Cardiology societies should develop separate guidelines for treating female heart patients
Cardiovascular disease remains the leading cause of death for women, and growing evidence shows that men and women experience heart disease in fundamentally different ways. Those differences need to be more fully reflected in clinical guidelines, according to Janet Wei, MD, Erika J. Glazer Chair in Women’s Cardiovascular Research, Education and Innovation at the Smidt Heart Institute at Cedars-Sinai Hospital.
She explained that heart disease is not a one-size-fits-all condition. Women have unique risk factors and distinct patterns of disease presentation that are often overlooked in current guidelines, which are mostly based on data from men.
"We've learned over the last couple of decades that women unfortunately have different types of risk factors that we need to consider beyond just the traditional risk factors. There are risk enhancers that are sex-specific, how a woman experienced their pregnancy actually relates to their future cardiovascular health. Did they have a premature menopause? Did they have an adverse pregnancy outcome like preeclampsia in pregnancy? Are they actually experiencing menopause at an earlier age? And so these are things that we do think will be important in understanding someone's cardiovascular risk," Wei explained in an interview with Cardiovascular Business.
Unique cardiac risks and presentations in women
"Cardiovascular disease, unfortunately, is the leading cause of death in women of all ages. And it is also the leading cause of death in pregnant and postpartum women. That's something that most people don't know," Wei stressed.
She said this is one reason interest has increased in the last decade in the field of cardio-obstetrics.
"Pregnancy is like a stress test for a woman. It's actually causes dynamic changes in heart rate, blood pressure and volume status. And for women who may have a predisposition to having a heart attack, to having heart failure or other valvular or arrhythmic diseases, it's a particular period of time that we need to pay close attention to their health," Wei stressed.
Women are also more likely than men to suffer heart attacks without significant blockages in the coronary arteries, a condition known as MINOCA (myocardial infarction with non-obstructive coronary arteries). Wei noted that microvascular dysfunction, coronary vasospasm and plaque erosion are more common among women, often making diagnoses more complex because its does not fit the traditional scenario seen in men where there is chest pain and a culprit coronary artery lesion causing a blockage. In the past, this lack of a clear artery obstruction often led women to being discharged and told if was nerves or digestive issues when they actually did have ischemic disease.
Traditionally, women also present with cardiovascular disease about a decade later than men. This is largely due to the protective effects of estrogen before menopause, Wei explained. However, she warned that cardiovascular mortality in women, especially those under 55, is on the rise again after a decade of decline.
"Unfortunately, the a statistics of cardiovascular mortality are rising. We had a significant improvement in mortality for both women and men in the prior decade, but in the last decade, we're seeing both women and men increasing mortality. And for women, it's the women who are under 55 where that we're seeing higher rates of cardiovascular disease," she said.
This underscores the urgent need for earlier risk assessment, particularly among younger women and those with a history of pregnancy complications or early menopause.
Rethinking cardiac treatment strategies in women
Women may also respond differently to cardiovascular medications and procedures than men. For instance, they face higher risks of bleeding after a heart attack or surgery and often benefit from less invasive strategies such as radial artery access for catheterizations.
In one session Wei chaired at the American Heart Association (AHA) 2024 meeting, speakers discussed the need to reassess antithrombotic therapy strategies and procedural planning, such as aortic valve sizing in transcatheter aortic valve replacements through a sex-specific lens.
Wei also emphasized that women have a higher risk for bleeding complications. She said physicians need to take that into consideration and try to balance ischemic risk versus bleeding risk.
She also highlighted emerging differences in how women respond to newer treatments like GLP-1 receptor agonists, commonly used for weight loss and diabetes. There is now evidence that women lose a lot more weight compared to men and there is ongoing research into whether or not this may impact their future cardiovascular outcomes.
Calling for sex-specific guidelines
With growing evidence of cardiovascular sex differences between men and women, Wei is among many cardiologists calling for major cardiovascular societies like the American College of Cardiology (ACC) and AHA to develop sex-specific guidelines.
"We need to separate the sexes and we need to better understand how hormones premenopause, postmenopause, perimenopause, all play into the management of women," Wei said.
As awareness increases and research continues to shed light on the distinct cardiovascular needs of women, Wei believes the future of heart care will move away from generic models and toward truly individualized, sex-specific medicine.
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: [email protected]