Heart Disease in Women: There IS a Difference.

Heart disease is a leading cause of death for women in the United States, yet it is still perceived as a disease of men. In fact, women are 50 percent more likely than men to be diagnosed incorrectly after having a heart attack.
Understanding differences -- from basic anatomy to the way they experience heart attack symptoms -- can help women take charge of their heart health.

Host, Jonathan Fialkow, M.D. welcomes cardiologist Andrea Vitello, M.D. who focuses on women's heart issues as part of Miami Cardiac & Vascular Institute's prevention and risk reduction team.

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Announcer:

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life.

Dr. Fialkow:

Welcome Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at the Miami Cardiac & Vascular Institute, where I'm also chief of cardiology at Baptist Hospital and the chief population health officer at Baptist Health.

Dr. Fialkow:

Heart disease is a leading cause of death for women in the United States. In fact, it causes about one in four female deaths. Yet it remains perceived that it's a disease of men. Why is that? And why do women experience heart disease symptoms and signs differently than men? Studies show that women wait more than 30% longer than men to get to a hospital after first experiencing symptoms of a heart attack and women are 50% more likely than a man to be diagnosed incorrectly after a heart attack. And since heart disease is felt to be preventable over 80% of the time, what drives this avoidable consequence in women and what can we do about it?

Dr. Fialkow:

To discuss what is different about a woman's heart from a man's, and what women can do to help themselves when it comes to heart health, is Dr. Andrea Vitello. She's a cardiologist at Miami Cardiac & Vascular Institute, and part of the Miami Cardiac & Vascular Institute prevention and risk reduction team. And she's a special focus in prevention and women's heart issues. Welcome, Andrea, welcome to the podcast.

Dr. Vitello:

Thank you so much, Jon. Thanks for the invitation.

Dr. Fialkow:

So Andrea, let's start with some basic concepts. We'll get into various things like how women perceive heart problems and what women should do to keep themselves heart healthy. But are there any structural differences between a woman's heart and a man's heart or their blood flow or arteries? What are the actual anatomical physical differences?

Dr. Vitello:

In terms of just anatomy, we know that females tend to have smaller coronary arteries than males do. And so that's one of the main things that we see when we are diagnosing females with cardiovascular problems. We can see that in invasive studies. And it certainly helps in terms of knowing this information for how we treat them moving down the road. They can also be prone to certain other types of microvascular disorders more so than men.

Dr. Fialkow:

So actually let's talk about that from the get-go. You mentioned microvascular disorders. We tend to think as the arteries as tubes that bring blood to the heart itself and to the rest of the body. And when they narrow, that's when people get chest discomfort, angina, that's when they can have heart attacks, though we know it's a little more complex than that. What is a microvascular abnormality and why do we find it's difficult to sometimes diagnose?

Dr. Vitello:

So what I'm referring to with microvascular disease is, you're absolutely right, we do have tubes that are essentially our arteries and our blood supply throughout our body. But beyond these tubes are even smaller tubes and even smaller tubes and even smaller tubes so that we get down to the capillary level. So the very smallest of the smallest blood vessels that we can't really visualize with our eyes directly, but we know exist because this is what helps provide our bodies and our tissues with adequate amounts of oxygen and nutrients. So it's disorders at these smallest level of blood vessels that tends to be more prevalent in women than men.

Dr. Fialkow:

So does that provide for differences in the way a woman presents with let's say heart disease or artery disease, and secondly, does that lead to any problems or differences in the way we diagnose women with disease? The fact that their disease can sometimes be in the smaller blood vessels than the large, big, juicy ones that we see more commonly in men?

Dr. Vitello:

So certainly, I think it plays a role in terms of how women present and also how we assess and treat them down the road. So in terms of how women present, women can present with cardiovascular disorders very similarly to how a man can. But in addition to that, I would say that there are some marked differences with how women tend to present with, for instance, a heart attack. So women can have symptoms including shortness of breath, fatigue, weakness, dizziness, nausea. So they can be a little bit more subtle in terms of the types of symptoms that we're watching out for. They can also be very obvious symptoms that we traditionally ascribe to having cardiovascular disorders like a heart attack, for instance. You might experience chest pain, chest pressure. But again, in females, it tends to be less likely to be the more obvious presentation, chest pain, chest pressure, and more or less these other more subtle symptoms. Shortness of breath, weakness, fatigue, dizziness, those types of things. So women can present with different types of symptoms.

Dr. Vitello:

But in addition to that, once they actually do present with these types of maybe less profound types of symptoms, I think that it also unfortunately impacts how we diagnose and potentially delay assessment of what might be going on. So in a female that's presenting to the emergency room with shortness of breath, the list of what could potentially be causing shortness of breath is quite large. But we do know that women can have regular heart attacks just like men can, and they can also have small vessel disease that are maybe a little bit harder to diagnose. They might have laboratory findings that suggest that there is some kind of damage to the heart, but maybe they might not show up in the same way.

Dr. Vitello:

So when a patient goes to the hospital with a heart attack, they oftentimes get an invasive procedure to help diagnose what's going on. And these are harder to identify on some more invasive types of tests if you have microvascular problems. Yet we know that women with microvascular disease are equally as high risk as those with the very obvious large vessel disease as well.

Dr. Fialkow:

So women have structural and anatomic differences, which is kind of clear, as you alluded to. Smaller blood vessels tend to be smaller body size. But even the way the disease presents anatomically is a little different. Small vessels, not the big blood vessels. Then when they actually have symptoms, well, of course, a woman can have the same crushing chest pain that we read about in the textbooks and we see on TV, but sometimes you're saying fatigue, dizziness, symptoms that they don't always think of as the heart can sometimes be the signs. And then when they come to the emergency room, it might be missed as well. Do you see that? Have you seen cases, for example, where a woman either has symptoms and is told, "Oh, it's not your heart," and turns out it is in follow up? Have you had circumstances like that?

Dr. Vitello:

Absolutely. Unfortunately it's just, I think that not only do women maybe ascribe their symptoms to something else, but also do practitioners who are evaluating female patients. They might also believe that their symptoms are not related to ischemic heart disease or low blood supply problems to the heart. I think, traditionally, even within the field of cardiology, we think of ischemic heart disease related to obstructive epicardial coronary arteries. So these are the large blood vessels that we can directly visualize with invasive procedures but we're a little less able to address the microvascular problems that we can't really see. We can't identify and say, "Here's a picture. This is what you have." It's harder to diagnose those, but it can still be major risk.

Dr. Fialkow:

I would presume that in your practice and what you've seen in these types of cases, and especially as an expert in women's heart disease, and I've seen cases like it as well, so a woman might have symptoms, they bounced around the doctors. No one could figure out what it is. Then they might wind up with an actual heart attack, which obviously in retrospect would say, "Wow, that's what those symptoms are." Yet, at the same time, we don't want every woman who feels a little tired to say, "Oh my God, I got to go to the emergency room." So by the time someone comes to your office saying, again, "I've been short of breath lately and can't explain it. Or I used to be able to walk long distances, now it's tiring." Or someone refers them. Is it the same kind of evaluation and workup if they might have this microvascular component? And if so, are there different treatments for women with this microvascular component than with the large blood vessels?

Dr. Vitello:

It is certainly the same type of cardiovascular evaluation. Certainly, we want to make sure that history alone is very, very helpful in terms of understanding what's going on with a woman's symptoms, what are they experiencing, what is limiting them, what are maybe activities that they used to be able to do that they are no longer able to accomplish. And so that can be very helpful to understand. But yes, in terms of diagnostic evaluation, it's still very important to make sure that we are checking stress tests when appropriate and getting more and more thorough evaluations if their initial testing is abnormal.

Dr. Vitello:

So even if the stress test points to an abnormality but the gold standard invasive procedures don't necessarily say that there's a large blood vessel that they can fix with a stent, it's still part of understanding what might be going on with the rest of their vascular supply. Understanding that they might have small blood vessel disease that we can't necessarily fix with traditional treatments like stents, like small wire mesh tubes that push blood vessels open. Sometimes the blood vessels are simply just too small to accommodate something like that. But then we're still also assessing their other risk profiles. What is their blood pressure? What is their family history? What is their cholesterol? What is their physical activity? What kind of dietary habits are they adhering to on a regular basis? And is this also an area where we can help improve their cardiovascular health?

Dr. Fialkow:

So this is great information. I want to delve into this again, this microvascular presentation a little bit. So a woman comes in with symptoms either at the hospital level or to a doctor's office. And hopefully, someone aware of how women can present a little differently with cardiovascular disease. They get a workup, we find the heart's not getting blood. We might do an intervention and we say, "Wait a minute. There's no major blockage here. It's not your heart." But you're saying in certain circumstances, it still could be their heart. The woman's not crazy, obviously. And then though the important part is the treatments would still be to get your blood pressure under more aggressive control, lower your cholesterol, improve your lipids, don't smoke. Which means it's not a death sentence saying, "Well, no big blockage, good luck." There are things you would offer them in terms of improving their health and staying healthy. Is that right?

Dr. Vitello:

Absolutely. I think that that's really well said. Unfortunately, I think that that's where a lot of practitioners may fall short and they say, "Well, we don't see an obvious blockage. You're done." But this is where it actually still does apply to a female patient. We still need to be aggressive at regulating your risk factors, at controlling blood pressure, at controlling cholesterol values. And some other areas that maybe females don't necessarily consider that they fall short, but maybe this is physical activity, maybe it's dietary habits. So I think in general, we need to recognize that cardiovascular disorders can present in typical ways as well as in not so clear-cut ways. But everyone should understand what their cardiovascular risk is, regardless of the symptoms that they're having.

Dr. Fialkow:

So that's a great segue. So you mentioned quite articulately that lots of symptoms can be signs of impending cardiac problems beyond just chest discomfort and women, men as well, should be sensitive to that. And again, just basically if you're not feeling right, get checked out. But there have been some studies that have shown that women tend to seek care later than men, including when they're actually having heart attacks.

Dr. Fialkow:

First, is that something you've actually seen in your practice when you're speaking to a woman? It seems like they were more symptomatic for some time and either didn't recognize it. And if so, why do you believe that's the case? What goes through a woman's mind? Is it denial or is it I'm too busy? Is it true, and if so, why?

Dr. Vitello:

I think that there is truth to that. And I don't think that there's going to be one clear-cut answer that tells us why exactly that is the case. I know I've had a number of patients that attribute their symptoms to something else. They're tired because they had a stressful day, or they're a little bit short of breath but maybe they're not exercising so much. And so maybe they consider that their symptoms are related to other circumstances that are happening within their life. I'm sorry, what was the second part of your question?

Dr. Fialkow:

So, I appreciate that. So if in fact women do seek care later, what are some of the reasons? You mentioned some of them, they attribute it to other symptoms, which is a good one. And I think the other thing would be just do you see it where, "I don't have the time. I got to take care of the kids. I work. I have all these other responsibilities." I find in my practice, it might be skewed, a lot of times the men come in because their wives sent them, and I've never seen a woman come in because the husband sent them. Obviously an anecdote. But do you find that just even culturally exist?

Dr. Vitello:

Certainly. I think that unfortunately, as females, they might be putting their own health on the back burner, so to speak, relative to the rest of their family's health and delaying seeking care for something that they think that they might not have, or maybe they don't really want to have. And so having some level of ignorance about what might be going on might be where part of the problem lies. In addition to that, I think that some traditional risk factors that we think of as being problematic for cardiovascular health might actually be present at a very early age, but maybe our female patients don't consider that they have these higher cardiovascular risks. So therefore this symptom that they're experiencing can't possibly be related to their heart.

Dr. Fialkow:

What would be some of those conditions, so a younger woman might be a marker that they are the higher risk for cardiovascular disease as they get older?

Dr. Vitello:

So certainly something that is unique to females is conditions that develop during pregnancy. Pregnancy-induced hypertension. So a female who has not had high blood pressure traditionally, but then during pregnancy develops high blood pressures. Blood pressure's over 140 on the top, under 90 on the bottom. Those types of blood pressure readings after 20 weeks gestation can certainly raise risk for cardiovascular disorders. Preeclampsia, which is a more serious form of hypertension experienced during pregnancy that has other issues that go along with that. Preterm labor.

Dr. Vitello:

And so when you're asking someone about their cardiovascular health, understanding what their pregnancy history was doesn't seem like it would be a related risk factor but it certainly is. So having preterm labor, anything where you're delivering because of pregnancy-induced complications, delivering under 37 weeks, that's a higher marker risk for cardiovascular disease. Gestational diabetes. That's a marker for higher cardiovascular risk. Autoimmune disorders.

Dr. Fialkow:

So a woman who has gestational diabetes but the sugar returns to normal after the delivery of the baby, that condition does indicate a higher risk for cardiac disease as they get older?

Dr. Vitello:

Yes, it does.

Dr. Fialkow:

So these are the markers you're saying of someone who in their younger, healthier lifetime might say, "Hey, listen, I need to be more attentive towards my cardiovascular health and fitness," which is interesting. How about, and this is probably a topic which maybe our producers will have us do in the future in and of itself. Couple of minutes before we wrap up on hormones. Positive and negative. So is there anything that testosterone does, for example, in a man that's beneficial to the heart or drives a heart condition, and in that answer also the big one is what is it about estrogen? Is estrogen good for a woman? Is it bad for a woman? What's the current of status of recommending estrogen-replacement therapy after menopause? Speak a little bit about the hormonal components of a woman's risk for cardiac events.

Dr. Vitello:

Certainly, that's also a fairly complicated topic in and of itself. But what they say is that we know that cardiovascular disease tend to develop about 10 years later in women more than men. So part of this is probably related to some of these hormonal changes. And prior to menopause, hormones like estrogen can be protective against heart disease related to possibly changes in how cholesterol is metabolized as well as how blood pressure is regulated. But after menopause, this changes a little bit. And what studies have shown is not necessarily that adding back estrogen all of a sudden confers more cardiac protection, so that's not the right answer and it should never be given just for purposes of lowering your cardiovascular risk. It can be helpful for treating menopausal symptoms, but again, not for lowering cardiovascular risk. So I think that that's in and of itself a fairly complex process. Incompletely understood, but that's what's known at this point.

Dr. Fialkow:

But you mention a major component, which is prior to menopause, women's rates of heart disease is lower than a man's. After menopause, it accelerates and catches up. So it does speak to some, at least, inherently natural protective benefit of estrogen and maybe other hormones and stuff. But it shouldn't prevent a premenopausal woman from following a healthy lifestyle, right? Because there are premenopausal women who do wind up with cardiac disease, right?

Dr. Vitello:

Oh, absolutely, right. I think part and parcel for all of this is that you have to be as aggressive about lowering your risk early on and understanding what your risk factors might be to even understand how you can impact that risk for your lifespan. Don't wait until you've already developed the symptoms to then start making preventative actions in terms of helping your cardiovascular health. It starts at an early age in understanding how you can be proactive about this is very, very important.

Dr. Fialkow:

Well said. And on that note, just to summarize, women have very high rates of heart disease. It's not just a disease of men. Interestingly, women actually can have anatomical differences than a man. And sometimes even the reason they have cardiac disease, as you said, microvascular small vessels, the usual medical system is geared to its finding those large blockages.

Dr. Fialkow:

So when women have these symptoms, they should follow their body and make sure that it's addressed by someone who has that knowledge and that expertise. And then of course, hormonal differences, which might be driving that. And no excuse not to follow a healthy lifestyle, exercise, eating food in its most natural form, avoiding processed foods, a lot of refined foods, not smoking, et cetera.

Dr. Fialkow:

So to that end, any final comments, and maybe you could speak a little bit about how you uniquely address women with heart disease in your practice?

Dr. Vitello:

Certainly, I think that it's important to understand what one's risk is. So I do a fairly thorough history in making sure that I understand what type of symptoms they have, if they have any. And if they don't, what types of behaviors are they following on a regular basis? Are they being physically active? And if not, why is that the case? Is it because of symptoms that they might not be attributing to cardiovascular problems? Or is it because they've maybe found another reason not to be physically active? Looking at their blood pressures, their blood sugars, looking at their cholesterol disorders, understanding more about their pregnancy history, their other medical problems, cancer history, as well as another risk factor for cardiovascular disorders.

Dr. Vitello:

And then also helping them to create a timeline to schedule time so that they make healthy behavior changes. Making time for adequate physical activity, which is just as important as all other preventive measures that we do in medicine. Making time to make good dietary choices. And again, knowing what that looks like for them in their long-term health goals down the road.

Dr. Fialkow:

So very individualized, customized approach to the patient in whom you're evaluating, which is unique and certainly fantastic. Really appreciate that, Andrea, your time, your expertise. Lot more we can do in women in particular, women and heart disease. I'm sure we will have you back for our podcast to dive deeper into some of these topics, but it was a great overview. I really appreciate the info.

Dr. Fialkow:

And to our listeners, remember that you can send us your comments and suggestions for future topics at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. On behalf of everyone at Baptist Health, thanks for listening and have a safe and healthy holiday season.

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