Coronary artery disease is the leading cause of mortality among American women over the age of 25, and is responsible for approximately 27 percent of all deaths in this group. The problem is especially severe among black women who are more likely than white women to die from coronary artery disease, the most common form of heart disease. Approximately 435,000 American women have heart attacks each year; 42 percent of these women will die within a year compared to 21 percent of men.
"In spite of mounting evidence that obesity, diabetes, and hypertension contribute significantly to the development of this heart disease, these potentially modifiable risk factors are rising among women, who also are quitting smoking at a slower rate than men," says Phyllis Supino, EdD, a cardiovascular epidemiologist at Weill Cornell Medical College of Cornell University. "Moreover, when confronted with initial symptoms of a heart attack, an all too common manifestation of coronary artery disease, women tend to wait longer than men to go to an emergency room -- a delay that often can be lethal."
Because of its importance, clinical epidemiologists and other health professionals are trying to learn why women tend to pay less attention to their cardiac health than they should and, though far from conclusive, some interesting answers have begun to emerge. Dr. Supino suggests that one possible reason is the common belief that heart disease is an illness reserved for men or only for the elderly, even though it is the number one killer of women in nearly every age group. She notes that "only about 13 percent of women view heart disease as a health threat and may fail undertake 'heart-healthy' lifestyle changes or seek appropriate care."
A second reason, she adds, are she further adds that "gender differences in presentation in some manifestations of heart disease. "For example, heart attack symptoms in women sometimes do not fit the better-known picture of heart attack symptoms found in men." For example, chest pain is a common presentation, on average, women are less likely than men to experience classic mid- or left-sided chest pressure radiating to the shoulder, arm, neck or jaw, and are more likely to experience upper-stomach, mid to low stomach and back pain alone or in combination with mid-chest discomfort. At the same time, women are more likely to complain of nausea and shortness of breath, but less likely to complain of sweating."
Dr. Supino further comments that "as a result of these differences, some women may not realize that they are having a heart attack and, instead, may believe their symptoms to be gastrointestinal.... Even when such symptoms are recognized as cardiac in origin, some women's responses still may be delayed because of preference for of self-treatment, bad advice from family members or friends, greater tolerance for pain, or other factors that are not as yet well understood a desire to self-treat in order to maintain control of their lives." The effects of such delay may be dire. Dr. Supino notes that "once a heart attack occurs, heart muscle begins to die. Coronary reperfusion with thrombolytic therapy or angioplasty during the first 1-2 hours after a heart attack may dramatically improve a patient's chance of survival, but benefit rapidly declines with time."
Dr Supino suggests that a third reason may be a disproportionate focus on breast cancer, which many women view both as a threat to femininity and potential killer. In support of this view, a report from the National Center for Health statistics showed that women fear dying from breast cancer far more than they fear dying from heart disease, even though breast cancer causes relatively far fewer deaths.
"The relative lack of attention that women display towards their own cardiac health is mirrored by the health care system that is largely modeled on the experience of male patients," she remarks. For example, for many years, women were excluded from or grossly under-represented in studies designed to test the effectiveness of new drugs, devices and procedures. As a result, the utility of these interventions is better understood in men. Dr. Supino notes that "diagnostic tests are less likely to be ordered to evaluate chest pain in women than in men, in part because of '"atypical'" presentations in women and the belief by many of their physicians that their patient is unlikely to have coronary artery disease.
Even when ordered, certain diagnostic tests may not be as accurate in women, in part, because of their unique anatomy or other characteristics. Treating physicians tend to be slower to recognize heart attacks in women because "classic" chest pain and expected changes on the electrocardiogram occur less frequently in women than in men. Lack of an accurate diagnosis invariably delays appropriate treatment." The effects of such delay may be dire. Dr. Supino notes that" once a heart attack occurs, heart muscle begins to die. Coronary reperfusion with thrombolytic therapy during the first 1-2 hours after a heart attack may dramatically improve a patient's chance of survival, but benefit rapidly declines with time."
She adds, "Even after a documented heart attack, women tend to be offered aggressive therapy such as coronary artery bypass grafting or less frequently than men, though such therapies have the potential to improve survival. When such therapy is offered, it is typically later in the course of disease, at a more advanced age, and in the setting of other medical problems--bringing with it the increased likelihood of complications. As a result, 42 percent of women who have heart attacks will die within a year compared to 24 percent among men, and 35 percent of women compared to 18 percent of men will have another heart attack within 6 years."
Dr. Supino urges that "heightened awareness of these issues is important to patients and health care providers alike to reduce poor clinical outcomes among women. There is hope that recent initiatives sponsored by the American Heart Association, the National Institutes of Health and the National Coalition for Women with Heart Disease to promote in the area of women's health, awareness, resource allocation, and including focused research and media attention, will help to reverse these disparities and save many lives each year."