Heart disease is the number one killer of women in the United States. As many women as men die from it each year. Yet it’s still often thought of as a man’s disease — and signs of it can be overlooked by both women and their doctors.
That’s because researchers have only begun to gather information about what heart disease looks like in women during the past decade, says Martha Gulati, MD, an associate professor of medicine in cardiology and public health at The Ohio State University. Gulati is an expert in women’s heart health and the co-author of a 2013 review of best practices for heart disease treatment in women.
In 2006, the Women’s Ischemia Syndrome Evaluation (WISE) study reported findings that surprised many doctors: women with heart disease did not show the common pattern observed in men, in which arteries become blocked by plaque made of cholesterol. Instead, in women, plaque frequently builds up evenly around the arteries, narrowing the blood vessels yet not blocking them. As a result, women may experience the symptoms of ischemia, such as chest pain during exertion, but “pass” gold-standard tests for heart disease like an angiogram, which looks at the condition of arteries.
As a result, Gulati says, women often undergo repeated testing without receiving a diagnosis — never mind relief from their symptoms. It’s a “big public health issue,” she says. The WISE study estimated that women with heart disease are tested to the tune of $750,000 over their lifetime. Those with obstructed heart vessels, by comparison — often men — cost just over $1 million across a lifetime, usually because they’re receiving stents or coronary bypass surgery to alleviate blockages.
Researchers are increasingly looking at how heart disease progresses in women, but there’s still a lot they don’t know, Gulati says. “We’re spending a lot of money on these women. They’re coming to the hospital again and again, and yet we don’t know how to diagnose them, and we don’t know how to treat them.”
When blood vessels narrow without being blocked, it’s increasingly known as coronary microvascular disease. It might also be called small-vessel disease, microvascular disease, or endothelial dysfunction. “The reason there’s so many different names is that we don’t have this completely figured out,” Gulati says. “Are there certain medications that work in these women that are specific for this disease? That’s the area of research that’s going on right now.”
Even if researchers don’t yet know the best way to treat coronary microvascular disease, one thing is clear: women who have it should still receive standard care, Gulati says. “You don’t ignore them even if they don’t have obstructive disease. Maybe you do additional testing to try to find out if the small vessels are involved … but you wouldn’t take them off everything and say, well, they don’t need aspirin, they don’t need a cholesterol-lowering agent, they don’t need the full standard of care. If they have signs and symptoms of ischemia, we treat them fully.”
National data, Gulati says, shows women often aren’t given life-saving medications like aspirin or techniques like cardiac catheterization, or they don’t receive treatment quickly enough. "Even when women have obstructive coronary artery disease, they’re not getting the same treatment compared to men," she says. Women of color are most at risk. "Black women notoriously get the worst treatment when you look at the national data. We have to change it."
Until researchers understand how heart disease presents differently in women, “women have to be their own biggest advocates,” Gulati says.
Ask your doctor, she suggests: Are you sure it’s not my heart? Am I at risk for heart disease? What can I do to reduce my risk? If you’re in the hospital with symptoms, ask: Did I have a heart attack? Are you sure I didn’t? “The risk for heart disease or stroke right now is really about one in two for women, and we should always be asking these questions,” Gulati says.
If you’ve had a heart attack and your doctors don’t find any vessels to put a stent in, she says, you should either be referred to a specialist who looks at women with microvascular disease, or get additional testing. If doctors don’t find an obstruction in an artery, “it shouldn’t just stop there,” she says, “like, ‘We’re done.’ That’s the most important thing.”
“If you aren’t getting answers about why this happened, then seek out someone who will answer your questions,” she advises. “Is there anything you can do to change your lifestyle, or is there a medication that might save your life? That’s ultimately what we all want.”
Watch this dramatic representation of a heart attack in women.
September 22, 2015
Christopher Nystuen, MD, MBA