Cardiovascular disease in women is an integral area of research in the ongoing studies of women's health. Cardiovascular disease (CVD) is an umbrella term for a wide range of diseases affecting the heart and blood vessels, including but not limited to, coronary artery disease, stroke, cardiomyopathy, myocardial infarctions, and aortic aneurysms.
Since the mid-1980s, CVD has been the leading cause of death in women, despite being presumed to be a primarily male disease. Two types of CVDs are shown to be the leading causes of death in women globally, according to the World Health Organization: ischemic heart disease and stroke. Although, on average, women will develop CVD 5-10 years later than men, the overall number of CVD diagnoses in men and women is similar.
Until recently, the gender-specific data available on cardiovascular disease (CVD) have been sparse for numerous reasons. The risks of CVD were unaccounted for in women due to gender biases, under-representation in clinical trials, and lack of research. These factors contributed to an increase in preventable deaths in women due to CVD. Thus, this is now an integral area of research in the ongoing studies of women's health.
Overall, these factors are instrumental in the key differences seen in CVD presentation, which must be accounted for in diagnostic and treatment practices by healthcare providers.
Diagnostic gap Cardiovascular disease in women may be misdiagnosed or underdiagnosed for several reasons. CVD, especially heart attacks, often presents symptoms in women differently than in men due to anatomical and hormonal differences. Research has shown that women may present with symptoms that are classically associated with heart attacks, such as chest pain and shortness of breath, but also with atypical symptoms such as neck, jaw, arm, or shoulder discomfort, nausea or vomiting, heartburn or indigestion, fatigue, headaches, and palpitations. Some healthcare providers may misidentify the causes of these symptoms, attributing them to gastrointestinal or psychological causes instead.
Moreover, although certain factors traditionally associated with developing CVD include age, high blood pressure (hypertension), smoking, diabetes mellitus, and abnormal amounts of cholesterol in the blood, and are similarly influential on women as on men, recent research has found additional risks that should be added to this list as non-traditional or emerging factors. These include pregnancy-associated disorders such as pre-eclampsia and gestational diabetes, polycystic ovary syndrome, and even depression. This discrepancy is furthered by the under-enrollment of women in research studies, establishing a CVD treatment baseline in women for healthcare practitioners.
Furthermore, the anatomical features of the cardiovascular system differ in size between men and women. The size of the vessels in women is generally smaller than in men. Thus, a smaller blockage can cause as much damage to women as a regular-sized blockage in men. Women also have a smaller ventricle size than men. This lowers the volume pumped out of the ventricle to the rest of the body, thus requiring a faster heartbeat faster to ensure a similar amount of blood is pumped out as men. These differences in addition to the cardiovascular functional differences, i.e. a slower fight or flight response, sympathetic activity, and a high rest and digest response, parasympathetic activity, may result in differing presentations of women's illnesses.
Shifts and trends According to a survey conducted by the AHA in 2000, women are now more aware of CVD as the leading cause of death in women than in 1997. Close to 90% of women are now aware that women experience heart disease symptoms gradually in later years and that the initial hours of treatment are critical to reducing damage to the brain and heart. This is further supported by a study done in Italy in 2022 that found a vast majority of their participants were able to successfully identify CVD as a leading cause of death in women.
However, many women are still unaware of the impact of CVD on women's health. This may be due to infrequent exposure to the concerns of a deficit of personalization in education to these groups, and little involvement of women in CVD research until 1986. Numerous studies have noted that many women were unable to identify common risk factors or acknowledge whether they were at possible risk of developing CVD, with quite a few even believing that CVD was a male-exclusive condition.
This lack of awareness appears to be prominent in women aged 25 to 34 years. Nearly 72% of women in this age group consider cancer to be the leading cause of death; however, as age increases, the understanding of heart disease has also been shown to increase. A national survey conducted by the AHA in 2012 suggested increased rates of awareness and consciousness. According to the fifteen-year trend report, some of the significant changes are as follows: In 2012, the level of awareness increased in women from different ethnicities, with percentages rising to 65% white, 36% black, and 34% Hispanic. In terms of knowledge of the symptoms of a heart attack, 18% of women responded with nausea, while 56% responded with chest pain. In case of experiencing a heart attack, 10% of Hispanic women were reported to initially take aspirin, compared to 22% of black and 18% of white women. The top 3 health management issues were reported to be exercise (by 49% of women), weight (by 47%), and cholesterol (by 45%). Analysis of data suggests further improvement in the educational efforts and awareness among women, especially of racial and ethnic minorities, as they face higher mortality rates. As a follow-up, a recent 2019 AHA survey of the awareness of CVD being the leading cause of death in women has shown a decline in the last decade. The greatest differences were seen among Hispanic women, non-Hispanic Black women and the age group of 25 to 34 year old. These trends are similar to those found in the 2012 survey done by the American Heart Association. This shift in knowledge demonstrates a need for cardiovascular health programs targeted to women to ensure that they can successfully access the needed resources to ensure successful CVD treatment and prevention.
Moreover, trends have also demonstrated a difference in CVD risk and treatment amongst women from different ethnicities. In the 1980s, African American women had double the mortality rates compared to other women between the ages of 30 and 39. Although this number has improved, in comparison to white women, the disparity persists. A 2007 study that black and Hispanic women were nearly half as aware (31% and 29% respectively) than their white counterparts (68%). This is alarming as minority groups are at an increased risk of higher cholesterol levels and many other risk factors that cause CVD. Studies have found this may be due to lack of educational intervention being targeted to these groups to ensure equity access to health resources.
Future research is working to establish gender-specific guidelines and ensure that treatments, diagnoses, and overall practices are adjusted to encompass the differences of women with CVD in clinical application.
Signs and symptoms CVD is the leading cause of death in women worldwide. Studies have shown a recent successful decline in CVD mortality overall. However, there is a strong indication for male-specific reductions being implemented in practice; thus, female mortality remains high, despite the incidence of CVD being lower. The number of women surviving and dying from CVD far outweighs the number of men in comparison.
Due to anatomical and biological differences, women with CVD have been shown to present with the expected symptoms, as well as unusual and unexpected symptoms of CVD in comparison to men. The traditional, or common, symptoms seen in both men and women include:
Chest pain or feeling of crushing pain in the chest Radiating pain in the arms or shoulder Heartburn
However, some studies have shown that chest pain is not as common a symptom in women. Thus, its absence cannot rule out the likeliness of CVD.
For the atypical symptoms, numerous symptoms are often vague and seem unattached to specific diagnoses. Women generally develop angina and are less likely to present with myocardial infarction at the onset of cardiovascular diseases. The other symptoms to account for include:
Pain or discomfort in the neck, jaw, upper back, or abdomen Shortness of breath Nausea/vomiting Sudden and random sweating Fatigue Lightheadedness or dizziness
Overall, these symptoms seem to be more present at rest than at any other time of day for women and at times of emotional distress. Women also tend to report milder symptoms, while also experiencing a combination of more symptoms than men.
To ensure that practitioners can detect all cases and forms presented to them, it is crucial to ensure that women's diagnostic tests are adjusted to include all these symptoms.
Risk factors Numerous risk factors are associated with developing CVD. A number of them are considered traditional, as they are found in men and women with CVD at high rates. However, there are also unique risk factors found only in women that are commonly associated with this group developing CVD. The following list includes the predominant ones found in many cases of CVD in women.
Smoking Smoking has been well established as a risk factor for plaque formation, which can lead to developing different forms of CVD. Previous studies have shown that 4-5 cigarettes per day almost doubled the risk of CVD, and 20 cigarettes per day increased the risk of CVD by 6 times. Women who smoke face up to a 25% increased risk of developing CAD compared to their male counterparts, with studies showing that reduction in smoking decreased the incidence of CAD in women by 13%. Furthermore, second-hand smoking may increase the risk of CVD by 25%.
Obesity Obesity is associated with several other factors that can increase the risk of CVD, such as dyslipidemias. With increasing body mass, the risk of developing various CVDs, such as ischemic stroke and coronary artery disease grows as the unhealthy lifestyle maintained prevents the cardiovascular system from functioning optimally. Women make up about 40% of obese adults over the age of 20. Postmenopausal women are also more likely to experience fat redistribution to the abdomen and develop metabolic syndrome, resulting in increased susceptibility to obesity.
Hypertension Chronic high blood pressure (hypertension) alters the structure of vessels over time, such as narrowing or complete blockage of blood flow. This can subsequently lead to CVDs, including stroke. The prevalence of certain disorders, such as fibromuscular dysplasia, is increased in premenopausal women and can lead to secondary hypertension. These factors, including others such as preeclampsia, have been shown to contribute to the risk of developing hypertension, and thus, consequently, CVDs from the resulting damage. Women who have chronic hypertension have a much higher risk of developing cardiovascular disease compared to women with normal blood pressure.
Lipids Cholesterol is a type of lipid with diverse bodily functions. There are several types of cholesterol, but the main two are high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C). Then, the levels of these forms of cholesterol-carrying protein can be determined by a blood test. HDL cholesterol removes LDL-C from the bloodstream and returns it to the liver, where it can not cause cardiovascular damage.