When you think of heart disease and heart attacks, you may conjure up images of older, overweight men being affected. However, women are affected just as frequently. Most women with coronary artery disease (CAD) have a reasonably typical form of the disease (a quick review of typical CAD.) But, importantly, women are, on average, about 10 years older than men with CAD. These women have roughly the same outcomes as men, when matched age for age - at least when their CAD is diagnosed and treated in a timely fashion. The majority of women with CAD fall into this "older patient, typical CAD" pattern.
However, there are three aspects of CAD in women that are more common to women than men, and when they occur they often lead to missed diagnoses and inadequate therapy:
- The symptoms of CAD can be different.
- The usual diagnostic tests are more likely to give the wrong answer.
- The disorders affecting the coronary arteries can be different, especially in younger women.
These differences, coupled with the false notion that women just don't get heart disease, contribute mightily to critical delays in diagnosis and treatment - and ultimately, to disability and death. Let's look at these factors more closely:
1. The Symptoms of CAD in Women & Silent Heart Attacks
When women have angina (a type of chest pain), they are more likely than men to experience "atypical" symptoms, such as a hot or burning sensation, or even tenderness to touch, in the back, shoulders, arms or jaw; often they have no chest discomfort at all. Any good doctor will think of angina whenever a patient describes any sort of fleeting, exertion-related discomfort located anywhere above the waist, and they really shouldn't be thrown off by "atypical" descriptions. However, because many doctors persist in believing that CAD is uncommon in women, they are all too likely to write such symptoms off to mere musculoskeletal pain or gastrointestinal disturbances.
Heart attacks also tend to behave differently in women. Frequently they experience nausea, vomiting, indigestion, shortness of breath or extreme fatigue - but no chest pain. Unfortunately, these symptoms are easy to attribute to something other than the heart. Women also are more likely than men to have "silent" heart attacks - that is, heart attacks without any acute symptoms, and that are diagnosed only at a later time when more cardiac symptoms occur.
2. Diagnosing CAD in Women Works a Bit Differently
Diagnostic tests for CAD can be misleading in women. The most common problem is seen with stress testing - in women, the ECG during exercise can often show changes suggesting CAD, whether CAD is present or not, making the study difficult to interpret. Many cardiologists routinely add something known as an echocardiogram or a thallium study when doing a stress test in a woman, which greatly improves diagnostic accuracy.
In women with typical CAD, coronary angiography is every bit as useful as in men; it identifies the exact location of any plaques, and guides therapeutic decisions. However, in women with atypical coronary artery disorders (to be discussed in the next section,) coronary angiograms often appear entirely normal, a result that can be very misleading. In women, angiography is notthe gold standard for diagnosis.
3. Atypical Forms of CAD in Women
At least 3 atypical coronary artery disorders occur in women, usually in younger (i.e., pre-menopausal) women. Each of these conditions produce chest pain with "normal" coronary arteries (that is, coronary arteries that appear normal on angiogram unless special care is taken.) Click on each of these conditions to learn about them: Prinzmetal's Angina, Cardiac Syndrome X (CSX) and Female-Pattern CAD.
