Cardiovascular disease in women – underdiagnosed and undertreated

The numbers speak for themselves. In Australia, about 20 women die of coronary heart disease each day – almost three times as many deaths as breast cancer. Indigenous women are up to twice as likely to have cardiovascular disease (CVD) and to die from coronary heart disease or stroke than non-Indigenous women.

And yet, for women in Australia CVD has historically been underdiagnosed, undertreated, and under-recognised.

According to Associate Professor Sarah Zaman, an Academic Interventional Cardiologist at the University of Sydney and Westmead Hospital, GPs could make a difference in this area of healthcare by considering the gender gaps and CVD risks – traditional and emerging – in women.

Did you know?

• Only 48% of older women with hypertension have adequate blood pressure control.
• Women with hyperlipidaemia receive preventive medications like statins at lower rates, compared to men.
• Women are more sedentary than men, and this gap worsens with age.

“These are risk factors we could all be targeting in our clinical practice,” says Associate Professor Zaman.

Emerging risk factors for CVD

These include hypertensive disorders of pregnancy (HDP), pre-eclampsia, gestational diabetes, pre-term birth and early or premature menopause.

“These confer a two- to three-fold risk of CVD, independent of other traditional risk factors,” explains Associate Professor Zaman.

“This onset of heart disease is early – it occurs eight to 10 years after the affected pregnancy. We’re talking about women in their 40s, and this is where we need to think about screening.”

Routine tests

A heart health check or absolute cardiovascular disease risk assessment should be considered for individuals aged 45 and over (or 30 years for First Nations people).

Absolute risk is defined as the likelihood of developing CVD over the next five years, considering age, sex, SBP, smoking status, cholesterols levels, diabetes status, and left ventricular hypertrophy (LVH) on ECG. An annual test is covered by Medicare for those aged 40 to 74.

Clinicians can also do a CT Coronary Artery Calcium Scoring Test in a patient who is intermediate risk on the calculator, or a patient who is low risk but who has some risk-enhancing factors present.

“This is low dose radiation and it gives us images of calcified cholesterol plaque in the heart arteries,” explains Associate Professor Zaman. “If you have a woman in her 40s or 50s, this presence of calcium is highly abnormal and would push you towards intensive medical therapy.”

The tool allows clinicians to risk stratify patients for long-term cardiovascular events, but it carries a financial cost for patients.

Heart attack symptoms

Understanding the gender differences in heart attack symptoms is helpful, says Associate Professor Zaman. And GPs can play an important role in patient education.

The most common symptom is chest pain, accounting for 87.0% of presentations in women and 89.5% in men. But more women also present with dizziness, nausea and vomiting.

She believes these additional symptoms can distract clinicians from the main issue – chest pain – and contribute to some delays in heart attack care for women.

“The key message here is that women are as likely as men to have chest pain as part of a presentation for a heart attack, but they may have more associated symptoms that distract from the chest pain symptom,” she says.

Menopause and heart health

Professor Susan Davis AO, an endocrinologist and the Director of the Monash University Women’s Health Research Program, says changes that occur at menopause “meaningfully contribute to a postmenopausal increase in cardiovascular disease risk”.

Early or premature menopause is linked to an increased risk of all-cause mortality and CVD-specific mortality. She recommends these women be put on hormone therapy even if they don’t have symptoms, unless they have a major contraindication.

Citing data from the Women’s Health Initiative (WHI) study, Professor Davis says oestrogen therapy protects women against type 2 diabetes – a disease that puts women at greater risk of CVD.

Oestrogen also restores endothelium function in postmenopausal women. It boosts sleep quality too, but with less or no effect on women without vasomotor symptoms.

“I am not suggesting that oestrogen should be used to prevent cardiovascular disease,” she explains. “But it may offer cardiometabolic protection, especially in women with an early menopause.

“It does not cause cardiovascular disease, and that’s the myth that’s been out there since the WHI study.”

Advances in the field

Progress has been made in women’s heart health with better understanding of sex-specific risk factors and awareness of differences in presentation, treatment and outcomes of heart disease.

Greater awareness of these differences will ensure equity in preventive and secondary treatment of CVD.

To hear more from these experts – including the latest insights on the female-predominate heart attack types – watch our recent webinar.