Women are eight times more likely to die of a heart attack than breast cancer, yet few bother to get screened for heart disease, which is the leading cause of death for both men and women.
Heart disease shows both an age and gender bias. The symptoms, risk factors, management and outcomes of heart disease can differ widely for men and women, with the disease often being undertreated, misdiagnosed or missed altogether in women.
In India, heart disease rates for both genders are nearly the same, though there are far fewer women smokers. Men develop heart disease a decade or so earlier than women, but the odds are stacked against women after menopause at around age 50. Still, women are more likely to get a mammogram done to screen for breast cancer screening than an angiogram to detect heart trouble.
A 2015 study of 10,450 consecutive patients at a hospital in Ahmedabad showed that 6,867 of them had heart disease. While more men smoked, hypertension (persistent high blood pressure), diabetes, obesity and family history of heart disease were more common in women.
The study found that women with heart disease had more depression and poorer health outcomes, with depressed women having lower quality of life, higher rates of re-blockage of the heart’s vessels, and early death as compared to depressed men.
Studies from India show women get sub-optimal treatment, irrespective of age or economic status. Physicians were less likely to use invasive treatment options such as surgical bypass or putting in stents (where a metal scaffold is inserted to prop open a blocked artery) to treat women, found the study. Instead, women were more often prescribed medicines to manage their disease, irrespective of the risk factors or the extent of disease.
Under-diagnosis in women is not a problem unique to India. A study from Israel found heart disease was treated more aggressively in men than women even when women had more risk factors. While smoking and chronic obstructive lung disease was higher in men with heart disease, women patients had higher “bad” cholesterol (low density lipoprotein), blood fats called triglycerides, hypertension and diabetes. Yet men underwent bypass and stenting more often than women (21.8% versus 1.6%).
Menopause plays a big role in accelerating women’s heart risk after age 50. Young women’s blood vessels are protected by the female hormone estrogen, which keeps the inner layer of artery wall flexible so they can relax and expand to accommodate blood flow. With the drop in natural estrogen levels after menopause, this protection disappears and women run the same risk of heart disease as men. The American Heart Association recommends against using hormone replacement therapy (HRT) as it does not reduce the risk of heart disease and stroke in postmenopausal women.
Apart from estrogen, what compounds the assault on older women’s hearts is a clutch of metabolic changes that accompany menopause. Bad cholesterol goes up, high-density lipoprotein “good” cholesterol falls. South Asians in particular have low levels of a subtype of heart protective “good” cholesterol called HDL2b, which is deficit in close to two in three women in India, says the Indian Heart Association.
As women get older, their chances of developing hypertension become greater than men. Those who had pregnancy-induced hypertension, have a family history of hypertension or mild kidney disease are likely to have hypertension as they grow older.
Recurrent miscarriages, those with high levels of homocysteine amino acid, and high C-reactive protein, which is a marker for inflammation, also raise heart risk independently, as does the use of the contraceptive pill in combination with smoking in younger women.
With age, women often gain weight, become less active or develop diabetes, which in combination with hypertension, becomes a stronger predictor for heart disease in South Asian women than men. Abdominal fat is deadly, with heart risk for a South Asian woman beginning when her waist size crosses 32 inches, compared to 36 inches for other ethnic groups.
Prescription medicines to control blood fats, sugar and blood pressure must be combined with a diet low in saturated fat (oils fats that solidify at room temperature, such as ghee, butter, vegetable oils and animal fats), trans fats in packaged food, cholesterol in meats, eggs and dairy, sodium in salt and processed food, and added sugars. Eating fruits, vegetables, legumes, nuts, seeds and whole-grains lowers risk, as do not smoking and exercising for at least 50 minutes five times a week to get the heart pumping.