Heart Disease in Women - Diagnosis, Treatment and Prevention

Dateline: 05/24/98

Heart Disease in Women is a very important, unique and exciting topic. This article is a part of a series that focuses on the special problems of Heart Disease in Women.

DIAGNOSIS, TREATMENT AND PREVENTION OF CORONARY
ARTERY DISEASE IN WOMEN

Diagnosis of Coronary Artery Disease in Women

The diagnosis of coronary artery narrowing in women differs from the case in men because

• coronary disease is less prevalent in women

• clinical presentation is different in women

• diagnostic tests are less accurate in women

This is even more significant when one considers the fact that women have a higher fatality rate with first heart attacks than men, and sudden death due to coronary artery disease is more likely to occur in asymptomatic women than men.

Clinical Presentation

Chest pain as a symptom is notoriously difficult to evaluate in women. Women with classical angina pectoris had a 71% probability of angiographic evidence of disease compared with 36% of women with probable angina. Nonspecific chest pain syndromes in women have an excellent prognosis and are rarely associated with significant disease on arteriography.

Nearly 90% of women with a heart attack had chest pain as a feature of initial clinical presentation, similar to that of men. However, in contrast to men, women with heart attack were significantly more likely than men to present with other non-specific complaints like upper abdominal pain, breathlessness, nausea, and fatigue.

Non-Invasive Testing

Electrocardiographic (ECG) stress testing in women has a lower sensitivity and specificity compared with men, not only because of gender differences in prevalence and extent of disease, but also because women are less likely to achieve an adequate heart rate response during the test.

These data suggest gender has a significant impact on the accuracy of widely available diagnostic tests and should be a consideration in the choice and interpretation of noninvasive tests.

Emerging data on electron beam computed tomography (CT), a noninvasive screening technique that detects calcium deposits in the wall of diseased coronary arteries, suggest minimal gender differences in diagnostic and prognostic usefulness. As new techniques are developed to help detect coronary disease, gender-specific information about test efficacy will need to be provided to clinicians. The physician must then plan follow-up evaluation and management on the basis of both pre-test and post-test probability of disease in women.

Overall Prognosis

Several reports have documented a worse prognosis for women with coronary artery disease than for men. This might be due to

• increased severity of illness at presentation

• increased age

• presence of other associated diseases in women

• lesser likelihood of receiving early cardiovascular intervention

• differences in the efficacy of techniques to restore coronary blood supply

Treatment - Coronary Revascularization in Women

There are also gender differences in the success rates of interventions meant to improve coronary circulation (myocardial re-vascularization). After percutaneous transluminal coronary angioplasty (PTCA), women have an excellent long-term prognosis after a successful procedure, similar to that observed in men. However, procedure related complications and death rates for PTCA is three times higher for women as compared to men.

The Coronary Artery Surgery Study (CASS) demonstrated a similar rate of bypass grafting for men and women. The 15-year survival rate approached 50% for men and women with initial medical treatment. A greater survival rate was associated with surgical treatment for men (52%) versus women (48%), which was attributable to differences in operative deaths.

Women have been sicker at the time of bypass surgery but show similar patterns of recovery and improvements in psychosocial and physical functioning after bypass surgery.

Adjunctive Drug Therapy and Secondary Prevention

Treatment with beta-blockers is associated with a 21% reduction in mortality, a 30% decrease in sudden death, and a 25% lower reinfarction rate in both men and women. In high-risk women with prior coronary events like a heart attack, lifestyle modifications and drug therapy are of greater importance. Women at high baseline risk of coronary disease have the most to gain from using the risk-reduction strategies.

The evidence for benefit in secondary prevention among women is much stronger than the evidence for primary prevention. Aspirin treatment reduced risk of subsequent cardiovascular events by about 25%. Lipid-lowering therapy also appears to provide substantial benefit in secondary prevention in women. Although data are limited (six trials have included women with CHD and hyperlipidemia), these studies suggest a greater than 50% reduction in mortality among the treated women.

Rehabilitation

Studies that have included women suggest they have similar improvements in functional capacity and other outcomes compared with men.

In a recent national survey on gender differences in cardiac rehabilitation programs after heart attack, women were found to be less likely to enroll in a program (6.9% versus 13.3%) or to undergo postbypass surgery (20.2% versus 24.6%) than men. In addition to lower program attendance, dropout rates are greater for women.

The reasons for gender differences in rehabilitation program usage remain unclear, but may be partly related to the degree of encouragement by the attending physician. The issue of participation in cardiac rehabilitation is critical for women because they have a worse prognosis after cardiac events compared with men.

In conclusion, cardiovascular disease in women will continue to be a public health priority as significant numbers of aging women are at increased risk for complications and death related to coronary artery disease. Healthcare systems need to emphasize healthy lifestyles for young women. This approach will help prevent development of risk factors and minimize the need to manage them at a later time.

Healthcare providers and patients too need to be sensitive to gender differences in presentation, prognosis, and responsiveness to treatment of coronary artery disease in women. Scientists must continue to examine potential differences between men and women in the pathophysiology and clinical outcomes of coronary disease.

More research in minority women is of particular importance, given the high level of risk factors and mortality rates in this population. Health educators will play a pivotal role in communicating and translating scientific developments about women and heart disease. Public policy makers should take the lead in ensuring that women of diverse backgrounds and circumstance have equal access to care. It is only through a multifaceted approach that cardiovascular science and medicine can be advanced for the betterment of all.