Heart Disease in Women

Aka: Heart Disease in Women, Coronary Artery Disease in Women, Cardiovascular Disease in Women

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II. Pathophysiology: Contributing Factors Specific to Women

  1. Premature Coronary Artery Disease affects women to greater extent than men
  2. Obstetric cardiovascular complication associated delayed risks (typically >10-12 years after pregnancy)
    1. Preeclampsia
      1. Post-pregnancy Hypertension (RR 3.4)
      2. Ischemic Heart Disease (RR 2.2, and increases to RR 7.7 if PIH at <37 weeks)
      3. Cerebrovascular Accident (RR 1.8)
    2. Gestational Diabetes
      1. Cardiovascular disease in first 10 years after pregnancy (RR 2.0)
      2. Li (2018) Diabetes Res Clin Pract 140:324-38 [PubMed]
    3. Obesity
      1. Excessive weight gain during pregnancy and difficulty losing weight after pregnancy
      2. Obesity is associated with increased heart disease risk (RR>2) and stroke
      3. Associated increased risks include Obstructive Sleep Apnea
    4. Other pregnancy related complications that increase cardiovascular disease risk
      1. Miscarriage (OR 1.45, increases to 2.0 in Recurrent Miscarriage)
        1. Oliver-Williams (2013) Heart 99(22): 1636-44 [PubMed]
      2. Preterm Birth (RR 1.56)
        1. Wu (2018) J Am Heart Assoc 7(2): e007809 [PubMed]
      3. Placental Abruption (OR 1.8)
      4. References
        1. Grand (2019) Circulation 139(8): 1069-79 [PubMed]
  3. Hormonally-related issues
    1. Hyperandrogenic states
      1. Polycystic Ovary Syndrome (PCOS) is associated with a doubling of cardiovascular disease risk (RR 2)
      2. de Groot (2011) Hum Reprod Update 17(4): 495-500 [PubMed]
    2. Premature Menopause (before age 50 years)
      1. Includes surgical Menopause or other hypoestrogenemia cause
      2. Median time of 12 years from Menopause to cardiovascular disease
      3. Increases risk of first cardiac event before age <60 years (but risk returns to baseline by age 70 years)
      4. Zhu (2019) Lancet Public Health 4(11): e553-64 [PubMed]
    3. Hormone Replacement Therapy
      1. Variable cardiovascular and cerebrovascular risks
      2. Hormone Replacement Therapy is only recommended for symptomatic management (not for disease prevention)
  4. Vascular conditions more common in women
    1. Spontaneous Coronary Artery Dissection (SCAD)
    2. Aortic root dissection
    3. Vasculitis or Collagen vascular disease
      1. Systemic Lupus Erythematosus (RR 50 for women with SLE age 35 to 44 years)
        1. Manzi (1997) Am J Epidemiol 145(5): 408-15 [PubMed]
      2. Rheumatoid Arthritis (RR 1.5 increased cardiovascular mortality)
        1. Avina-Zubieta (2008) Arthritis Rheum 59(12): 1690-7 [PubMed]
    4. Stress Cardiomyopathy
      1. Transient myocardial syndrome with extreme stress
  5. Mental health conditions
    1. Major Depression (RR 2 for Cardiovascular Disease in Women)
      1. O'Neil (2016) J Affect Disord 196:117-24 [PubMed]
    2. Emotional Stress
      1. Kivimaki (2018) Nat Rev Cardiol 15(4): 215-29 [PubMed]
    3. Adverse Childhood Events
      1. Soares (2020) Heart 106(17): 1310-16 [PubMed]

III. Findings: Acute Chest Pain Presentations in Women

  1. See Chest Pain
  2. See Acute Coronary Syndrome
  3. Women often present atypically with Myocardial Infarctions
    1. Common presenting coronary equivalents include Dyspnea, weakness, Nausea, Palpitations, Syncope
      1. Chest Pain or pressure may be completely absent
      2. Results in women with ACS on average presenting 2 hours after men
    2. Even prior stress testing may have been falsely reasuring
      1. Non-occlusive CAD is twice as common in women
      2. Non-occlusive Plaque may embed within artery wall, erode and cause acute thrombus or vasospasm
    3. Presentations are more similar as men and women age (contrary to prior doctrine)
      1. By age 75 years old, both men and women present without Chest Pain in 50% of cases
    4. Greatest discrepancy between male and female ACS presentations are in the under age 45 cohort
      1. Women with MI under age 45 present without Chest Pain in 20% of cases (contrast with 13% in men)
      2. Spontaneous Coronary Artery Dissection (SCAD) represents 40% of MI in women age under 50 years
    5. References
      1. Canto (2012) JAMA 307(8): 813-22 [PubMed]
      2. Pepine (2015) J Am Coll Cardiol 66(17): 1918-33 +PMID:26493665 [PubMed]
  4. Myocardial Infarction symptoms in younger women are often atypical
    1. Chest Pain
    2. Back, neck, Shoulder, or Abdominal Pain
    3. Shortness of Breath
    4. Nausea or Vomiting
    5. Cold sweats
    6. Fatigue
    7. Weakness
    8. Anxiety
    9. Anorexia

IV. Evaluation

  1. See Cardiac Risk Assessment
  2. ASCVD Risk Estimator
    1. https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
  3. ASCVD Risk Estimator, Framingham Score and NCEP III guidelines underestimate risk in women
    1. Does not account for Obesity, inactivity, Hypertriglyceridemia, Family History
    2. Women are under-represented in cardiovascular research studies
  4. Reduced non-invasive stress Test Sensitivity in women
    1. Women often have single vessel disease
    2. Women more often fail to reach a maximal stress test (>5 Mets are required)
    3. ST depression and Chest Pain with Exercise are not good predictors in women

V. Management

  1. See Cardiac Risk Management
  2. General monitoring and management
    1. Blood Glucose
    2. Lipid Panel
    3. Blood Pressure
    4. Healthy Body weight (and BMI reduction in Obesity)
    5. Tobacco Cessation (and other Substance Abuse management)
    6. Exercise Program (150 minutes moderate Exercise per week)
    7. Healthy Diet (e.g. Plant Forward Diet)
    8. Major Depression screening and management
  3. Pregnancy related complication monitoring
    1. Hypertensive Disorders of Pregnancy
      1. Gestational Hypertension should normalize by 12 weeks post-partum
      2. Evaluate and manage as Hypertension if persists
    2. Gestational Diabetes Mellitus
      1. Screen for Diabetes Mellitus at 12 weeks postpartum
      2. See Gestational Diabetes Management for postpartum protocol
  4. Cardiovascular Risk-Based
    1. Cardiovascular Risk estimation based on ASCVD Risk Estimator (see above)
    2. Follow general monitoring and management measures as above
    3. ASCVD Risk 5 to 20%
      1. Consider contributing risks in women as above (e.g. pregnancy) and general Cardiac Risk Factors
      2. Consider Statin (esp. for ASCVD risk >7.5 to 10%)
      3. Consider Aspirin 81 mg daily (ASCVD risk >=10% and age 40 to 59 years)
    4. ASCVD Risk >20%
      1. Statin
      2. Consider Aspirin 81 mg daily (age 40 to 59 years)

VI. References

  1. Westfall (2023) Am Fam Physician 108(6): 595-604 [PubMed]

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