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India needs to rethink heart disease in women
This article is authored by Dr Ramakanta Panda, chairman, Asian Heart Institute, Mumbai.
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Over four decades of surgery and counting, I have lost track of the women who arrived at my hospital a full day, sometimes a week, after their heart attack. There have been two occasions when women came in to report heart disease in their husbands. Over the course of their husband’s surgery and recovery, the women did a casual check-up, only to discover that they had full blown heart disease too.
It's not that they were careless; most had been managing households, jobs, in-laws, and children with a discipline I have rarely seen matched. They arrived late because nobody, including many doctors, recognised what was happening to them. Chest pain is what we are trained to look for. Women often present with breathlessness, nausea, fatigue, or pain in the jaw and back. Someone talks them out of an underlying cardiac cause.
This is not a failure of individual doctors. It is a failure written into the foundations of cardiology itself. Consider three trials that shaped how we treat heart disease worldwide.
The Multiple Risk Factor Intervention Trial, one of the most influential studies in preventive cardiology, enrolled 12,866 men and not a single woman. The Physicians' Health Study, which established the now-universal practice of low-dose aspirin to prevent a first heart attack, studied 22,071 male physicians exclusively. The Helsinki Heart Study, which shaped decades of cholesterol-lowering therapy with gemfibrozil, enrolled 4,081 men; its own drug label, to this day, states plainly that its findings could not be extended to women, who were simply never studied.
All of this has real consequences on my operating table today: much of what we consider standard cardiac care; drug doses, risk thresholds, the very definition of a normal ECG or troponin level, was calibrated on male physiology. A woman's smaller coronary arteries, different clotting profile, and distinct hormonal environment were treated as a footnote, if they were considered at all. We are, in effect, still fitting many women into a template drawn from a man’s body.
Indian women carry additional risk markers that our conventional models barely register. Pregnancy complications, pre-eclampsia, gestational diabetes, gestational hypertension, are not isolated events confined to nine months. They are the cardiovascular system's early warning system, signalling a woman's lifetime risk of heart disease years, even decades, before any chest symptom appears. Multiple pregnancies compound this risk further. Menopause, arriving with the loss of estrogen's protective effect, marks another inflection point where a woman's risk profile can shift sharply upward within a few short years, often exactly when she is least likely to be screened, because she doesn't look like a cardiac patient.
What troubles me most is how quietly this gap operates. A woman with textbook risk factors, abdominal obesity, diabetes, a history of pre-eclampsia, can pass through a standard checkup with a clean bill of health, because nobody asked about her pregnancies, because her cholesterol was interpreted against male-derived cutoffs, because her fatigue was attributed to stress rather than her heart.
Closing this gap does not require new technology so much as new attention. It requires obstetricians and cardiologists to talk to each other. It requires risk calculators built on data that actually includes women, particularly Indian women, whose patterns of diabetes and early-onset disease differ from Western cohorts. It requires every physician taking a woman's history to ask about her pregnancies as seriously as they ask about her father's heart attack.
I have spent my career repairing hearts. I would prefer, increasingly, to prevent the damage. For India's women, this may well begin with finally seeing them as the specific, non-default patients they have always been.
(The views expressed are personal)
This article is authored by Dr Ramakanta Panda, chairman, Asian Heart Institute, Mumbai.
