CVD presents differently in women than it does in men—guidelines should reflect that
Over the past few decades, research has clearly shown that there are distinct characteristics of ischemic heart disease in women that are not seen in men. While women often need tailored diagnostic approaches for diagnosis and treatment, the one-size-fits-all approach using the male heart disease presentations as the standard of care has likely impacted female mortality in terms of cardiac deaths, which is the No. 1 killer in the world for both men and women.
Emily Lau, MD, director of the Cardiometabolic Health and Hormones Clinic at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, shed light on the critical issue of gender differences in chest pain imaging evaluations in sessions at the American College of Cardiology (ACC) 2024 meeting earlier this year. She spoke with Cardiovascular Business about her presentation.
“Women are more likely to present with non-obstructive coronary disease,” Lau explained. “This means they may not have significant blockages in their arteries, but they still experience symptoms of heart disease.”
In decades past, many women who presented with heart attack-like symptoms were found not to have a major coronary artery blockage, so they were discharged and sent home. In many cases, however, they had microvascular disease or spontaneous coronary dissections (SCAD).
Lau emphasized that ischemic heart disease manifests differently in women compared to men, impacting their diagnosis and treatment. She pointed out that women typically have smaller coronary arteries, greater vasomotor reactivity, and more significant endothelial shear stress, leading to a higher prevalence of non-obstructive coronary disease when presenting with angina.
'Yentl Syndrome' impacts clinical research and cardiovascular care in women
It has been found over the past 40 years that many women do present with atypical symptoms that differ the normal presentations. However, Lau was critical of the term "atypical" because it assumes symptoms of men are the norm, when in fact women have several symptoms of heart disease that differ from men but are very prevalent.
In her ACC presentation, she touched on the historical gender disparities in cardiovascular disease management and referenced the “Yentl Syndrome,” coined by cardiologist Bernadine Healy, MD, the first female director of the National Institutes of Health (NIH). Healy said like the 1983 movie "Yentl," where Barbra Streisand had to disguise herself as a man to attend school and study the Talmud, there is a tendency to disregard women’s cardiac symptoms unless they resemble those of men. Lau said this has led to under-diagnosis and under-treatment of cardiovascular disease in women for years.
Despite increased awareness about the sex differences in cardiovascular disease presentations, Lau pointed out that women remain underrepresented in clinical trials, with most large cardiovascular trials including only about 25-30% women. She called for more efforts to include women and racial and ethnic minorities in clinical research to ensure that the data reflects diverse populations.
Streisand, aware of the use of her movie title and role to call out discrepancies in women's cardiovascular care and research, in 2008 provided a $5 million endowment to Cedars-Sinai Hospital women's cardiovascular research heart center in her name.
Diagnosing heart disease in women
Lau discussed the importance of selecting the appropriate imaging modality based on the patient’s pretest probability and symptomatology. For low-risk women, such as young, healthy premenopausal women with atypical symptoms, an exercise treadmill test combined with cardiac ultrasound is usually recommended. Conversely, for women with a high suspicion of microvascular disease, cardiac perfusion PET or cardiac MRI are valuable diagnostic tools due to their ability to quantify coronary blood flow reserve and clearly diagnose microvascular disease.
Lau said the phenomenon of ischemia with non-obstructive coronary arteries (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) are more common in women. She highlighted the importance of further diagnostic evaluations in cases where initial tests show no significant blockages.
“For too long, if a woman’s coronary angiogram didn’t show obstructive disease, the diagnostic evaluation often stopped there. We need to continue investigating to identify other potential causes of ischemia or myocardial infarction,” Lau said.
There is a movement to change the cardiovascular diagnostic guidelines to include specific female presentations and to stop using the term "atypical." Lau said there is interest to include more specific sections on information on female cardiac presentations and the best tests to detect the causes of their symptoms. She said there also is interest in citing more clinical research to best guide therapy for women, rather than relying on the one-size-fits-all approach that is based on clinical data mostly from male patients.
“We need to acknowledge that there are abundant sex differences in the pathophysiology, diagnosis, and treatment responses of cardiovascular disease. Our guidelines need to be more precise and offer sex-specific recommendations," she explained.
Recent updates in guidelines have started to address these issues, but there is still a long way to go. Lau hopes that future guidelines will continue to evolve to better reflect the unique needs of women.
“Cardiovascular disease is a woman’s disease, not just a disease of middle-aged white men,” Lau concluded. “We must continue to emphasize this to our colleagues and patients to ensure that women receive the care they need and deserve.”
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com