When I did my cardiology training in the 1980s, I learnt that women with chest pain were ‘weird’, with strange symptoms.
This was because they almost never fitted the diagnostic framework we used for patients with chest pain. Too often, for instance, their angiograms (where we check for blocked arteries by introducing a special dye that shows up on X-ray) were normal.
As we lacked other options for treating them, the easiest way out was to consider their symptoms as signs of psychological distress.
But thanks to advances in imaging techniques over the past few decades, we now know there are important differences in how men and women experience heart disease — women are not ‘mini-men’ and those weird symptoms are not ‘all in the mind’ but entirely understandable, given how the female heart works.
The classic heart attack — where a coronary artery is suddenly blocked, causing pain in the chest, jaw and left arm — is three or four times more common in men than in women. Women do have these symptoms but alongside others, such as stomach complaints, nausea and chest tightness, which can be so dominant that the chest pain is barely noticed or even absent [File photo]
In women with angina — chest pain — the problem is much more likely to be due to blood vessel ‘spasm’ than to a blockage, as it is in men.
We also know stress can play a direct role in women’s heart disease. The number of heart attacks in middle-aged women is increasing and while unhealthy lifestyles, excess weight and little exercise are all factors, stress is leaving its mark — and this appears to affect women’s hearts more than men’s.
Yet while our understanding of the female heart has improved, its application in clinical practice still lags behind and doctors persist in a male-oriented way of treating patients.
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When aspirin is not the best medicine
Low-dose aspirin is often prescribed at the first slight chest pain as a preventative in women who have no previous heart problems.
But the evidence is clear that using aspirin this way is pointless, even if you have several risk factors for cardiovascular disease.
What’s more, in the over-70s, preventative use of aspirin increases the chance of early death from cancer; and almost half of all people who take aspirin daily develop stomach problems; and in the elderly it causes a great deal of bleeding.
(However, for patients who have already had a heart attack or stroke, aspirin really does have benefits.)
Studies show that less than 25 per cent of women with high blood pressure are adequately treated for it, for instance.
In men we call high blood pressure hypertension, whereas in women we say it is ‘stress’. Women are 50 per cent more likely to be misdiagnosed following a heart attack.
When I opened the first specialist cardiac clinic for women in The Netherlands in 2003, it was amazing to find so much resistance from the cardiology community.
And while there are now international guidelines for the treatment of women with cardiac diseases, the best advocates for change are women patients themselves.
That’s why I wrote my book: to give women the information they need to help them care for their hearts but also to gain the confidence to ask the right questions of medical professionals and, ultimately, become the champions of their own health.
Stress taxes women’s hearts
As we age, our heart muscle starts to contract less powerfully and our blood vessels lose the ability to widen.
The process begins in the lining of the blood vessel walls, which become less elastic, more rigid.
After the menopause, this process speeds up far more sharply in women than in men, particularly in the heart muscle’s microvessels (the tiny blood vessels that supply oxygen to the heart).
As well as leading to a greater decline in a woman’s stamina, it’s an important reason why chest pain is so prevalent in middle-aged women (the hormone oestrogen acts as a powerful vasodilator — a blood vessel dilator; the effect disappears after menopause).
This can cause symptoms during mild exertion or even rest — chest pain can occur in the middle of the night or early in the morning and linger for hours.Some women describe it as like someone squeezing their heart.
Women with these symptoms often feel very tired. This kind of angina (microvascular angina pectoris) hardly exists in men.
And it is often not recognised or its existence is denied, despite it being in the official European guidelines since 2013. Yet for many patients it can be extremely painful to have heart problems for years on end and not have their symptoms properly recognised.
Stress-related factors seem to play a bigger role in women’s angina than in the more recognised form, which is caused by blood vessels narrowed by a build-up of plaque and where the usual risk factors (such as smoking) are more important.
One striking thing is that women with this type of microvascular angina have a tendency toward perfectionism.
Artery problems not spotted
Angina linked to microvessel ageing is not the only difference in men and women’s experience of heart disease — it is also seen in the larger coronary arteries.
Significant narrowing in the coronary arteries can cause chest pain during exertion or emotional moments, or with changes in temperature. The pain can radiate out to the jaw, shoulder blades, armpits and left or right arm.
This can be treated by inserting a balloon to effectively ‘squash’ back the blockage, and a stent (a small metal cage) to keep the blood vessel open. This happens much more often in men and at a younger age than in women.
This is not a question of discrimination but is due to an actual sex difference in the pattern of atherosclerosis (furring-up of the arteries).
Women are far more likely to have a combination of mild atherosclerosis and the stiffer blood vessels that cause a lack of oxygen without the vessel itself being greatly narrowed.
But this lack of narrowed arteries doesn’t translate into better outcomes — in the long term, it leads to at least as many heart attacks and deaths as in men.
Angina linked to microvessel ageing is not the only difference in men and women’s experience of heart disease — it is also seen in the larger coronary arteries [File photo]
In women, the atherosclerosis tends to be spread out more widely through the blood vessel (which can cause the vessel to spasm or cramp), while in men it tends to focus in one area, causing a clear narrowing.
The problem is that the kind of tests (angiograms, ECGs to check the heart’s function) offered in daily medical practice won’t help women in these circumstances — there won’t be a significant narrowing in the blood vessels, so the arteries are regarded as ‘clean’ and the symptoms as not heart-related.
As a result, the symptoms and risk factors (such as blood pressure) are not treated, or treated insufficiently, and women can walk around with unrecognised heart symptoms for years.
The best test for women in these circumstances is to check the arteries’ hardness by calculating their calcium levels using a CT scan (another option, though not as good in my view, is to check the carotid arteries in the neck using ultrasound).
Specialist clinics also have experience in performing tests that identify stress in the microvessels. Angina pectoris patients should have their blood pressure closely monitored and brought down to lower-than-normal levels.
Standard angina drugs can worsen symptoms and cause headaches — there are various medications that can provide relief but, in practice, medication has to be tailored to the individual (this can mean we prescribe uncommon combinations of drugs that GPs may not know about).
It’s important for patients to accept the symptoms and not take on too much, letting go of perfectionism as far as they can.
Cardiologists stress the benefit of exercise but if the problem is abnormal artery functioning, relaxation is just as important.
Nausea could be a danger sign
The classic heart attack — where a coronary artery is suddenly blocked, causing pain in the chest, jaw and left arm — is three or four times more common in men than in women.
Women do have these symptoms but alongside others, such as stomach complaints, nausea and chest tightness, which can be so dominant that the chest pain is barely noticed or even absent.
Women, inclined to think they have just been too busy, mislead themselves and the doctor and often end up in hospital later, after precious time has been lost.
The nature of their heart attack is also often different — caused by spasms (or cramp) in the coronary arteries. Trigger factors for this cramp include high blood pressure, high cholesterol, smoking and diabetes but also stress.
‘Heart’ ills? It’s hypertension
At medical school 40 years ago, I learnt that high blood pressure causes no symptoms. But over the years, I have found it’s simply not true — about a quarter of the women who come to my clinic with inexplicable ‘heart symptoms’ turn out to have high blood pressure.
This is a particular problem for young and middle-aged women, where it can cause all kinds of symptoms that are wrongly dismissed as ‘all in the mind’ — such as fatigue, palpitations or the heart skipping a beat, breaking into a sweat easily, hot flushes, insomnia, headache, difficulty concentrating and not being able to lie on the left side.
(One sign of increasing blood pressure is that your pulse goes up much more rapidly at the slightest exertion, causing tiredness, shortness of breath and chest pain.)
In dealing with heart rhythm problems, the doctor may focus on that symptom — but the proper treatment of blood pressure can prevent it in the first place. However, high blood pressure in women is treated less readily and adequately than it is in men.
Women’s shape can lead to misdiagnosis
To check the rhythm and electrical activity of a patient’s heart, we use an ECG (or echocardiogram).
The problem is that the standard ECG set-up — leads and electrodes — is based on a slim adult male, who has a very different chest from an adult female.
Not only that, but on women with large breasts the electrodes used for the ECG are sometimes placed too far down, which can affect the reliability of the recordings.
The net effect is that the majority of women have a slightly abnormal ECG, even when there are no issues. This can make inexperienced doctors feel unsure and often leads to unnecessary investigations for women.
This doesn’t put the female patient’s mind at rest, because the thought tends to linger that something was not quite right on their ECG.
Your menopause hasn’t ‘come back’
At about the age of 60, more than a third of women have hypertension — most develop it after their 60th birthday.
Many women at this stage of life have symptoms they put down to the menopause ‘coming back’ (e.g. hot flushes) and they may be told it’s par for the course. But recurring menopausal symptoms at this age are more likely to be a sign of high blood pressure. Treating it properly can do wonders.
On average, each minute, a woman’s heart beats three to five more times than a man’s — a normal resting heart rate is fewer than 70 for a man, fewer than 80 for a woman.
After the menopause, a woman’s adrenal glands are activated more strongly, so the pulse increases more quickly during exertion than before — this can lead to symptoms such as palpitations, tiredness, shortness of breath, chest pain and a nagging sensation between the shoulder blades.
A low dose of beta-blockers can be a solution for these symptoms.
Learn to talk like a man
Men report, women interpret; communication styles differ between the sexes and this affects how doctors assess patients.
Women take more time to explain their symptoms, expand on events and introduce more emotion into their stories. But in doing so they risk losing the doctor’s attention, because doctors look for hard facts to make the correct diagnosis.
Women can also put doctors on the wrong track by interpreting their symptoms themselves —‘stress’ and ‘too much going on’ are often mentioned.
While stress is an ever-increasing risk for cardiovascular disease, it would help if women communicated their symptoms as matter-of-factly as possible and therefore they will be listened to better.
As a clinician, I have seen many distressing examples of women who for years were sent from pillar to post or even laughed at because a cardiologist didn’t understand their symptoms.
The doctor’s gender also affects how a patient is treated — recent research from Florida revealed that women who have had a heart attack have fewer complications and a lower risk of dying if they are treated by a female doctor.
Migraines can be a risk factor
Our health history and events in the past have a significant impact on future health and this applies especially to women.
Chronic headaches, migraines or problems concentrating at a young age, or pre-eclampsia in pregnancy, are associated with high blood pressure later in life, with implications for cardiovascular health.
One study, published in The BMJ in 2016, found women who develop migraines at a young age suffer more heart attacks and stroke.
Starting your periods early and irregular periods (including endometriosis, where womb-like tissue grows elsewhere in the body) are linked to a raised risk of cardiovascular disease.
Miscarriages can have a number of different causes but large studies show that a history of two or more is also linked to an increased risk of cardiovascular disease.
Chronic headaches, migraines or problems concentrating at a young age, or pre-eclampsia in pregnancy, are associated with high blood pressure later in life, with implications for cardiovascular health [File photo]
When women pass 40 and their oestrogen levels drop, all kinds of inflammatory diseases raise their heads — and such conditions (e.g. IBS, fibromyalgia, Crohn’s disease and asthma may be accompanied by a higher risk of heart disease.
Patients often have one or two classic risk factors, such as high cholesterol and high blood pressure.
Thyroid disorders — 80 per cent of those affected are women — are also associated with heart disease.
Because the risk calculators that GPs and cardiologists use don’t take into account any of these women-specific risk factors, they wrongly assume that all middle-aged women have a low risk of developing a heart problem or suffering a stroke.
But taking more fully into account a woman’s individual life and these ‘non-traditional’ risk factors could help them to identify high-risk women and help them take preventative steps.
Adapted from A Woman’s Heart, by Professor Angela Maas, published by Aster on September 24 at £9.99. © Professor Angela Maas 2020.
To order a copy for £8.49 (offer valid to 6/10/20), visit mailshop.co.uk/books or call 020 3308 9193. Free UK delivery on orders over £15.