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why heart health is different for women: 'she was having a heart attack, but made her son lunch before going to the emergency room'

because women tend to put the needs of others first, experience heart attacks differently than men and face distinct risk factors depending on life stage, they are more vulnerable to heart disease, says dr. sherryn rambihar, cardiologist at toronto's mackenzie health.

by maija kappler
published feb 16, 2023
last updated may 25, 2023
read time 10 minute read
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read time 10 minute read
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women's heart health a 'system failure': heart & stroke
we've gotten really good in the last 50 years at treatment strategies that work for the male pattern heart disease, but women may be getting less benefit. getty
earlier this month, the heart and stroke foundation put out a scathing new report about the state of women’s heart health in canada. titled “system failure,” the report explained that women continue to be left out of research, awareness and diagnostic protocols. as a result, women are more likely to suffer from certain heart conditions — including “broken heart syndrome,” a condition brought on by stress or emotional turmoil, and spontaneous coronary artery dissection. heart attacks present differently in women than in men, so it can be hard to even recognize a heart attack when it doesn’t involve the typical male-pattern “chest-clutching pain.” social factors, too, can exacerbate heart health problems in women: women are more often caregivers, and it can be hard for them to take time to prioritize their own health.
dr. sherryn rambihar is a staff cardiologist at toronto’s mackenzie health, and an adjunct assistant professor in cardiology at the university of toronto’s department of medicine. she also contributed to the heart and stroke report. rambihar shared her insights about what women need to know about heart health.

what i thought was so interesting about the report was the way it emphasized physical factors that make women more susceptible to heart attack and stroke, as well as the social factors. why is it so important to talk in depth about both of those?

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we know that from a distance, women’s and men’s hearts look the same, but how their disease develops and presents can be different. and we’ve talked about this in previous heart and stroke reports — about how women, for example, have smaller arteries compared to men; they may be prone to more different kinds of patterns of disease, like microvascular disease; that women can develop fatty buildups in different ways. these are all things that are established. however, i also think that it’s really important to acknowledge that every woman is an individual and what’s interesting about this particular report is that it’s focused on these discrete factors that affect their heart and brain in addition.
all women are not the same. this is what i think is the most important thing: that there are vulnerable populations based on ethnicity, socioeconomic status, sexual orientation, where you live in this country, what your body looks like, ability and others. and i think this is one of the first reports to talk about those sort of sociopolitical factors and how they interact with health care.
 

the report says women may experience multiple symptoms of a heart attack, rather than one major pain in the chest. how do heart attacks present differently in women than in men?

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the most common symptom people have  when they have a heart attack is chest discomfort. so the traditional sort of male pattern is chest discomfort, big ecg changes [changes in the electrical activity of the heart], big clot in arteries, go to the cath lab and have an angiogram. but many women with chest pain do not actually have a blockage. and so sometimes we can see that plaque, which is the cholesterol blockage, that can usually affect the blood flow to the heart muscle, can erode. there’s a term for it: “women erode, men explode.” it’s a different pattern of heart disease.
we’ve gotten really good in the last 50 years at the kind of research, diagnosis and treatment strategies that work for the male pattern heart disease, but women may be getting less benefit. women can have what we call microvascular disease, where the heart arteries can spasm, and they close off, and these can result in ecg findings that are different. (ecg, or electrocardiogram, is a heart rhythm strip that is given to patients who show up in the emergency room with chest discomfort to determine if they’re having a heart attack.) we used to say, “are you having a heart attack or not?” and if you’re not diagnosed with having one, you may not get the care that you need. sometimes when women go for an angiogram — an angiogram is when we take pictures of blockage in an artery and whether or not there are blockages to explain heart attack — we can see that the fatty plaque may be deposited differently in women.
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women who have heart attacks, with the research and diagnosis and treatments that have been directed to that over the last 50 years, they can be acknowledged, recognized, treated appropriately with expedited care, and do well. but if you’re not recognized to have it, then maybe we need better tools. maybe we need different tools. maybe we need different research. and this is sort of where the heart and stroke’s research directions are going.
when estrogen levels drop during menopause, as women age, they acquire cardiovascular risk factors at a faster rate than men. getty
when estrogen levels drop during menopause, as women age, they acquire cardiovascular risk factors at a faster rate than men. getty

what are some of the risk factors that can make women prone to heart attacks?

risk factors are a big deal because again, if you’re not aware that you’re at risk, how are you going to know or take your symptoms seriously? and women face distinct risk factors for heart disease and stroke and at different points in their life.
we know that the usual suspects associated with heart disease in women and men are the same as that nine risk factors that are very common. these are things you would expect: lipids or high cholesterol, smoking, high blood pressure, diabetes, whether you’re obese. and then some other interesting things — for example, psychosocial stress, which [speaks to] women facing different responsibilities in terms of their gender and roles and expectations.
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and then there are other risk factors — pregnancy is one of the most important issues here. there are unique risks of pregnancy-related conditions which we are now discovering can increase your future risk of heart events. so when people come and see me for various reasons, it’s very important that we find out if they have a history of gestational diabetes, or if they ever had pregnancy-induced hypertension or preeclampsia. and some older women are very surprised to be asked about that, because they haven’t thought that this is something that’s implicated in [heart and brain health]. but it is, and we know that now we can screen young women, so they are aware as they get older, that it’s really important for them to know their particular risks and get personalized care.
another women-specific risk factor: there’s a higher likelihood of women having autoimmune and inflammatory disease. things like lupus or rheumatoid arthritis. we’ve known this for a long time that these can have an impact in the development of heart disease, and so we also know that when women hit menopause, the risk goes up. and this is what contributes to a bit of a lag in women compared to men and developing heart disease. but when the estrogen levels drop during menopause, as women age, they acquire cardiovascular risk factors at a faster rate than men.
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the report makes at clear that women are at risk in part because so much of the medical research is done on men. why is there so little medical research involving women?

i think it’s very important to understand that back in the ’60s, there was a huge public health catastrophe where children born to mothers who were given thalidomide, a medication for morning sickness, were born without limbs. it was a horrible chapter in canadian [and international] health history. and after that, it was a knee-jerk reaction, because nobody wants children to get sick: drug regulators got rid of the option for any potentially pregnant women to be included in randomized clinical trials. and so as a result of that, we just assumed that women were small men, which isn’t the case at all. and so that’s why two-thirds of the participants in clinical trials on heart disease and stroke were men. and that’s changed. it changed in 1993. and i remember 1993 — i was watching the blue jays win the world series. it was not that long ago.
and now that things have changed, we now have large funded research organizations like heart and stroke, the institute of health research, other research organizations now including women, and are requiring gender and sex research, design, analysis and reporting. and i think with that increase, we will see a definite change in terms of some of the tests used to diagnose a heart attack in terms of the treatment received by women who are having heart attacks, the medications and getting them in a timely fashion — it will change. but there’s always a lag between the research and what we call knowledge translation, but i think acknowledging this gap was an important place to start. because originally they didn’t think women had heart trouble, and they didn’t think women would have heart attacks, and it resulted in women getting less aggressive care, and having worse outcomes. and these are problems.
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a point that’s made really effectively in the report is that even within the demographic of women, there are disparities. racialized women, queer women, poor women, women with disabilities, trans women all have worse health outcomes.

it comes back to this fact that not all women are the same. vulnerable populations are at much higher risk for development of heart disease with amplified risk. we talked about the overlapping factors: you could start with things like ethnicity, where you may have genetic predispositions to certain conditions and risk factors, and then overlapping on that you can have language and cultural barriers, and access to care barriers. and then minority women or women of lower socioeconomic status may be living in an area of poverty. when you’re living in poverty, you may not have access to healthy foods, adequate housing, or education, and these things are related to being more susceptible to heart disease and stroke.
the report also mentioned the role of gender-affiming hormonal therapy and trans women. [gender-affirming therapy can be crucial to the wellbeing of some trans people, but hormone therapy of any kind can also increase the risk of blood clots, heart attack and stroke.] i’ve actually had experience with that firsthand — about 15 years ago, i was on rotation, and i was treating a trans woman who needed hormone therapy, but also had a risk of blood clots in the family. she had to balance these things. this was part of her identity, but she knew there was a medical risk. we, as physicians, have to help give people the facts, and ultimately it’s their decision. these are two things that were very important to this individual, and only that person can know how important the relative role of these things are. so we provide the facts, and an informed discussion around it.
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i think it’s really important to understand that within canada, there are so many different groups of women who can be at increased risk. it’s really important for us to understand that there are societal and political issues that affect women, as well as their genetic predispositions in medicine.
when you’re living in poverty, you may not have access to healthy food, adequate housing, or education, these things make you more susceptible to heart disease and stroke. getty
when you’re living in poverty, you may not have access to healthy food, adequate housing, or education, these things make you more susceptible to heart disease and stroke. getty
 

another example that stood out from the report was the health of new moms. women who had gestational diabetes while pregnant are more likely to develop diabetes later on, and should get their blood sugar checked between six weeks and six months of giving birth, but research has found that they often neglect their own health while caring for their baby.

it’s true. i am a young woman, and i’m a cardiologist, and i enjoy taking care of young woman because i feel that sometimes they get dismissed in the health-care system. people wouldn’t take them seriously. the society of obstetricians and gynaecologists of canada produced a report about health care of pregnant and postpartum women, and found that there’s a significant gap in care when you look at it through an ethnicity lens. there’s been a lot of american research on this, i think in part because of serena williams having a [postpartum] pulmonary embolism [a blockage of the arteries in the lungs due to a blood clot]. and if serena williams is going to get dismissed, what’s going to happen to the regular person who may not necessarily have the knowledge or awareness to go seeking care? and you’re so busy — women often have the burden of responsibilities with their families.
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and it’s so interesting that it rarely changes along the spectrum of life. i have a patient whose husband had dementia. she’s the primary caregiver of her partner with dementia, and she was having a heart attack, and she did not go into hospital because she had nobody to watch her husband. i also have a patient who was making lunch for her son when she was having a heart attack. she made her son lunch and then went to the emergency room. sometimes women may have these issues, but they have babies at home and are the primary caregiver — they are more likely to prioritize the health needs of other family members over their own. it may just seem like a small thing to get that blood test, but when you have a newborn at home, everything becomes a struggle.
so often when i’m in my office, i do a lot of talking to people about trying to put themselves first. yes, there may be all these people that depend on you, but you’re no use to them if you’re unwell. it’s very challenging, because women are conditioned often to be in these caregiver roles. it’s hard for them to start advocating for themselves and their symptoms when for so long they haven’t been.
maija kappler is a reporter and editor with healthing.
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