Women’s Health

Overcoming common misconceptions to deliver better care

The underestimation of heart disease risk in women often arises from the misconception that females are inherently 'protected' against cardiovascular issues. This belief is grounded in the assumption that exposure to endogenous estrogens during the early stages of life functions as a delaying factor in the onset of atherosclerotic disease in women. While cardiovascular disease manifests itself 7 to 10 years later in women compared to men, it remains the predominant cause of mortality among women aged 65 years and older.² Additionally, recent studies have shown that over the past two decades, the occurrence of myocardial infarctions has increased in women ages 35-50, while declining in similarly aged men.²

Beyond the challenges of disease prevalence, there’s also the issue of disparity in diagnosis and treatment. A European Heart Survey on stable angina pectoris revealed that, compared to men, women were less likely to be referred for functional testing for ischemia. Furthermore, there is a lower rate of diagnostic angiograms and interventional procedures performed.² These gaps in recognition and clinical presentation of heart disease in women contribute to less aggressive treatment strategies.

Because only 30% of study subjects in clinical trials are women, the treatment plans for heart disease are mostly based on data from men.³ This issue is particularly concerning due to the distinct symptoms experienced by women. While men commonly exhibit classic chest pain, women often present with atypical symptoms like shortness of breath, nausea and fatigue. Compounded by guidelines primarily designed for men, this disparity can result in misdiagnosis, often categorizing women's heart disease as gastrointestinal issues or anxiety.

Differences in female heart health

Over the past 30 years, cardiology has made significant strides in identifying disease traits, metabolic patterns and understanding the causes of atherosclerotic coronary disease. Furthermore, there have been improvements in creating better combinations of medications, developing devices for the heart, identifying risk factors and suggesting lifestyle changes to prevent heart disease. A plethora of research has given us a strong and reliable stream of information to help healthcare providers and patients select appropriate options for meeting individual needs.

Although some research has been done to understand the differences in how heart disease affects men and women, we need more studies to fill the gaps in our knowledge. This will help healthcare providers intervene earlier and prevent the complications of advanced disease.

Unique presentation and risk factors

Because the pathophysiology of heart disease is different in women, so are their presenting symptoms. Women often experience heart disease that affects smaller blood vessels in the heart, leading to symptoms that are considered different or "atypical" compared to the classic description of a heart attack in men. Instead of the typical dull chest pain that radiates into the left arm, women may have variations in their symptoms. For example, women may present with more subtle symptoms such as profound fatigue, jaw or tooth pain and a new onset of shortness of breath with minimal or normal activity.

Risk factors unique to women involve estrogen production. There’s an increased risk of developing heart disease associated with early onset of menses (before age 11) or early menopause (before age 40). In addition to the risk factors that affect both men and women, there are specific risk factors that are unique to women. These include conditions like polycystic ovary syndrome, diabetes, preterm delivery, delivering a low-birth-weight baby, using birth control pills, and experiencing hypertension during pregnancy. It's important to consider these female-specific risk factors alongside the common ones such as essential hypertension, obesity, stress, smoking, diabetes, sedentary lifestyle and unhealthy diet.¹

Within the risk factor profiles comparing women to men, there are higher risks for Black women compared to white women, increasing where diabetes and hypertension are present.⁴

With an estimated 75% of caregivers being women, they may tend to prioritize caring for others over prioritizing their own health. This could postpone evaluation of their own symptoms, resulting in delayed diagnosis and care.⁵

Raising awareness and improving women’s heart health

Addressing gaps in knowledge and care for women with heart disease is crucial. One component of this strategy is underscoring their unique risk factors and placing an emphasis on disease prevention. Additional efforts include creating awareness through education, improving outcomes through evaluation and refinement of optimal medication combinations, and leveraging cardiac devices. These strategies have the potential to significantly improve outcomes and decrease the incidence of cardiovascular events in women.

Wearables can also be an asset for early detection and the prevention of heart disease. Women are more likely to use wearable healthcare devices, however, adoption rates lag in adults over age 50 and in those with lower incomes. These are both subgroups of this population that stand to benefit from use of the devices.⁶ With higher adoption rates, driven by support and education, wearable devices could be leveraged to improve care.

Wearable technology and heart health

Technological advancements have facilitated the integration of sensors into various wearables. These devices can capture and monitor a range of information, such as heart rate, arrhythmias and blood pressure.

Today’s wearable devices deliver continuous, real-time recording of data. This information facilitates the detection of cardiac arrhythmias including atrial fibrillation (AF), the most common type of arrhythmia. AF affects about 46 million individuals worldwide.⁷ Recently, many fitness bands and smartwatches worn on the wrist have gained The Food and Drug Administration (FDA) clearance and can alert the wearer, and their healthcare provider, to irregular heart rhythms.⁸ Newer technology integrates heart rate sensors into accessories like rings, necklaces, earbuds, chest straps, footwear and glasses.

Hypertension is a common risk factor, and to provide more information and timely care, blood pressure sensors like FDA cleared cuffless monitors are worn to help monitor blood pressure levels.⁹ There are also leadless patches, which are attached to the patient's chest to provide ambulatory echocardiogram (ECG) monitoring over extended periods of time.¹⁰

While wearables are an asset, the accuracy will depend on the type of device and what algorithms are being used to gather the data. In general, photoplethysmography (PPG) based heart rate measurements from wrist-worn devices show high agreement with those derived from simultaneous ECG tracings, although deviations have been reported in AF patients with high heart rates.¹⁰

Providers can empower and encourage patients to use wearables. Only one out of every four individuals with a diagnosis of cardiovascular disease or known risk factors actually use wearable devices.¹² Even then, those individuals rarely wear them on a regular basis. In a recent survey of women aged 30-75, barriers to adoption included accuracy and reliability of data, cost and comfort of wearing the device.¹³ Helping to identify wearables that are easier to use, offering education to those who may be resistant to new technology and seeking support from insurance providers to mitigate the cost impact could all be strategies to help improve adoption rates.

As new generations of wearables emerge, increasing accuracy and functionality, we expect a positive impact on earlier detection and intervention. Individuals that take a more proactive role in their care may lessen the burden on clinicians and ease the pressure on the wider health system.¹¹