Why Women’s Heart Health Is Not A Widely Covered Topic

21 Feb Why Women’s Heart Health Is Not A Widely Covered Topic

Why is Cardiovascular Health Not a Major Topic of Discussion When It Comes to Women’s Well-being?

Heart diseases have always been a topic of discussion and concern in relation to male health, leading to a lack of awareness when it comes to women. Little attention is paid to the fact that cardiovascular conditions are a leading cause of morbidity and mortality in women, especially after menopause. Statistics reveal that heart conditions are the number one cause of death in women, with 1 in every 5 women in the US dying from heart disease, which is ten times greater than deaths caused by breast cancer.²

Factors Responsible for Relative Cardio-protection During Reproductive Years and Thus Neglection of this Age Group:

When looked into depth, the causes for the stereotypical mindset of cardiovascular conditions being men’s diseases, “the jogging heart” comes first. The concept of jogging heart can be understood by comparing the hormonal activity going on in a woman’s body to changes induced by physical exercise done by a male of the same age.⁵ It is based on the premise that during the second half of the menstrual cycle, a woman’s basal heart rate increases, offering benefits comparable to that of moderate exercise. Additionally, the natural protection offered by estrogen before menopause prevents heart-related complications, decreasing the risk significantly. Estrogen is known to positively affect numerous tissues in the body, including the heart and blood vessels. It increases HDL (the good cholesterol), decreases LDL (the bad cholesterol), and relaxes and dilates blood vessels, allowing for adequate blood flow to vital organs, including the heart. After menopause, however, the estrogen levels fall, significantly increasing the risk of a cardiovascular accident. Thus, after menopause, the risk of heart diseases in women becomes equal to that of men.²
The good news is that cardiovascular diseases and their complications are preventable, but the lack of awareness delays the recognition of warning signs and subsequent actions, causing the development of heart diseases, that could otherwise have been avoided. Screening should be carried out for the prevention of heart diseases in the same manner as it is done for cervical cancer (Pap smear) and breast cancer (breast exams). Being conscious regarding your cardiac health substantially prevents complications in the long run and allows early detection and treatment of predisposing factors.

What are some reasons that you need to take a closer look at your heart health?

The overall mortality secondary to CVD may be decreasing in the US, but the situation is the opposite for women. The CVD mortality rate in women is rising.⁴ It has been noticed that even younger, childbearing-age women are also having some sort of cardiac problems now. In addition to having traditional risk factors such as hypertension, diabetes mellitus, dyslipidemias, family history, physical inactivity, metabolic syndrome, and obesity, there are risk factors unique to the female gender.¹

The unique risk factors in women are:⁶

• Pregnancy-related disorders like pre-eclampsia, pregnancy-induced hypertension
• Autoimmune disease
• Hormonal disorders such as polycystic ovarian syndrome
• Breast cancer treatment

Unique Risk Factors

The complex hormonal changes that occur in a female body throughout the reproductive years predispose them to a number of pathologies. While many times these are physiological changes, occasionally, they can turn pathological, leading to hormonal imbalance, collectively termed as hormonal disorders, which also affect the heart.⁵
Many of the risk factors are common for a widely prevalent hormonal disorder, polycystic ovarian syndrome (PCOS), and cardiac diseases. Having PCOS thus increases the risk of long-term cardiac complications. PCOS is frequently associated with obesity and dyslipidemias. According to studies, women with PCOS are twice as likely to suffer a cardiovascular event compared to healthy women. It also increases the risk of type 2 diabetes mellitus which again is a prominent risk factor for CVDs. Moreover, many women of reproductive age use hormonal contraceptive methods, combined oral contraceptive pills (COCPs – containing both estrogen and progesterone) being the most common. COCPs are known to increase the risk of developing hypertension, and thrombosis (blood clotting), thus predisposing to serious cardiac events.
Pregnancy-related hypertensive disorder, called pre-eclampsia, is also of particular interest here. It leads to generalized vasoconstriction (blood vessel constriction) and thus high blood pressure. Although it resolves after delivery, the subsequent risk of developing essential hypertension significantly increases. Pregnancy-related hypertension and weight gain double the risk for the development of ischemic heart disease and stroke. Pregnancy itself is a hypercoagulable state. This means the risk of developing a thromboembolic event increases during pregnancy. One of the common complications after delivery is the development of thrombosis which may gain entry to cardiac vessels leading to serious acute cardiac manifestations. The risk of the development of insulin insensitivity also significantly increases during pregnancy leading to the development of gestational diabetes mellitus (GDM). GDM increases the risk of a cardiac event seven times.
Autoimmune disorders such as systemic lupus erythematosus (SLE) increase the risk of cardiac diseases to a staggering nine times. Clinical interventions for common disorders in reproductive women, breast cancer being a prime example, come with their own set of side effects. The risk of cardiovascular events is significantly increased with radiotherapy. It is therefore essential that such cases are managed by a multidisciplinary team.

Risk factors unique to certain age groups

Some of the risk factors for CVDs are specific to age

Prepuberty:

• Early menarche
• Being overweight
• Acne
• High blood sugar levels

Adolescence:

• Irregular periods
• Obesity
• Acne
• Hirsutism

Reproductive period:

• Infertility
• Gestational diabetes mellitus
• Pre-eclampsia

Perimenopausal period:

• Diabetes
• Essential hypertension
• Obesity
• Stroke

Post-menopausal period:

• Withdrawal of the protective effect of estrogen
• Numerous chronic health conditions

Atypical Presentation

For women, CVD may present with atypical symptoms like profound sudden fatigue, shortness of breath, a general feeling of being unwell, neck pain or sensation of constriction or strangling in the throat, sense of foreboding – impending doom (due to intuition), syncope, dizziness or vertigo, indigestion (often feeling that if they burp, they will feel better), nausea, and vomiting. Because of a lack of knowledge regarding the presentation of CVD in women, these symptoms are often ignored.⁶ The result is that the cardiac health starts to worsen until it reaches a morbid state and then presents with an acute clinical event like myocardial infarction (heart attack).

Every woman must know the following factors that can increase the risk of CVD and related complications:

• Age 
• Diabetes 
• Smoking 
• Physical inactivity 
• Hypertension 
• Dyslipidemia 
• Metabolic syndrome 
• Obesity

Gender disparities

Women going through an acute cardiac event are not managed in a similar way as men. Younger women, in particular, are less likely to be properly managed by the acute MI protocol, and prescribed guideline-directed medical therapy (GDMT). They also do not often receive adequate treatment in a timely fashion or suitable prophylactic therapy such as fibrinolytic therapy. Furthermore, cardiological interventions like angioplasty, cardiac catheterization, thrombolytic therapy, and bypass surgeries are not routinely seen being performed in women.⁶ The studies regarding heart health also recruit male participants more frequently.⁵ Which means we are not well aware of any unique risk factors and manifestations of cardiac diseases in women. Although heart disease kills more women than men every year, the treatment of women’s heart disease was based—until recently—on medical research performed on men.

This disparity leads to increased mortality when the treatment is finally administered. Studies have shown that women treated by a male cardiologist are more likely to suffer mortality.⁶ Treatment given by female cardiologists has comparatively better outcomes.⁷ Usually, there is a similar outcome for both genders when treated by a female cardiologist. Female cardiologists, however, are very few in number which means women are more likely to die in ER if treatment is administered by a male cardiologist. Even though there are fewer men dying from heart diseases, there are more male cardiologists than female. There is a need to draw attention to this fact and encourage more women to pick cardiology as their field of specialization.

The Barbara Streisand Women’s Health Center is working to correct these gender inequalities and to educate women on how to recognize female-pattern heart disease symptoms. Additionally, The center provides convenient access to all of Cedars-Sinai’s diagnostic and treatment resources for heart disease and is designed to help women reduce their chances of heart disease through a preventive approach, including state-of-the-art screening and testing.

What are some daily actions women can start implementing to take a preventative approach and preserve the health of their hearts?

As mentioned earlier the risk can be reduced and heart diseases can be prevented in women. Just following some simple tips and sticking to them can help a lot. Even if you do not have any of the aforementioned risk factors, you still need to take the necessary precautions. 

1. Dietary modifications:

Whatever you eat reflects on and from your body. The healthier food you consume, the better your body will perform. Add more vegetables, fruits, and a small amount of whole grains, and cut down on sugars and processed food in your diet. Avoid consuming empty calories, which are foods that only provide energy but have no nutritional value, fast food for example. The idea is to eliminate harmful and toxic substances (like pesticides and herbicides) from the diet and take nutritionally rich food items that serve as important metabolites. This not only improves cardiac health but also improves general well-being.

2. Mind-body techniques:

Try yoga and meditation. They relieve stress, balance the autonomic nervous system and positively affect healthy functioning. The cardiovascular system is under the influence of the autonomic nervous system, which has two arms: parasympathetic and sympathetic nervous systems. The parasympathetic system is activated in a relaxed state, while the sympathetic tone of the autonomic nervous system prepares the body for fight and flight response.

To understand this, consider an example. Imagine you are sitting peacefully in a garden, relaxing and all of a sudden, a lion comes in. Facing an unanticipated danger you will start to sweat profusely, your heart will beat much faster (palpitations), your eyes will open wide and your blood pressure will shoot up. All of this happens because the sympathetic system has become activated and caused these changes, also collectively referred to as ‘Fight, Flight and Fright’ response. 

The point of emphasizing the functioning of the sympathetic autonomic nervous system is that the majority of heart and vessel disorders are associated with an increased sympathetic tone.⁸ The treatment, therefore, often comes in the form of sympathetic blockers.

Yoga and meditation have been proven to relieve stress and thus decrease sympathetic overactivity.⁹ The result is heart and vessel functions returning to normal.

3. Move Your Body:

The most important of all risk factors is the presence of visceral fat, the fat that is accumulated around our internal organs such as the heart, liver, and intestines. It is highly inflammatory and contributes to the acceleration of atherosclerosis. Movement is the most important preventive and curative option for all types of CVDs. Inflamed cholesterol (fat)  in the body deposits in the arterial wall and blocks the lumen causing atherosclerosis. With time, the lumen becomes so narrow that the blood flow to the respective organ diminishes or even gets completely obliterated. When fat deposits in the vessels that supply blood to the heart, cardiac events like myocardial infarction and angina occur, which if severe, may lead to death.

If you would like to get more information about cardiovascular disease and treatments from functional medicine perspectives, schedule an integrative medicine consultation at our office, call 212-696-4325.

I’d love to talk to you and answer your questions.

Stay healthy and strong!

Elena Klimenko, MD 

References:

1. https://www.cdc.gov/heartdisease/women.htm
2. Alkabban FM, Ferguson T. Breast Cancer. [Updated 2020 Nov 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
3. Eskes, T., & Haanen, C. (2007). Why do women live longer than men?. European journal of obstetrics, gynaecology, and reproductive biology, 133(2), 126–133. 
4. Garcia, M., Mulvagh, S. L., Merz, C. N., Buring, J. E., & Manson, J. E. (2016). Cardiovascular Disease in Women: Clinical Perspectives. Circulation research, 118(8), 1273–1293. 
5. Garcia, M., Mulvagh, S. L., Merz, C. N., Buring, J. E., & Manson, J. E. (2016). Cardiovascular Disease in Women: Clinical Perspectives. Circulation research, 118(8), 1273–1293. 
6. Giardina E. G. (2000). Heart disease in women. International journal of fertility and women’s medicine, 45(6), 350–357.
7. Nakayama, A., Morita, H., Fujiwara, T., & Komuro, I. (2019). Effect of Treatment by Female Cardiologists on Short-Term Readmission Rates of Patients Hospitalized With Cardiovascular Diseases. Circulation journal : official journal of the Japanese Circulation Society, 83(9), 1937–1943. 
8. Remme W. J. (1998). The sympathetic nervous system and ischaemic heart disease. European heart journal, 19 Suppl F, F62–F71.

Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical hypotheses, 78(5), 571–579.