Cardiologist Jacqueline A. Eubany, MD, FACC, FHRS, often speaks to women in local communities about heart disease, especially during Women’s Heart Health Awareness month in February. “During the question-and-answer portion, I get asked the same questions over and over,” Dr. Eubany said. “Some of the questions are basics about heart disease that I thought everyone knew.”
One fact that many Americans don’t know: heart disease is the number one cause of death in women in the United States.
“I came to realize that there is a lack of education about the subject matter,” Dr. Eubany said. So she wrote a new book, “Women and Heart Disease: The Real Story,” to help answer these basic questions. “I decided to write this book to explain heart disease in a way that is easily understood by people who do not have a medical background, and to have one place where the information can be found.”
In this interview, Dr. Eubany discusses the cardiovascular risk factors, the potentially misleading symptoms of heart disease in women, and the disparities and delays in care for women as compared to men.
MDLinx: Why is coronary heart disease (CHD) in women under-detected and under-diagnosed?
Dr. Eubany: CHD is under-detected and under-diagnosed in women for several reasons. Women are not aware of the fact that heart disease is the number one killer of women in the United States. When women have symptoms that can potentially be related to an acute cardiac event, they downplay their symptoms and don’t seek medical attention ASAP. By the time they get around to seeking medical attention, which is when their symptoms become very severe, they are pretty late in the disease process where 100% recovery may not be achieved with medical intervention. In other words, the damage has been done and is irreversible.
Also, about 43% of women who come to the ER and are later diagnosed with heart attack did not present with the classic symptoms [such as chest pain] that are associated with a heart attack. Their nonspecific symptoms lead to a delay in diagnosis and therefore poorer outcomes compared to their male counterparts.
MDLinx: What are some of the CHD risk factors that are more significant in women than in men?
Dr. Eubany: For the most part, women have the same risk factors for heart disease as men do. However, some of these risk factors have more of a severe effect on women compared with men. For example, women who smoke have a 25% higher incidence of a myocardial infarction compared to men who smoke. Also, women who have diabetes mellitus and have a heart attack have a higher mortality rate than males with similar medical conditions.
There are also some risk factors for heart disease that are inherent to women. Examples include taking oral contraceptive pills, postmenopausal state, and receiving chemotherapy for breast cancer. These conditions confer a slightly higher risk for cardiovascular disease.
MDLinx: Why is CHD sometimes a more serious condition in women than in men?
Dr. Eubany: Compared with men, women tend to have a poorer prognosis after having a heart attack, for several reasons. For one, they may delay medical attention. Research shows that women tend to seek medical attention later. As primary caregivers for their families, they tend to put everyone else’s needs ahead of their own. Also, women tend to disbelieve that their symptoms are life threatening, which contributes to delay in getting medical attention and therefore poorer prognosis.
Another reason is that women often have nonconventional presenting symptoms, including fatigue, nausea/vomiting, and shortness of breath. Approximately 43% of women who present to the hospital and are later diagnosed with a heart attack do not present with the classic symptoms of a heart attack. These nonconventional symptoms then lead to delay in therapy and therefore poor outcomes.
MDLinx: What are some of the psychological and social factors that may contribute to the risk for CHD in women?
Dr. Eubany: Some factors that can contribute to heart disease include stress, lack of sleep, and depression.
A severe stressful situation, like the death of a loved one, can bring about “broken heart syndrome” or takotsubo cardiomyopathy. The sudden and acute surge in stress hormones can produce symptoms and clinical findings consistent with a heart attack. Most patients recover fully from this syndrome, but a small percentage have long-term sequelae.
Lack of sleep can also contribute to heart disease by causing weight gain. A lack of sleep slows down your metabolism and produces an imbalance in hormones that regulate appetite in favor of the hormone that causes an increase in appetite, resulting in weight gain. Obesity, as we all know, is a strong risk factor for cardiovascular disease.
Depression has also been shown to be associated with cardiovascular risk. Research has shown that women who have a diagnosis of depression have a higher incidence of heart disease and are more likely to die from heart disease than women who are not depressed.
MDLinx: How does CHD treatment and prevention differ between women and men?
Dr. Eubany: Studies have documented the disparities in receiving care in women having myocardial infarctions compared to their male counterparts. In a study published in the Journal of the American College of Cardiology in 2005, women who presented to the ER with heart attack were less likely to get an ECG within 10 minutes. Women were also less likely to receive life-saving medications—including heparin, ACE inhibitors or glycoprotein IIb/IIIa inhibitors—and less likely to undergo emergent cardiac catheterization compared to men. All these therapies, if given early, can lead to an excellent prognosis in patients who present to the ER with a heart attack.
There have also been documented disparities seen in routine outpatient doctor visits. Compared to men, women are less likely to be counseled about their risk factors and are less likely to be advised about ways of modifying their risk factors.
MDLinx: CHD kills more women than breast cancer does. But in the public eye, breast cancer seems to be considered more devastating. What do you tell your patients to get their attention about heart disease?
Dr. Eubany: I usually lay out the statistics about women and heart disease, as well as the mortality rates associated with heart disease in women. For one, heart disease kills more women than breast cancer and lung cancer combined. I then ask patients to name family members who have died from breast cancer and to name family members who have died from cardiovascular disease. They can always more readily name family members who have died from cardiovascular disease than they can breast cancer.
MDLinx: African-American women are at an even greater risk for CHD than white women. How can clinicians increase awareness and prevention in African-American women in particular?
Dr. Eubany: I think more education is needed—more education in the community, organized by people/organizations that are trusted and well respected in their community, like a church, a community center, or social/nonprofit organizations. These organizations can host events where people who have suffered heart disease are invited to tell their stories and speak about how they overcame it. These organizations can also host events like health fairs, health walks, or short seminars to educate about heart disease, etc.
MDLinx: Is there any other facet about CHD in women that you'd like to get across?
Dr. Eubany: One last point I would like to stress is that everyone should know their risk factors for heart disease. If you can control your risk factors, you can decrease your risk for a cardiovascular event by up to 80%!
About Dr. Eubany: Jackie Eubany, MD, FACC, FHRS, is a board-certified cardiologist and electrophysiologist who practices in Orange County, CA. She served in the United States Navy for 12 years. More information about her book is available at www.womenandheartdiseasebook.com.