Half a century ago, it was a common misconception that heart disease was mostly a male problem. This is because men often adopt behaviors that increase the risk of cardiovascular disease. Before menopause, hormonal effects were protective in women. A male-dominated medical research institution designed and tested diagnostic tools only in men and subsequently inappropriately applied them to women, often missing the signs and symptoms of heart disease in women. Health education messages and risk reduction programs target men exclusively. Even clinical trials of the drugs had only men as subjects. Because the threshold for suspecting heart disease was unusually high in women, few women sought care for symptoms. Those who did were often misdiagnosed by doctors who didn’t expect the women to have heart disease.
Cardiovascular disease involves the heart as well as the blood vessels throughout the body, including those that supply blood to the heart and brain. Myocardial injury may result not only from occlusion of the heart’s blood vessels but also from myocarditis (inflammation of the heart muscle), which is caused by infections or autoimmune phenomena where the body’s immune mechanisms switch to splinter to target the heart. Other forms of heart muscle disease also occur, without a clear etiological factor (cardiomyopathy). This cardiomyopathy may also be associated with pregnancy.
Diseases that cause heart damage among women
The internal valves that separate the chambers of the heart are also susceptible to disease. Rheumatic heart disease has until recently been a widespread cause of autoimmune valve damage in young adults, with some forms more common in women. This was caused by the body’s reaction to a bacterial throat infection caused by streptococcus. With the widespread use (and misuse) of antibiotics and improved living conditions, this threat has receded. Age-related degeneration of some valves may occur in older decades. The covering of the heart (pericarditis) can also become inflamed due to a viral or tubercular infection. The arteries that supply blood to the brain, lungs, or extremities can manifest the disease in several ways. High blood pressure can arise during pregnancy, which threatens both the mother and the baby. Veins are no exception – deep veins in the legs and pelvis can develop into clots that may travel to the lungs and be life-threatening (pulmonary embolism).
myth vs reality
While there are many ways in which women can suffer from cardiovascular disease, the major causes worldwide are coronary heart disease and cerebrovascular disease. The former manifests itself in angina pectoris or heart attacks. The latter causes strokes (temporary or permanent paralysis of some parts of the body). As societies go through evolutionary transitions, both increase in the incidence of some geographical differences where these two perturbations are more dominant. As life expectancy increases, these become more common but can occur at a younger age as well as living habits change. To prevent these disorders through public health programmes, detect their risk factors and signs early, create capacity in health systems to manage them effectively and facilitate long-term self-care.
For this to happen, it is important to break the myth that cardiovascular disease is uncommon in women. In many countries, cardiovascular disease is the leading cause of death among women. Risk factors for coronary and cerebrovascular disorders are common and often modifiable. High blood pressure, smoking, diabetes, obesity, unhealthy eating habits that lead to abnormal patterns of blood lipids and lack of physical activity are all toxic to blood vessels everywhere in the body, and those that supply the heart and brain are particularly vulnerable.
Why women should be vigilant
Before menopause, female sex hormones tend to protect the blood vessels. High-density lipoprotein (HDL) cholesterol is higher in women of childbearing age than in men. Tobacco use significantly reduces HDL cholesterol and significantly increases the risk of heart attacks in women, even more than in men. Hence the phrase “If a woman smokes like a man, she will die like a man,” which countered the tobacco industry’s campaigns to target women as clients. High blood pressure is very common in men. Diabetes becomes more common as body fat increases (especially when it builds up in the abdomen). While women usually tend to have more fat around the hips than the abdomen (pear-shaped, men usually show an inverse (apple-shaped) pattern) this distinction is canceled when a woman smokes, becomes physically inactive, becomes obese, and is under severe stress. They sleep less or develop diabetes, and then women develop heart attacks at a relatively young age.
Polycystic ovary syndrome (PCOS) is associated with an increased risk of vascular disease due to the many associated metabolic abnormalities, and may present as coronary disease at an early age.
Heart attack symptoms vary
The symptoms of a heart attack are not always the same as the symptoms of a heart attack in men. There may be mild chest discomfort rather than the crushing central chest pain that men describe. The pain may be in the upper back, neck, lower jaw, arm, or upper abdomen rather than the chest. Extreme tiredness, feeling completely tired or short of breath may be the only symptoms. Women may feel chest discomfort from intermittent spasm in the coronary arteries, even when the lumps are not blocking the blood vessels. These pains are not related to exertion.
Women are more likely to have microvascular disease, a disease of the tiny blood vessels that feed the inner layers of the heart muscle. Because many of these presentations are ‘atypical’, when matched with ‘classical’ symptoms in men, clinicians trained on textbook descriptions collected from male experience may miss the diagnosis. Until recently, men’s interest in women’s hearts didn’t extend beyond Valentine’s Day emojis!
Coronary angioplasty and stenting have been shown to give women a lower benefit compared to men in early follow-up studies, whether because of late detection of coronary artery disease, age at presentation associated with more comorbidities or because of smaller caliber coronary arteries. Recent innovations in medical stents and newer anticoagulant drugs have narrowed these differences. However, delays in disease recognition and care delays are persistent problems, particularly in low- and middle-income countries.
A big challenge for women
Cardiovascular disease, which manifests as a disruption of blood flow to the heart or brain, has become a major challenge to women’s health in India. Several recent studies have indicated a high prevalence of coronary risk factors (eg, hypertension and diabetes) in Indian women, especially in urban areas. Low HDL cholesterol and high triglyceride levels (indicating a “metabolic syndrome”) are common in India and pose a significant risk of cardiovascular disease.
The National Family Health Survey (NFHS-5) reports that 24 percent of Indian women aged 15 to 49 are overweight or obese, while 56.7 percent are abdominally obese. These portend a high risk of developing cardiovascular disease and diabetes in the future. Cultural barriers of a patriarchal society reduce opportunities for regular exercise, even as consumption of unhealthy foods increases due to pernicious market mechanisms. It is essential that we create social conditions where women can promote and protect their health, even when health systems must be prepared to assess and correct cardiovascular risks at different stages of their lives.
(The author is head of the Public Health Foundation of India [PHFI]. opinions expressed are personal)
from San Jose News Bulletin https://sjnewsbulletin.com/why-women-need-to-take-good-care-of-their-heart-health/
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