Ask Dr. Pat

Dr. Pat Consults: Heart Disease in Women: Recognizing the Symptoms

Recently a lot of attention has been given to potential biologic differences in women that account for different symptoms and outcomes, as opposed to deficiencies in diagnosis resulting from an inherent bias within the healthcare system. Fortunately, unlike older studies of CAD, whose subjects were predominantly male, more recent studies include large percentages of women and are beginning to clarify this issue of biology vs. bias.  

Such studies indicate that the symptoms of CAD in women, contrary to recent popular claims, are much more similar to those of men. In fact, angina, the hallmark symptom of CAD, produced by a reduction of blood flow to the heart, is more common in women than it is in men. It is important for patients and physicians to recognize this symptom.

In both sexes, angina is most frequently described as a tightness or pressure in the center or lower chest, with or without radiation to the neck or either arm.  Many patients with angina will deny having chest pain at all, since the sensation is not sharp or knifelike. In both sexes the symptoms may include a burning quality at times, accompanied by burping or other symptoms of indigestion; this may create confusion in the diagnosis. However, stomach ailments do not get worse with exertion, provocation, or exacerbation with activity. And stomach symptoms do not resolve with rest. These symptoms are red flags in either sex.

In these situations (exertion, for example), the increased workload of the heart requires more fuel and temporarily exceeds its blood supply. Angina may occur without activity when, as discussed below, an atherosclerotic plaque is disrupted and the artery becomes nearly or completely occluded. Such cases of unstable angina represent a medical emergency and are often, but not always, preceded by episodes of exertional angina. In any case, awareness of the prevalence of CAD among women, with elimination of the bias, should help rapid appreciation of the significance of these symptoms.  

Studies also indicate that physicians, as well as their female patients, underestimate their personal risk of heart disease and fail to identify and attend to risk factors that contribute to CAD. This lack of awareness is largely an extension of bias, but to some lesser extent may reflect an underappreciated biologic difference among women, in whom obesity, elevated triglycerides, and elevated inflammation as measured by C-reactive protein are more important promoters of plaque formation than they are in men. The Framingham Risk Score,  long considered a critical measurement that can predict future heart disease, underestimates a woman’s risks, which are better predicted by contemporary scores such as the Reynolds Risk Score,  which allows for the different risk factor profile among women.

Next Page: Shortcomings in the Treatment of Women with Heart Disease

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  • Delores Lyon May 14, 2015 at 3:16 pm

    Thanks for sharing this advice on detecting heart disease in women. I had no idea that some women aren’t diagnosed with heart disease because of bias from the doctor. It sounds like it is really important to have a doctor that knows all of the symptoms of heart disease, and who is not willing to rule a high triglyceride count out as part of the woman’s biology. Heart conditions are really serious, and should be treated very seriously if there is any chance you could have one!

  • Margret Avery February 23, 2015 at 11:53 am

    This is a great article Dr. Pat – thanks for posting!