Women with severe aortic stenosis remain underdiagnosed, undertreated—here’s how cardiologists can make a difference
Women with cardiovascular disease (CVD) are consistently underdiagnosed and undertreated compared to men, and those disparities are true for aortic stenosis (AS) as well. Women with symptomatic severe AS (ssAS) are up to 35% less likely than men to undergo aortic valve replacement (AVR),1 for example, and they often have to wait longer just to be referred for further care.2
Cardiologist Nisha Parikh, MD, director of the Women’s Heart Program at the Northwell Cardiovascular Institute in New York City, says the unequal treatment of male and female heart patients is nothing new.
“CVD has always been seen as something that primarily affects men,” she explains. “In fact, decades ago, public health pamphlets were created for women to make sure they would help take care of their husband’s heart health—all without really recognizing that women also were affected by CVD.”
However, there have been considerable improvements in recent years as clinicians, researchers and even device manufacturers have started to understand that CVD and ssAS are issues that impact women just as much as they impact men. Parikh adds that even more improvements can be seen if cardiologists can continue to educate themselves, and the patients they serve, about this subject.
Increasing awareness about aortic stenosis in women
Awareness among cardiologists around the different ways men and women present with ssAS is the primary reason these disparities in care have started to fade.
Male heart patients, for instance, typically report symptoms more commonly associated with AS such as chest pain or syncope. In female heart patients, however, AS makes its presence known in surprising ways. 3,4
“Women tend to present with atypical symptoms for AS,” Parikh explains.4 “They may experience dizziness and/or fatigue, for example, but dizziness and fatigue could be related to many other things. That patient, and even her physician, may miss the fact that it is a result of a serious heart condition.”
Even when women do present with more typical symptoms, she adds, “we still tend to dismiss it and attribute those symptoms to something other than CVD or normal signs of aging. There’s still this communication gap with physicians at play that we have not totally solved.”
Another difference is the fact that women are more likely to present with a small aortic annulus than men. And because small annuli patients are more likely to be affected by AS, this puts women at a disadvantage.5 Knowing in advance that a female patient is more likely to present with a small annuli can help cardiologists deliver the best care possible and even anticipate potential issues such as prosthesis-patient mismatch (PPM) down the line.
Women also present with symptoms later in life than men, which means the average female heart patient is older, more likely to be frail and may present with more comorbidities than the average male heart patient.2 All of these factors can have cardiologists thinking twice about treatment, either with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Data show that the end result is fewer women being referred for a valve replacement.1
Now that more is known about these differences, it is up to care teams to reconsider how they think about the heart health of their female patients. Moderate AS should be monitored more closely, Parikh says, to ensure the patient is not “lost to follow-up” and a treatment plan can be finalized as soon as it is necessary. In addition, there are steps providers can take to bring in patients earlier for imaging assessments.
“Family or cascade screening is one way to see that more female patients are evaluated,” she says. “Bicuspid aortic valves (BAV) can increase the risk of AS,6 for instance, so if you are able to identify BAV patients, early screening may provide some real value.”
Patient education a key piece of the aortic stenosis puzzle
Communicating with women about their heart health is vital to improving care. Knowledge is power, and the single quickest way to help patients is making them aware of the symptoms, available treatments and outcomes associated with ssAS
“We don’t talk enough about the fact that women do have favorable short- and long-term outcomes when their ssAS is treated appropriately. They even have better reverse remodeling after AVR than men, so their hearts normalize to a greater extent following treatment. That is a message our general cardiology community needs to hear so they can communicate it to their patients.”
Nisha Parikh, MD, Director of the Women’s Heart Program, Northwell Cardiovascular Institute
General cardiologists can have a significant impact here. They generally have known their patients for an extended period of time and have many opportunities to speak with them.
“We don’t talk enough about the fact that women do have favorable short- and long-term outcomes when their ssAS is treated appropriately,” Parikh explains. “They even have better reverse remodeling after AVR than men, so their hearts normalize to a greater extent following treatment.4 That is a message our general cardiology community needs to hear so they can communicate it to their patients.”
Getting more patients involved in shared decision-making as early as possible also keeps them informed, allowing them to play an active role in their healthcare.
“Choosing the right treatment for symptomatic severe AS, TAVR or SAVR, should involve the entire medical team,” Parikh says. “A lot of centers now have these multidisciplinary valvular clinics where surgeons, interventional cardiologists, structural cardiologists, and general cardiologists can all communicate with one another as well as with the patient. That can be really valuable.”
Get SMART: Why clinical trials should enroll more women
One of the most impactful ways clinicians can improve care for women with ssAS is getting more of them involved in clinical research. Most trials focused on cardiac health only enroll 30% or 40% women,7 making it much harder to know how the technology or treatment being evaluated will affect a female patient.
“Historically, we have designed our heart treatments for men,” she explains. “Researchers thought these diseases impacted men more than women, so they recruited more men than women. It could be why, for example, we see things such as PPM more often in female patients. It’s a self-perpetuating issue, really, and we need to break free from it.”
The researchers behind the recent SMART (SMall Annuli Randomized To EvolutTM or SAPIENTM) trial looked to buck that trend. SMART compared TAVR patients with a small aortic annulus treated with supra-annular, self-expanding valves (Evolut TAVR), and intra-annular balloon-expandable valves (SAPIEN TAVR). Some 87 percent of patients enrolled in the SMART trial were women, far exceeding the industry standard.8
“I commend Medtronic and the SMART trial researchers for setting an example and enrolling so many women in that trial,” Parikh says. “It’s important to have valves that are designed with the anatomy of women in mind, and it’s just as important to have valves that can address the risks associated with a small annulus. These are both major issues that we need to continue studying.”
Looking ahead
While women with ssAS may remain underdiagnosed and undertreated, there is hope on the horizon. If cardiologists can continue to learn more about how women present with atypical symptoms of AS, embrace patient education and enroll more patients into clinical trials, the future for this high-risk, historically marginalized patient population is bright.
“We have come a long way in how we take care of our female heart patients” Parikh says. “Now that we’ve started getting these messages out, both to cardiologists and to the patients themselves, we are seeing real progress.”
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Additional data about treating aortic stenosis in women is available here.
References:
1. Rice CT, Barnett S, O'Connell SP, et al. Impact of gender, ethnicity and social deprivation on access to surgical or transcatheter aortic valve replacement in aortic stenosis: a retrospective database study in England. Open Heart. September 2023;10(2):e002373.
2. Stehli J, Johnston R, Duffy SJ, Zaman S, Gusberti TDH, Dagan M, Stub D, Walton A. Waiting times of women vs. men undergoing transcatheter aortic valve implantation. Eur Heart J Qual Care Clin Outcomes. 2023 Nov 2;9(7):691-698.
3. Nau DP , Ellis JJ , Kline-Rogers EM, Mallya U, Eagle KA, Erickson SR. Gender and perceived severity of cardiac disease: evidence that women are “tougher.” Am J Med. November 2005;118(11):1256–1261.
4. Iribarren AC, AlBadri A, Wei J, Nelson MD, Li D, Makkar R, et al. Sex differences in aortic stenosis: identification of knowledge gaps for sex-specific personalized medicine. Am Heart J Plus Cardiol Res Pract. (2022) 21:100197.
5. Herrman, H.H., Desai, N.D., Incidence, Implications, and Treatment pf patients with Severe Aortic Stenosis and Small Aortic Annulus. Circulation. Feb 2024. 149(9),656-657.
6. Harris C, Croce B, Munkholm-Larsen S. Bicuspid aortic valve. Ann Cardiothorac Surg. 2017 Nov;6(6):721. doi: 10.21037/acs.2017.11.07. PMID: 29270387; PMCID: PMC5721100.
7. Jin, X., Chandramouli, C., Allocco, B., et al. Women’s Participation in Cardiovascular Clinical Trials from 2010-2017. Circulation. 2020; 141:540-548. DOI:10.1161/CirculationAHA.119.043594
8. Howard C. Herrmann, MD, Roxana Mehran, MD, Daniel J. Blackman, MD, et al. Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus. NEJM. April 7, 2024.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.