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Ask Stanford Med: Cardiologist Jennifer Tremmel responds to questions on women’s heart health

Thank you for taking the time to submit questions about the growing body of research on women and cardiovascular disease and other issues related to women's heart health. Here are my responses.

@ntopliffe asks: What are the differences between a male and female heart?

If you simply looked at a male and a female, you wouldn’t be able to tell the difference - although the female heart may be slightly smaller than the male heart because women are generally smaller. However, the pathophysiology of male and female hearts is often very different. Women and men can have different types of coronary plaque. Women, especially young smokers, develop plaque that erodes while men develop plaque that ruptures. In addition, women appear to be more likely to have functional problems with their arteries, such as endothelial dysfunction, coronary vasospasm and microvascular disease.

These functional problems can cause symptoms even though the heart arteries look perfectly normal. Women, particularly young women, are more prone to having dissection of their heart arteries. This appears to be strongly related to hormonal changes and is most frequent in the months after giving birth. Finally, women and men  often get different types of heart failure. Men develop hearts that don’t pump well, while women develop hearts that don’t relax well.

MCG asks: Past studies show that the number of heart attacks is rising among women and falling among men. What factors are contributing to this gender gap in heart attack prevention?

There are a number of gaps between women and men that lead to disparate outcomes between the sexes. In particular, physicians tend to underestimate a woman’s cardiovascular risk, which leads to less aggressive risk factor modification, testing and treatment. Women also underestimate their own risk and don't recognize that heart disease is the leading cause of death for their gender. Therefore, they may be less proactive about prevention and less cognizant of concerning symptoms. Specific risk factors, such as smoking and obesity, are unfortunately prevalent among women. Ultimately, it's up to each person to decrease her own risk.

Erin asks: I’ve heard that heart attacks have somewhat different symptoms in women than men. What symptoms should women watch out for?

The most common symptom in both women and men is chest pain. But for women this may not be the most prominent symptom. It is also worth noting that, while doctors use the word “pain”, it may not actually feel like a pain. Instead, it may feel like a burning, tightness, pressure or some other sensation. A better word than “pain” might be “discomfort." This discomfort may radiate, or seem to originate, in the jaw, back, mid-stomach or either arm. One of the distinguishing factors between women and men is that women tend to report more associated symptoms. These may include classic symptoms such as shortness of breath, nausea and vomiting - but may also include several less classic symptoms including fatigue, dizziness and palpitations. In general, women report a greater number of less common symptoms, with women being significantly more likely than men to report less than four symptoms.

While it is most common for both genders to get their symptoms with physical exertion, women may also experience their symptoms at rest, during sleep and with emotional stress. Likewise, women may have an increased frequency of symptoms around the time of their menstrual period.

Anne M asks: Since the early 1990s, the National Institutes of Health has mandated that women and minorities be included in all of its clinical research studies. How much progress has been made in including more women in clinical trials related to cardiovascular diseases? And does more need to be done to enroll more women in studies?

The progress remains poor. I think several things need to be done to enroll more women, but an awareness and effort on the part of physicians and patients are needed to correct the problem. We need physicians to recognize that women are under-represented and to make a concerted effort to enroll more women in their trials. We also need female patients to seek out research studies and participate in them. Women need to recognize that by participating in studies they are doing it for the benefit of all women, particularly their daughters and granddaughters. My impression is that once women understand this they are very willing to step up to the plate.

@TracySherman asks: A recent study showed stress can be harder on a woman's heart than a man's. How can negative emotions impact your heart?

There is evidence that stress, chronic anxiety, depression and anger may each independently impact heart health among women and men. Research shows that people who have these psychosocial conditions may be at higher risk for developing cardiac problems. Likewise, among those who have these psychosocial conditions and already have coronary artery disease, the risk of recurrent cardiac events is higher than for those who don't.

The mechanisms that cause this increased risk are still unclear, but most experts agree that it is likely a combination of both physiological (e.g. increased blood pressure, decreased immune response) and behavioral (e.g. low motivation for action) characteristics of those with psychosocial problems that contribute to the increased risk. Our best advice, coming from my clinic’s psychologist Katie Sears, PhD, is to give ample attention to mood and stress factors in your life that could be impacting your heart health. Sears also suggests making stress management techniques part of your regular routine.

ST asks: How can you differentiate between the cardiac symptoms of high stress and something like cardiac neurosis? Is there long-term damage to the heart for someone who frequently has a fast heart rate, fatigues easily and is lethargic?

It can be difficult to distinguish symptoms due to a heart problem vs. a psychological problem (stress/anxiety). Often these two issues are interrelated, making the distinction even more challenging. Both can cause chest pains, shortness of breath, palpitations, light-headedness and a sense of doom. To definitively determine that your heart is okay, it generally takes a full cardiac evaluation. Often, I see women (and some men) who have had their symptoms attributed to a psychological cause when, in fact, there is an issue with their heart. Other times, their heart is fine and their symptoms are due to stress/anxiety. It is our job as physicians to sort this out for you.

If someone has a fast heart rate, fatigues easily and is lethargic, I would aim to figure out why and then correct the underlying cause. Does this person have some underlying illness, are they eating poorly, drinking too much caffeine, and/or not exercising enough?

Marcia asks: Is data being collected on the number of heart disease-related deaths in women that may be related to chemotherapy medications for cancer treatment?

Fortunately, heart disease-related deaths from chemotherapy are rare. However, the exact number is not known in either women or men because such data is not routinely identified or collected on a national level. At Stanford, we have been tracking heart events related to chemotherapy and have also been increasingly proactive about screening for heart problems with certain chemotherapeutic agents. Ronald Witteles, PhD, one of my colleagues, is to be commended for taking the lead in this important area.

Responses to questions submitted as part of the Ask Stanford Med feature are meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Ask Stanford Med: Cardiologist Jennifer Tremmel taking questions on women’s heart health, The Beast cut in on my song: Living with coronary microvascular dysfunction, A focus on women’s heart health, Understanding and preventing women’s heart disease and Gap exists in women’s knowledge of heart disease
Photo by Larkyn T

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