It’s great to see State street adorned with American Heart Association (AHA) flags to celebrate American Heart Month. Though for a cardiologist, every month should be heart health month, it does help to intensify the message every February.
February also celebrates the Go Red for Women campaign, a remarkably successful cause campaign launched in 2003 aiming to raise awareness about cardiovascular diseases (CVD) in women. I remember when I was first captivated by the emerging story surrounding women and CVD. It was at the start of the new century and there was no denying the data. CVD had been the most common cause of mortality in the United States for more than 50 years but it wasn’t till two decades ago that we noted a disturbing trend-one that could no longer be ignored.
Each year, the American Heart Association (AHA) updates heart disease and stroke statistics in the United States. It is a comprehensive and exhaustive evaluation of the impact of CVD on the US population as a whole. The document is rich with data on everything from mortality trends to survey results regarding all the known risk factors that drive CVD. It breaks down data by type of CVD (six different diagnoses make up CVD; coronary heart disease and stroke are the two most prevalent), sex, age and race.
The figure I remember most vividly was one that compared CVD related mortality in men and women over time. Starting in 1979, with the help of research improving our understanding of CVD and development of advances in pharmacotherapy and mechanical treatment of coronary heart disease, men derived a drastic and steep decline in mortality. A trend which was good reason to celebrate. In complete contrast, the mortality trend line among women was climbing, reaching its peak in the year 2000. And with this, the mortality gap in CVD between men and women was widening and caught us (the medical community) completely off guard. We would spend the next two decades first deconstructing the possible explanations for this trend and then use the power of science, education and social media among other things to construct the solution.
The Go Red for Women campaign became the microphone through which we would spend the next two decades disseminating the message about the under recognized risks of CVD in women. In addition to spreading the word about the risk of CVD, the campaign has had immense impact through various other avenues. Advocacy efforts led to passage of the Heart Disease Education, Analysis, Research, and Treatment (HEART) for Women Act in 2011 mandating that there be adequate representation of women, racial and ethnic minorities in clinical studies, that studies be powered to examine sex specific outcomes and that there be a report on the quality and access of care for women with CVD. The campaign continues to go red and strong, now existing in over 50 countries and helping to continue to fight for the cause.
Over the last two decades, we have uncovered many striking differences in CVD which are specific to women. First, it didn’t take a deep dive to realize that part of the explanation for the worrisome mortality trends was related to perception. Women did not perceive themselves at risk for CVD and furthermore, providers did not think women were at risk for CVD, in particular heart disease. Women who were at risk were unaware and even when they had more pressing symptoms, they were more likely to present late in the course of what often was a heart attack.
Second, there was concern that women did not have classic symptoms of what is infamously known as the ‘Hollywood heart attack’ (man clutching his chest and falling to the ground). Thanks to detailed study on sex differences in symptoms, we now know that women are more likely to have atypical symptoms, but the vast majority actually do have typical symptoms at the time of their heart attack. Women had to be reminded to pay attention to symptoms which were not usual for them and were occurring with exertion or stress.
Third, we have discovered that not only are women at risk for what we have considered a traditional heart attack where there is visible narrowing of the heart arteries, but they are also having heart attacks with open arteries. Women can have chest pain symptoms with testing suggesting impaired blood flow to the heart muscle without narrowing of the main heart arteries. These two entities, myocardial infarction with open arteries and microvascular angina are almost always seen in women and have led to the hypothesis that there are sex differences in how atherosclerosis effects blood vessels with women being more likely to have diffuse disease of the major heart arteries and being more likely to have problems with the small microvessels. This becomes important when considering treatment options as medical therapy plays a larger role in treating these entities.
In addition, we have uncovered two fascinating diagnoses which are not new but have been under recognized. Both are almost exclusively seen in women. First, the Broken Heart Syndrome (also known as Takastubo syndrome) has been described now in thousands of cases and is a heart attack which is usually triggered by an emotional event. The usual presentation is a woman presenting with classic signs and symptoms of a heart attack after witnessing something emotional and or tragic. The heart arteries have no blockages but the heart muscle appears to be stunned. Most patients are treated supportively and make a full recovery. The other is known as Spontaneous Coronary Artery Dissection or SCAD. SCAD occurs in younger women and presents like a heart attack. When the heart arteries are evaluated, there appears to be a spontaneous tear one of the heart arteries. Though the exact cause of SCAD is not confirmed, we have learned through large patient registries that conservative treatment over mechanical treatment is preferred and safest.
Finally, as the treatment armamentarium expanded for women presenting with heart attacks, we started to notice sex specific risks of treatments. For example, women undergoing invasive treatments such as heart catheterizations and stent placement were noted to have increased risk of procedural bleeding and with it were having worse outcomes. This sex specific risk is thought to multifactorial with some of the explanation is related to anatomical differences in arteries and some related to differences in the effects of blood thinners and their metabolism. In an attempt to mitigate the bleeding risk, current practice as evolved away from using drugs which are associated with increased bleeding and most importantly, we have transitioned to using the smaller, safer radial artery as the default site for procedural access. This has had enormous impact on bleeding complications and has preferentially improved outcomes among women given their predisposition.
These are just a few of the many lessons we have uncovered trying to navigate our way to answers about women and CVD in the 21st century. As I re-examine the mortality curve, just as the problem had drawn our attention in 2000, the progress is loud and clear in 2016. It has been remarkable to take a 20/20 hindsight view in the year 2020 of where we were and where we have come in 2 decades. The colossal team effort speaks to the power of science, community, advocacy and universal commitment to ensure that we study and treat all at risk for CVD, especially women and minorities. Though much more work is needed and continues, there is no denying where the heart is on the matter of women and CVD.
Dr Ahmed is an Interventional Cardiologist at Santa Barbara Cardiovascular Medical Group and was formerly Assistant Professor of Medicine at the Geisel School of Medicine. Dr. Ahmed completed Internal Medicine residency at the University of Massachusetts, a Women’s Health fellowship at Cedars-Sinai Medical Center, followed by general Cardiology and Interventional Cardiology fellowships from the University of Vermont. Read On