrow tubes (catheters) through blood vessels and into the heart. Scar tissue is created on the heart muscle to break up the electrical signals that trigger atrial fibrillation. One reason women don’t receive this effective treatment as often may be because symptoms such as fatigue and weakness are not discussed with or recognized by a physician, so diagnosis is overlooked or delayed.

How and when to get diagnosis and treatment: If you notice an irregular heartbeat or are experiencing unusual fatigue and weakness, see your doctor immediately for an evaluation. An electrocardiogram or more prolonged heart rhythm monitoring can help make the proper diagnosis. Don’t let a physician dismiss your worrisome symptoms as being “all in your head” or simply a sign of aging. In addition, at your regular checkups with your health care provider, consider asking for a heart rhythm evaluation. Some smartwatches have features that detect heart rhythm problems, and while these are not reliable diagnostic tools, it’s worth calling your health care provider to discuss further evaluation options if you suspect a problem. Even without technology, it’s smart to check your own pulse every now and then to make sure your heart beats evenly 60 to 100 times a minute.

► Spontaneous coronary artery dissection (SCAD)

SCAD is a little known and poorly understood type of heart attack. It happens when there is a spontaneous tear in one or more blood vessels leading to the heart. This can slow or block blood flow to the heart, triggering changes in heart rhythm, a heart attack or sudden death. SCAD is most often seen in women in their 40s and 50s and is the top cause of heart attack in women under age 50 as well as the top cause of heart attack in women who are pregnant or new mothers. Men do experience it, although less frequently.

The surprising thing is that it often happens to women who have no recognized risk factors for heart problems, such as high blood pressure, elevated low-density lipoprotein (LDL) cholesterol or diabetes.

“Although there have been substantial advances in the understanding of SCAD during the past decade, it continues to be misdiagnosed, underdiagnosed and mismanaged, but there is a growing body of science that has improved the recognition and care of women with this type of heart attack,” says Dr. Hayes, who directs the SCAD Research Program team at Mayo Clinic.”

Risk factors for SCAD are not completely understood, but being female, having recently given birth and having an underlying abnormality of the arteries such as fibromuscular dysplasia (FMD) appear to increase risk. In FMD, also found predominately in women, the muscular layer of the arteries is weakened, increasing the risk of aneurysms, dissections and blockages. Extreme emotional or physical stress may be a trigger for SCAD.

Symptoms of a SCAD attack: SCAD is similar to heart attack and is a medical emergency. Symptoms include chest pain; a rapid heartbeat or fluttery feeling in the chest; pain in the arms, shoulders or jaw; shortness of breath; sweating; unusual, extreme tiredness; nausea; and dizziness.

When to get help: With any symptom of SCAD or heart attack, call 911 or emergency medical help. You do not want to postpone treatment for SCAD. Your life depends on it.

►Getting the Care You Need — Don’t Put It Off

According to Dr. Hayes, to make sure you are protecting yourself from the dangers of cardiovascular disease and to know when and how to react in a cardiac emergency, there are three levels of smart self-care.

  1. Take emergency action. It’s important that you or someone else calls for emergency medical help (typically 911 in the United States) immediately if you have a persistent racing heart, loss of consciousness, or severe shortness of breath or if you experience chest pain or discomfort in other areas of the upper body, pain or discomfort in one or both arms, or pain around the body or head, jaw and neck — especially if persistent or accompanied by nausea, lightheadedness or shortness of breath. “Don’t dismiss how you’re feeling just because it resembles a symptom that’s simply age-related or could be from going through perimenopause,” cautions Dr. Hayes.
  2. Schedule prompt follow up.  Make a medical appointment sometime within the next week or so to evaluate your symptoms if you have been feeling short of breath or getting chest pain or pressure when you are active, noticing new or worsened swelling in your legs or abdomen, awakening at night with a rapid heartbeat, or experiencing a racing heart associated with shortness of breath, chest pain or lightheadedness.
  3. Initiate active surveillance and preventive heart care. In preparation for your next medical appointment, gather your personal and reproductive medical history and family history of heart and vascular conditions, and write down any questions you may have about what a heart-healthy lifestyle is and what your cholesterol, blood pressure and glucose levels are and should be. Then talk to your doctor about what you need to do if those indicators of heart health are not in a healthy range. Use the opportunity to start a dialogue about your heart health and keep that conversation — and cardiac checkups — going at every appointment.

►Finding Your Voice

If you’re looking for great information and intelligent peer support for your heart health journey, visit the Women’s Health group on Mayo Clinic Connect and search for “heart.” Also take a look at WomenHeart, where Joy O’Neal is a volunteer dedicated to helping empower women. They also offer interesting publications from the WomenHeart and the Society to Improve Diagnosis in Medicine’s joint Convening on Missed and Delayed Diagnosis of Heart Disease in Women meeting.

Women’s Heart Health is a five-part series that looks at all aspects of cardiovascular well-being and disease and discusses how women can make sure they protect their heart health, receive timely and appropriate cardiovascular medical care, and maximize recovery from any heart health issues.

Sharonne N. Hayes, M.D.

Dr. Hayes is a cardiologist and Professor of Cardiovascular Medicine at Mayo Clinic. She has over 25 years of experience in treating complex heart and blood vessel conditions, especially those that uniquely or disproportionately affect women. She founded and practices in the Women’s Heart Clinic and has diverse research interests that include sex and gender-based cardiology, spontaneous coronary artery dissection (SCAD), health equity, and the utility and optimal role of social media in clinical practice, medical research and health education.

LaPrincess C. Brewer, M.D., M.P.H.

Dr. Brewer is a cardiologist and Assistant Professor of Medicine within the Mayo Clinic Division of Preventive Cardiology, Department of Cardiovascular Medicine in Rochester. In addition to her clinical expertise in preventive cardiology, she focuses her research on increasing minority participation in cardiovascular clinical trials and addressing cardiovascular health disparities through innovative, community-based behavioral interventions for cardiovascular disease risk factor modification in underserved communities and special populations.

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