- According to a new study, women may be twice as likely to experience a fatal heart attack compared to men.
- Women have several unique risk factors that may explain this higher risk, including premature menopause, pregnancy complications, gestational hypertension, and delivering an infant that is premature.
- Other risk factors for heart disease in women include more well-known issues: diabetes, blood pressure, smoking, and family history.
- Women are frequently underrepresented in research for cardiovascular disease, and many unique risk factors and symptoms are often poorly understood.
Cardiovascular disease is the leading cause of death around the world, according to the World Health Organization. While cardiovascular disease does not discriminate against gender, men are more likely to have cardiovascular conditions than women.
But new research is showing that women may be more than twice as likely to die after a heart attack than men.
“There are a lot of prior studies that have shown poor outcomes among women after heart attacks, and we attributed those differences to the fact that we know women are older when they present with heart attack and have more associated comorbidities,” said Dr. Anais Hausvater, a cardiologist at NYU Langone Heart, specializing in women’s heart health who was not involved in the study. “But in this study, they adjusted for those factors and compared younger women. These findings tell us that there is more to it.”
The study, which was presented at Heart Failure 2023, a scientific congress of the European Society of Cardiology, was a retrospective observational study. It included 884 patients with an average age of 62 years. Twenty-seven percent were women.
Increased heart attack risk among younger women
As Hausvater indicated, previous studies have found that women with ST-elevation myocardial infarction (STEMI) have a worse prognosis during their hospital stay compared to men.
“A STEMI is the highest risk type of heart attack, where every minute counts. This is the type of heart attack when you’re running the patient to the cardiac cath lab. Every minute of delay can contribute to worse outcomes,” said Hausvater.
Those studies attributed those findings to older age and an increased number of comorbidities. This study, however, compares short- and long-term outcomes after STEMI in women and men and looked at whether the differences in gender were apparent in both premenopausal women (55 years and under) and postmenopausal women (over 55).
The study followed patients admitted with STEMI and treated with PCI within 48 hours of symptom onset over a five-year period. Adverse outcomes were defined as 30-day all-cause mortality, five-year all-cause mortality, and five-year major adverse cardiovascular events (MACE).
Of those studied, women had higher rates of high blood pressure, diabetes, and prior stroke. Men were more likely to be smokers and have coronary artery disease.
The researchers compared the risk of adverse outcomes between women and men after adjusting for other factors like diabetes, high cholesterol, hypertension, coronary artery disease, heart failure, chronic kidney disease, peripheral artery disease, stroke, and family history.
At the 30-day mark, 11.8 percent of women had died compared to 4.6 percent of men. At five years, 32.1 percent of women had died versus 16.9 percent of men, and 34.2 percent of women experienced MACE within five years, whereas 19.8 percent of men experienced MACE.
Unique heart disease risks for women can lead to a delay in care
“We know that there is some protective effect of estrogen and that postmenopausal women tend to have higher risk,” said Hausvater. “But we’re seeing in the last 10 years heart attacks among younger women, which is concerning. A lot of that likely has to do with the fact that there are risk factors for heart disease unique among women that are under-recognized.”
Hausvater said that these potential risk factors can include premature menopause, pregnancy complications, gestational hypertension, and delivering an infant that is premature.
“All of those increase risk but are not captured by doctors, and women don’t know that they are risk factors for heart disease. We know from survey studies that women tend to be less aware of their heart disease risk.”
Heart attack symptoms in women
According to the American Heart Association, women are frequently underrepresented in research for cardiovascular disease, which can paint an incomplete picture when understanding how the disease affects different genders.
According to the AHA, “Some risk factors for heart disease are specific to women, such as risks related to menopause and treatments for breast cancer, and some, such as depression, carry a different risk for cardiovascular disease in women than in men.”
“Psycho-social stress is another risk factor important for women and women, but especially women,” said Hausvater. “Increased stress, depression, and anxiety is a factor of heart disease that tends to affect women more.”
A lower recognition of symptoms of heart disease could be one of the contributing factors to this study’s findings. Increasing women’s knowledge of heart disease symptoms could help prevent adverse outcomes.
“Chest pain is the most common among men, but women tend to have multiple symptoms at the same time. They may also have shortness of breath, fatigue, and nausea. But because the symptoms are different, it can mean a woman delays in seeking out care. It can also delay treatment when in the hospital.”
More research is needed
This study was an important step in understanding the unique risks of heart disease for women. But more work is needed to understand the full picture.
“The other thing to consider is that we know a lot of the treatments we use for heart attacks, like medication and other treatment options, have been studied in large trials predominantly made up of men. Women are very much under-represented in all of these clinical trials. It’s possible they are less effective in women, and we need proper representation of women in these trials,” said Hausvater.
Increased awareness can save lives
All of the traditional cardiac risk factors are equally important for women, such as a history of diabetes, blood pressure, smoking, and family history. But for patients who are women, there are additional specific risk factors.
“I would say both women and providers need to be aware of these risk factors to understand their risk for heart disease,” said Hausvater. “If I’m seeing a patient like this in the clinic, I would adjust my risk assessment and it might lower my threshold to start a cholesterol medicine. My recommendations for lifestyle intervention would be much stricter if I felt they were at higher risk. It is important to understand the risk.”