Q: Many of my older women patients think they
are at much higher risk for breast cancer than
coronary heart disease (CHD). How can we raise women's
awareness about their risks of CHD and thereby
encourage them to take measures to prevent it?
A: All clinicians have to educate women about their vulnerability
to CHD and recommend ways to lower their
coronary risk. Almost a quarter of a million American women
die of CHD each year, compared with 40,000 who die of breast
cancer.1 Postmenopausal women have a 31% lifetime risk of
dying of CHD, compared with a 2.8% risk each from hip fracture
(as a surrogate for osteoporosis) or breast cancer. One in
3 women older than 65 years has clinical evidence of CHD.
Q: Acute myocardial infarction (MI) is underdiagnosed
in women far more frequently than in men. What
are the chief diagnostic pitfalls?
A: In both sexes, chest pain is by far the most prevalent
presenting symptom. But an atypical presentation
is much more common in women than in men.
Women with MI may describe pain in the neck, arms,
back, shoulder, or abdomen. A presentation that involves
such diffuse pain can complicate the diagnosis. Generally,
however, even such nonspecific symptoms have
an acute onset and should not be discounted. A woman
may experience such symptoms and not understand
their potential ominous significance. If she makes an
appointment to see her physician 2 or 3 days later, the
acute phase may have passed and the MI may never be
diagnosed. Or worse -she may not live to keep that
Furthermore, a subgroup of older patients of both
sexes -many of whom are women with diabetes -may not
experience any pain during an MI. They may feel extreme
fatigue, shortness of breath, or a sensation of being "totally
washed-out." Even in this group, however, the onset of
symptoms is relatively abrupt, and patients may therefore
go to the emergency department(ED). In this setting, a
high index of suspicion among health care professionals is
ED physicians sometimes follow the patient's lead
and take the wrong diagnostic path. Some women who
do not understand the nature of their symptoms will
clutch their chests and say, "I'm having indigestion."In
contrast, a man with the same symptoms and presentation
will say, "I'm having a heart attack," and will be managed
appropriately. If we educate women to realize that
they are vulnerable to CHD and MI, many more will realize
that their symptoms may be far more serious than
Q: Does underdiagnosis of MI in women account
for the fact that women are also undertreated
A: Unfortunately, yes. Women in an ED are treated less frequently than they should be with thrombolytic therapy
and less often than men with ß-blockers, aspirin, angiotensin-
converting enzyme inhibitors, and other drugs.3
This is not because physicians choose to undertreat women;
it's simply that MI is often not suspected, and therefore urgent
ECG and other diagnostic tests are not done. This results in
omission or delay of life-saving therapies.
Also, women typically present to the hospital later than
their male counterparts following symptom onset. This is
true not only with a first MI, but with recurrent MI as well.
Delayed hospital admission means that women may miss
the window of opportunity for certain
interventions, particularly coronary
Q: Women have worse outcomes
than men after treatment
for MI. Is this a result of inherent
biologic differences, of age at
presentation, or other factors?
A: Women aged 60 to 70 years
have higher mortality after MI
than age-matched men, both during
hospitalization and in the first 2 years
after the event. It is not yet clear
whether this is a function of biologic
differences, risk factors, treatment issues,
or comorbidity. Women with a
first MI are likely to have a higher risk
factor burden than men -that is, they
tend to have concomitant diabetes,
hypertension, and/or dyslipidemia.
When we adjust the data for these conditions,
the differences in mortality decrease,
but the higher incidence of
death in women does not disappear.
The obvious challenge, then, becomes primary prevention:
if we address risk factors earlier and more aggressively, we
might significantly reduce women's cardiovascular risk.
Although the absolute risk of coronary events in both
sexes increases with age and although CHD is most common
in older women, younger women are at risk as well -and
these younger women have worse outcomes than their male
counterparts after both MI and coronary artery bypass graft
(CABG>) surgery. The reasons for this are unclear. Among
women younger than 50 years, post-MI mortality is more than
twice as high as among men of the same age 4.Following MI,
a young woman is also at very high risk for recurrence.
Mortality for men and women after MI is similar
among those older than 75 years. Among the very elderly,
however, women with MI tend to do slightly better
than men. These differences have not been explained.
One possible reason for the fact that women generally
outlive men is that women seem to incur most of their serious
diseases later in life, whereas men are more likely
to be afflicted in middle age. Perhaps this is another reason
that CHD in women has been neglected: the preponderance
of CHD is in elderly women. These women are
no longer at the peak of their family or career responsibilities;
perhaps they're retired. Their illness is not as visible
as in men with CHD, who may be stricken at the
peak of their career and family obligations.
Q: Which risk factors for CHD
should I be especially
concerned about in my female
A: Cigarette smoking and diabetes
are strongly associated with an
increased risk of CHD in women. Cigarette
smoking seems to be a particularly
important risk factor in younger
women, possibly because smoking is
often their major risk factor. Smoking
is strongly associated with plaque erosion
in premenopausal women. 5More
young women take up the smoking
habit than any other subgroup. This
puts them at greatly increased risk.
Diabetes virtually abolishes the
sex-based cardiovascular protection
that is presumed in women. Women
with diabetes are at much higher risk
for MI than diabetic men; their risk is
the same as that of women who've already
had an MI. Diabetes appears to
greatly magnify the adverse effects of
other risk factors, such as smoking, hypercholesterolemia,
and hypertension.6 Moreover, women with diabetes are
more likely to have unfavorable lipid profiles and to be hypertensive
and obese. The reasons and the mechanisms
have yet to be completely elucidated.
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