Heart Disease, Strokes, Peripheral Vascular Disease in Women
#1 Killer of Women
By: Samuel (Jody) Stagg, III, M.D., F.A.C.C., F.A.C.P.
When giving lectures especially to a predominantly female audience, I always ask, “How many of you are worried about dying from heart disease?” and a few hands go up. I then ask, “How many of you are fearful of breast cancer and uterine or ovarian cancers as your likely cause of death?” and then most of the hands go up. Wrong! Wrong! Wrong! It’s not that those cancers aren’t severe and life-threatening problems, but the facts are that cardiovascular disease is the leading killer of women in this country. One woman dies every minute from cardiovascular disease in the Untied States.1Heart disease is the number 1 killer of women. One out of two, one-half, 50 percent, however you want to say it, of women will die from cardiovascular disease. That’s correct. Half of the women in any room are likely to die from some form of cardiac or vascular disease, and only about 1 out of 25, or 4 percent, will die from breast cancer. One out of nine women, or 11 percent, will get breast cancer, but only 4 percent will die from it.2 All cancers combined cause only 22 percent of deaths in women.3
Women account for over half of cardiovascular deaths in the U.S. You always think of heart disease as the disease of men, and certainly it is a major cause of morbidity and mortality in men, but over half of cardiovascular deaths are in women. There are over 3 million women who have survived heart attacks in the United States, and the risk of congestive heart failure is higher in women than in men. In fact, over 62 percent of heart failure deaths are in women.4,5
Cardiovascular death rates from 1979 through 2002 significantly dropped in men but stayed the same in women. In fact, currently, death rates from cardiovascular disease in women are significantly higher than in men.4
Why isn’t cardiovascular mortality dropping in women?
- Different clinical features and risk factors in women versus men
- Ethnic and racial disparities
- Less aggressive diagnosis and treatment strategies in women
Women just aren’t aware of the severe problem cardiovascular disease causes them. Awareness is lacking! Between 1997 and 2012 studies show that awareness nearly doubled from 30 to 56 percent of the significance of cardiovascular disease in women but still was at a level only a bit above 50 percent. It’s even lower than that in minority populations with only 34 percent of Hispanics and 36 percent of African-Americans being aware of the severe problem cardiovascular disease can cause women.6
Clinical features of cardiovascular disease in women
Coronary artery disease in women starts on average 10 years later than in men, and women also have more co-morbidities (diabetes, hypertension, hypercholesterolemia, obesity) than in men.5You may wonder why heart disease starts at a later age in women than men, and it’s because of the protective effects of endogenous estrogens in women before menopause. Heart disease is infrequent in women before menopause, especially in non-smokers. Premenopausal women smokers have nearly the same risk as men. Postmenopausal women carry the same risk of cardiovascular disease as men.4
Clinical symptoms of myocardial infarction (heart attack) in women
Almost 70 percent of men presenting with a heart attack have chest pain, whereas only 58 percent of women present with chest pain. So a lot of women present atypically, without chest pain at all. The most common symptoms of a heart attack in women are shortness of breath, weakness, and fatigue. There is a significantly higher in-hospital mortality in women than in men, and this is felt to be attributable to both the older age of the women presenting with the disease and increased co-morbidities, as well as delay in diagnosis and treatment and less aggressive therapy.
Women who present without chest pain fare worse than women presenting with chest pain and heart attacks
More of the women presenting without chest pain had diabetes, they presented later in the course of the heart attack, they had larger heart attacks, and they received less aggressive therapy. They also had an increased incidence of sudden cardiac death in this patient population.7
Risk Factors for Cardiovascular Disease
Most of the risk factors for cardiovascular disease are the same in men and women, but some are significantly more predictive of developing heart disease in women.
The typical risk factors are:
1) Older age, lipid abnormalities (increased LDL, decreased HDL)
2) Family history of coronary artery disease
3) Diabetes mellitus
7) Metabolic syndrome
8) Sedentary lifestyle
What factors are more predictive of coronary artery disease in women?
1) Diabetes mellitus8
3) High risk lipid panel9, 10
4) CRP (C-reactive protein)11
5) Smoking12, 13
1) Heart disease is the #1 killer of women.
2) Women aren’t aware of the problem.
3) Women have different risk factors and clinical scenarios of heart disease than men.
4) Women aren’t treated as aggressively as men.
5) Women and healthcare providers need to be aware of the problem and aggressively diagnose coronary artery disease and treat this #1 killer of women.
- AHA-Heart Disease and Stroke Statistics 2013.
- National Center for Health Statistics 1999:164-167.
- Kochanek, KD, et al. National Vital Statistics Report 2004; (53)5:1-115.
- American Heart Association Statistical Fact Sheet 2005.
- Cheng, C, et al. Chest 2004; 126:47-53.
- Mosca, L, et al. Fifteen-year trends in awareness of heart disease in women 2012:AHA National Survey, Circulation:2013;127.
- Canto, JG, et al. JAMA, 2012;307:813.
- Skerrett, PJ, et al. Cardiovascular Health and Disease in Women, 2nd Edition, Philadelphia, WB Saunders, 2002:39-70.
- Bass, KM, et al., Archives of Internal Medicine, 1993:2209-2216.
- Larosa, JC, et al. JAMA 1999; 282:2340-2346.
- Ridker, DM, et al., NEJM:2000.
- Willett, WC, et al., NEJM, 1987:317:1303.
- Njolstad, I, et al., Circulation, 1996:93(3):450.