We don't see heart health as a women's issue. Here's why that has to change
What do you think constitutes a women's health issue? There's a high chance that heart health doesn't fall under that umbrella in your mind.
But that most powerful biological machine at the core of your existence is a grafter. It beats three million times during the average person's lifetime. And it deserves - no, demands - your attention.
Roughly 23,000 women die from coronary heart disease each year. That's an average of one every 23 minutes. In fact, coronary heart disease kills more than twice as many women as breast cancer.
And yet, research published today by the International Menopause Society (IMS) notes how the perception of danger caused by cardiovascular disease among women has declined in recent years.
In 2019, versus a decade earlier, women in the US were 74% less likely to identify heart disease as a leading cause of death. (A picture similar, say cardiologists and charities like the British Heart Foundation, to that on these shores.)
This is especially concerning given the paper indicated multiple sex-specific risk factors for cardiovascular disease that so often fly under the radar.
This impacts women's awareness of the importance of taking heart-protective actions - and even their treatment in hospital (more on this later).
The situation becomes especially concerning for those women at - or approaching - menopause. While younger women have a lower risk than men of developing coronary heart disease, the leading cause of heart attacks, after the menopause the chance of a woman having a heart attack is drastically increased.
'Changes to a woman’s body during menopause, such as fallen oestrogen levels, are linked with a higher risk of developing cardiovascular disease,' explains consultant cardiologist Dr Sonya Babu-Naraya.
She's Associate Medical Director for the BHF, which is also highlighting the impact of midlife hormonal changes on heart health, this World Menopause Day.
'Cardiovascular risk [is made up of] a lifetime of choices and experiences,' says Dr Cynthia Stuenkel, Clinical Professor of Medicine at the University of California and author of the aforementioned IMS paper.
'But menopause offers the opportunity of a single point in time to step back, take stock, and do all you can toward promoting future cardiovascular health for the rest of your life.'
With that in mind, read on for our deep dive into what women of all ages and stages need to know about keeping their heart healthy - now and in the years to come.
Anatomy of a stereotype: Why many women don't consider their heart health
‘There’s a visual that people have of the type of person you’d expect to suffer a heart attack: a man in middle-to-later age, who might smoke, is a diabetes risk, doesn’t exercise and is overweight,’ explains Professor Chris Gale of the University of Leeds and spokesperson for the BHF.
‘But women are not immune to heart and circulatory disease - in fact, as many women as men are living with it in the UK.’ Circulatory disease is arguably an even bigger deal for you than for the men in your life; according to heart health journal Circulation, mortality rates are worse for women within the first year of a heart attack than for men.
It’s not a case of your female biology screwing you over - your heart health is in fact one area where your choices and actions can make a positive, formative difference.
Instead, multiple cardiologists told WH that the problem is cultural; a complex melange of issues around self reporting and diagnosis arising from the fact that the issue of female heart health appears to be locked in a cycle of false assumptions and missing information.
BHF-funded research has shown that women who have a heart attack are more likely to receive the wrong diagnosis and thus are less likely to receive evidence-based treatments, such as a stent, if they suffer one.
The heart charity warns that misperceptions about women’s risk of heart disease cost lives.
The biology of how heart attacks occur
‘There are three primary ways in which the heart can go wrong,’ explains London-based cardiologist Dr Amanda Varnava.
An issue with the heart muscle, which can become inflamed and struggle to pump as well as it needs to
A problem with the electricity of the heart, which causes it to beat too fast or too slow
A problem with blood supply in the coronary artery (the most common reason)
Unhealthy coronary arteries often occur, she explains, due to a process called atherosclerosis. That’s when the artery walls ‘fur up’, thanks to a build-up of fatty deposits and cholesterol called atheroma, which narrows the gap through which blood can travel.
Gradual accumulation can cause angina (this may manifest as chest pains or breathlessness), or the atheroma can build up rapidly, becoming brittle and vulnerable to bits of the fatty substance breaking off.
‘In this instance, a clot may form around the dislodged area of cholesterol, blocking the artery,’ she explains.
When the coronary artery can’t do its job, the specific area of the heart muscle that artery supplies blood to dies and can no longer pump oxygenated blood around the body. That’s heart failure.
It’s complex stuff; hearts don’t malfunction nice and neatly, and those three primary causes of heart failure often intersect.
For instance, the initial cause of the heart problem may be cholesterol build-up, not the muscle or its rhythm, but there will be a down-the-line effect.
The heart will try to heal itself by changing dead or damaged heart muscle cells into scar tissue.
But scar tissue can’t contract like heart muscle tissue can and, as a result, can’t help the heart to pump. ‘This can lead to rhythm problems and eventual collapse,’ adds Dr Varnava.
How heart attacks present differently in women
Further complicating the state of play is the growing understanding that heart attacks show up differently for women.
A sudden, crushing, clutch-your-chest pain? That’s more common in men; such indicators in women are more likely to include overwhelming fatigue, on-off pressure in the chest and pain in the back, neck or stomach.
You probably don’t know this, and therefore wouldn’t link those symptoms to heart problems - worryingly, doctors don’t seem to do so either.
Scientists at the University of Leeds highlighted that women are 50% more likely than men to receive the wrong diagnosis following a heart attack.
The same team then discovered that women were a third less likely than men to receive an artery-unblocking treatment and a quarter less likely to receive statin medication to prevent another heart attack.
The absence of clarity around heart health in women plays out in a self-perpetuating cycle: women don’t believe themselves to be at risk and delay calling an ambulance.
If a heart attack does strike, then there’s the chance that their immediate risk will be underestimated by medical professionals.
Research shows women are more likely than men to experience the types of heart attacks that arrive unannounced by typical risk factors; heart attacks like myocardial infarction with non-obstructive coronary arteries (or Minoca for short).
‘Unlike in classic coronary heart attacks [remember: where arteries fur up with cholesterol and lipids that block blood flow], the arteries that supply the heart are only minimally obstructed, if at all,’ explains Professor Gale.
So why does this lead to a heart attack? Simple answer: we don’t know yet.
Another is SCAD, which stands for spontaneous coronary artery dissection. ‘It occurs when a coronary artery near the heart develops a tear or bruise, which ends up blocking the blood flow,’ explains Professor Gale.
The exact number of women who experience this specific type of heart attack is hard to get at, but experts believe the women affected are disproportionately young, fit and generally healthy.
Things that can increase your heart disease risk
‘If anyone in your family has suffered heart failure under the age of 50, raise that with your GP, no matter your age,’ says Dr Varnava. Your ethnic origin can play into specific heart health concerns, too.
‘People of South Asian descent are more vulnerable to heart disease, while those of African or Caribbean origin are disproportionately affected by high blood pressure and associated problems.'
A 2023 study from the American Heart Association also indicated that racism plays a role.
A long-term study of more than 48,000 Black women found experiencing self-reported interpersonal racism in employment, housing and interactions with the police was associated with a 26% higher risk of coronary heart disease.
As for those sex-based difference mentioned above? ‘Women who have gone through the menopause - either naturally or because they’ve had their ovaries removed - before the age of 45 face an increased risk,’ explains Dr Varnava.
‘It’s thought to possibly be because these women have spent a longer time living without oestrogen, which is known to be protective.’
That’s not the only period of hormonal upheaval during which cardiologists want women to be mindful of cardiovascular warning signs – pregnancy and birth bring their own complications.
The aforementioned International Menopause Society paper found that women with recurrent preeclampsia during pregnancy experienced a three-fold rise in the risk of developing heart failure.
While high blood pressure or diabetes during pregnancy or menopause and experiencing premature menopause (before the age of 40) have all been recognised as cardiovascular disease risk factors.
‘The hormonal changes can cause a heart attack, so even if you’re fit and well you need to pay attention to the classic warning symptoms - particularly breathlessness,’ says Dr Varnava.
‘It’s very rare, but the progesterone of pregnancy loosens your body’s tissues to enable you to dilate your cervix in order to deliver a baby; but it also means that arteries can tear more easily than in a non-pregnant state and cause a heart attack that way.’
How high blood pressure also affects heart disease in women
High blood pressure and diabetes both independently increase your risk of heart attack.
The former by driving the build-up of cholesterol in the coronary arteries and placing strain on the heart, the latter by making your body a more fertile ground for a process called glycosylation to take place.
‘That’s when glucose molecules [which are more prevalent in the bloodstreams of diabetics] attach to molecules and structures, such as proteins and cell membranes, within the arterial wall, promoting atherosclerosis - that “furring up”,’ explains Dr Varnava.
She adds that obesity exacerbates all these processes and increases their severity.
There are also reports, she explains, of obesity-specific cardiac death, and warns that outcomes of different surgical interventions - transplants, pacemakers, etc - are far poorer for a patient who is severely obese.
It follows that eating in a way that compounds these problems should be curtailed. We’re referring to processed foods and those high in saturated fat or sugar, which spike blood sugar, further raise blood pressure and contribute to excess body weight.
It’s not simply about what you consume, either: oral hygiene matters, according to Dr Melissa Caughey, cardiology researcher at University of North Carolina School of Medicine.
She explains that people who have inflammation of the gums (also known as peritonitis) are two to three times more likely to have a heart attack or other serious cardiac event – though, again, scientists are yet to identify a direct connection.
Lowering your heart attack risk: what role can food and movement play?
Short answer: a pretty significant one.
'It’s important to remember that there are two components to a heart-healthy diet,’ explains Dr Ali Khavandi, consultant cardiologist and founder of The Cardiologist’s Kitchen, an initiative that aims to help people at risk of cardiovascular disease make food and lifestyle changes.
‘The first is avoiding damaging foods and the second is getting enough of actively protective foods.’
His three rules of thumb: eat more plant-based fibre (such as whole grains and cruciferous vegetables; factor in regular servings of unsaturated fats (which you’ll find in olive oil, nuts and oily fish, such as mackerel) and get plenty of variety.
'A lack of dietary diversity could lead to a wasteland of a microbiome in the gut, which very early research suggests could have a negative effect on long-term heart health,’ adds Dr Khavandi.
As for the notorious heart health saboteur, salt?
It’s a good rule of thumb to avoid jar sauces and frozen meals packed with it, but he says you needn’t make it a priority to lower your intake unless you have existing issues with high blood pressure. Save your more stringent exercising of moderation for booze.
‘Alcohol’s effect on heart health is like a J-shaped curve,’ explains Dr Khavandi. ‘Drinking a small glass of wine - Mediterranean style with dinner - may be protective, but go over that minimal amount and all alcohol becomes rapidly damaging.
'It’s energy-dense and if you drink more than you should, that’s a clear driver for visceral fat storage, type-2 diabetes and high blood pressure,’ he warns.
As for fitness? Well, it’s not exactly news that exercise is a cardiovascular health essential.
More noteworthy are results of an Iowa State University study that looked at the impact of resistance training on heart health, independent of aerobic activity and found that weight training alone is enough to lower your risk of having a heart attack or other cardiovascular event. Big news for spinning refuseniks.
Speaking of cardio, a study published in JAMA Cardiology offered up baffling results.
Participants who did over five hours of vigorous cardio each week were less likely to die from a cardiovascular event, and yet they developed an ominous build-up of atheroma (that blockage-causing mix of lipids and cholesterol) in their arteries.
Does that mean that, where your heart is concerned, you can have too much of a good thing? Not really.
‘These early signs of heart disease never got to the point where they blocked people’s arteries,’ explains Dr Varnava. ‘So, though there may have been some early signs on the CT scans, the end result is good'
In sum: exercise is good for heart health - no matter how much you do.
What's stress got to do with it?
While chronic stress (a response to emotional pressure over a prolonged period of time) is generally understood to raise blood pressure and heart rate, putting extra strain on the cardiovascular system, research on stress has been negligible compared with other physiological risk factors.
Multiple UK cardiologists contacted by WH were reluctant to draw a line between the two. But a new wave is challenging this view, pushing for health authorities to list emotional stress as a key modifiable risk factor.
Among them, Dr Sandeep Jauhar, US cardiologist and author of Heart: A History, in which he argues that, from the first big study of cardiovascular risk factors in the mid-20th century, scientists have overlooked the role of emotional and social disruption because cholesterol levels are easier to measure.
Results from a 2017 US study back him up. Researchers measured activity in the amygdala - the brain’s almond-shaped threat detector system - to determine whether its activity can predict someone’s risk of suffering a cardiovascular event.
Turns out that it can.
The scientists theorised that the amygdala may sense danger and signal to the bone marrow to produce extra white blood cells (to help fight infection and hasten repair in the event of a physical attack), which causes the arteries to develop the atheroma plaques and become inflamed.
While these results alone aren’t enough to influence national or global health policy, the Harvard cardiologist who led the study is now referring his patients for stress-management programmes.
'Anxiety and depression cause uncomfortable symptoms that can be felt, sometimes on an everyday basis, while risk factors for heart disease, such as high blood pressure, are usually symptom-free,’ he explains.
Heart health is a women's issue - the bottom line on how to protect yours
But just as mentally ‘well’ people know they need to nurture their minds to stave off depression, preventing a heart attack requires a similar cumulative, long-game effort.
We don’t need you to be excited about it, but we do want you to know that it’s an effort worth making.
While those in labs and consulting rooms may not have all the answers, they’re united on one thing: a body that’s nourished, well-worked-out and feeling the benefits of stress-relieving activities is a body that’s stronger and more capable.
It’s also a body that’s statistically less likely to experience a serious cardiac event and one that, should the worst happen, will be more resilient in its recovery.
The bottom line? Playing by the heart-healthy rules detailed above doesn’t equate to watertight insurance against things going wrong.
However, paying due care and attention to one of the hardest-working bits of your body amounts to one of the smartest investments in your health you’ll probably ever make
You Might Also Like
