Cardiovascular disease is the leading cause of mortality for both men and women. In Europe about 55 percent of all female deaths are caused by cardiovascular diseases, especially coronary artery disease and stroke.
Unfortunately, the risk of women is underestimated because of the perception that females are “protected” against cardiovascular disease but this protection fades after menopause. Indeed, women are better protected than men against heart disease before menopause thanks to estrogen, which increases their HDL and decreases their LDL cholesterol levels(1) , but this advantage disappears in the postmenopausal period leaving women with untreated risk factors vulnerable to develop myocardial infarction, heart failure and stroke. This explains why the incidence of CHD in women increases dramatically in middle age.
If we analyze the SCORE charts for the 10 year risk of fatal cardiovascular events it may appear that women are at lower risk than men. However, the only difference is that womens’ risk is delayed by 10 years: a 60-year old woman has an almost identical risk as that of a 50-year old man.
Furthermore, women who already had an heart attack - especially if they are diabetic, are twice as likely as their male counterparts to have another heart attack. Smoking while taking the contraceptive pill put women at an even greater risk of CHD.
The symptoms of CVD in women may be different from men's symptoms. The most common symptoms in women with a heart attack are :
- in the prodromal phase: unusual fatigue, sleep disturbance, shortness of breath, indigestion, anxiety, heart racing and weak or heavy arms;
- during the acute heart phase: shortness of breath, weakness, unusual fatigue, cold sweat, dizziness, nausea, weak or heavy arms.
Yet this difference is poorly recognised.
4) Diagnosis and Therapy
Due to the low number of ad hoc trials to study CVD in women :
- CVD in women is often not promptly and well diagnosed
- the majority of drugs are tested for safety and efficacy in male populations. Yet response to therapy in women may be different from those observed in males (2).
The Euro Heart Survey on angina (3) has shown that women are
- significantly less likely to be referred for functional testing for ischaemia, in particular for exercise testing,
- less likely to receive angiography even after adjustment for the results of non invasive tests, and were less likely to be referred for revascularization.
A smaller percentage of women receive secondary preventive therapies (aspirin or statin) while in fact the female gender is strongly associated with an increased risk of death and myocardial infarction, independently of age and other predictors of adverse outcome.
5) Steps to be taken
The understanding of all the differences is necessary for the improvement of the clinical management of cardiovascular diseases and for the development of possible new gender-specific diagnostic and therapeutic options.
It would be advisable to move to more focused evaluation in females. Thus, it is recommended that based on the specific question addressed, clinical trials enrolling only female patients or clinical trials enrolling a significant proportion of women - to allow for pre-specified gender analysis - should be conducted. Medical textbooks should underline the different prevalence of male and female symptoms in heart attack in women and doctors should be trained to recognise the symptoms.
6) “Women at heart”
The “Women at Heart” program of The European Society of Cardiology organizes initiatives targeted at promoting research and education in the field of cardiovascular diseases in women.
The Policy Conference on Cardiovascular Diseases in Women, held in Nice in June 2005, is part of the program; it brought together 60 cardiologists and experts from the European Society of Cardiology member countries and analyzed the contribution of medical research to fill the scientific gaps on cardiovascular diseases in women.
Moreover, the strategies and immediate actions for changing the misperception of cardiovascular disease in women, improving risk stratification, diagnosis and therapy from a gender perspective and increasing women representation in clinical trials have been discussed. A Statement from the Policy Conference has been provided and published in the European Heart Journal (4).
Tab. 1 A review of cardiovascular trials conducted in Europe between 1986-1997.
|Trial||Enrolled patients||% females||Reference|
|GISSI-1||11711||25||Lancet 1986; 1:397-402|
|ISIS-2||17187||23||Lancet 1988; 2:349-360|
|GISSI-2||12490||20||Lancet 1990; 336:65-71|
|GISSI-3||18023||22||Lancet 1994; 343:1115-22|
|4S||4444||19||Lancet 1994; 343:1383-89|
|ISIS-4||58050||26||Lancet 1995; 345:669-685|
|SMILE||1556||27||NEJM 1995; 332:80-85|
|EMIAT||1486||16||Lancet 1997; 349:667-674|
|GISSI-P||11324||15||Lancet 1999; 354:447-52|
|CIBIS-2||2647||19||Lancet 1999; 353:9-13|
|CHARM||7601||31||Lancet 2003; 362:759-766|
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.