By Sarah Handzel, BSN, RN

March 8, 2022 marks International Women's Day, when people around the world celebrate women's achievements and explore ways to eliminate bias, and create true equality. Cardiologists also have a place in these celebrations and initiatives, as women's heart health often differs from men's in terms of disease onset, presentation of symptoms, diagnostic disparities, and patient outcomes.

According to the Centers for Disease Control and Prevention, heart disease is the leading cause of death for women in the United States.¹ However, by creating greater awareness of problems specifically affecting women, clinicians can help expand the cardiology knowledge base and improve the health of women worldwide.

Important Differences in Men and Women's Heart Disease

Physiological, hormonal, and even sociocultural factors all play a role in women's heart health. A 2017 study in the E-Journal of Cardiology Practice notes that women have patterns of ischemic heart disease that differ from male patients.² Adjusted for body surface area, women's coronary arteries are smaller in diameter compared to men. Women also tend to have fewer calcifications, less focal obstruction, and a more diffuse pattern of atherosclerosis.² This could be contributing to increased rates of microvascular disease among women, which may increase their risk of heart-related disorders.

The Role of Hormones

Estrogen, the primary female sex hormone, also plays a role in heart health. Estrogen affects the cardiovascular system by:³

Causing vasodilation of coronary and systemic blood vessels
Eliminating free radicals that can damage arteries
Increasing HDL cholesterol while decreasing LDL cholesterol
Promoting blood clot formation

Other hormones, such as insulin, are relevant to women's heart health as well. Even though insulin sensitivity is generally higher in women, a combination of lifestyle factors and other conditions, including a history of gestational diabetes or polycystic ovarian syndrome, may lead to the development of heart disease if left untreated.⁴

Sociocultural Factors in Cardiovascular Disease

The ability to eat a heart-healthy diet, get regular exercise, and improve or eliminate stress also impacts cardiac health. Women typically earn less compared to men and are more likely to be the sole parent in the household.^5,6 These social determinants can influence heart health considerably—for instance-single women may face greater food insecurity and working mothers may not be able to build in opportunities for regular exercise.

The American Heart Association speculates that behavioral and environmental factors make up 80% of a patient's risk for cardiovascular disease.⁷ It is therefore imperative that cardiologists have conversations about lifestyle factors with each female patient.

Symptoms Differ Between Men and Women

A wealth of research identifies differences in heart-disease-related symptoms between men and women. For example, women with angina may experience gastrointestinal symptoms and shortness of breath along with, or instead of, prolonged and unprovoked chest pain. Men are more likely to experience profound chest pain as a symptom of heart attack, while women usually also exhibit shortness of breath, nausea and vomiting, and back or jaw pain.⁸

Other conditions, such as sudden cardiac death (SCD), may result in similar clinical presentation, regardless of the patient's sex. However, ECG differences can act as significant predictors of SCD: Women may show longer QT intervals as well as more instances of pulseless electrical activity (PEA)/asystole than men.

Heart Issues Affecting Women More Than Men

Certain cardiovascular conditions seem to affect women disproportionately compared to men:⁹

Angina. Clinicians typically diagnose two specific types of angina in women more than men: stable angina and variant (Prinzmetal's) angina. These two types of angina typically do not result in significant cardiac events. However, without treatment, it is possible for either to deteriorate into unstable angina, a significant risk factor for cardiac arrest.
Cardiac syndrome X. It's thought that hormonal changes and factors such as coronary microvascular disease (MVD) could result in cardiac syndrome X. Women tend to have higher rates of MVD, usually occurring in younger women. Factors such as low estrogen levels before menopause and functional problems with the ovaries are thought to contribute.¹⁰
Stress-induced cardiomyopathy. Also known as "broken heart syndrome," symptoms of this condition may occur at any time. A surge of hormones triggered by extreme stress, grief, anger, or surprise could induce the condition. The decline in estrogen levels after menopause may also be a risk factor for stress-induced cardiomyopathy.

To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.

Using ECG to Guide Clinical Decisions

ECG is an invaluable tool for clinicians in diagnosing and treating women's cardiac issues. From standard 12-lead ECGs to wearable devices, equipment that offers real-time information about the heart's electrical activity can help to inform diagnostic opinions and treatment decisions. Normal ECGs can rule out many cardiac diseases and electrolyte abnormalities, show chamber size and cardiac structure, and offer more details about women's heart health.

Unlike other, more invasive procedures, ECG can be performed inexpensively and in almost any location. Clinicians should be sure to properly place ECG leads on women's chests, as misplacement can lead to incorrect readings of waveforms and disruption of stratification. Errors commonly occur when placing electrodes on women due to the location and amount of breast tissue present.

As wearable device use increases, point-of-care ECGs may enable the general public to screen for cardiac problems like arrhythmia, or access more information about their general fitness. These results can then be shared with clinicians to help make diagnoses and monitor treatments.

As research into artificial intelligence (AI) expands, it's anticipated that ECG technology combined with AI will reveal population-level information that could help predict disease trends. Such systems could also help support the diagnosis of undetectable cardiac conditions.

Additionally, the growing number of women cardiologists is poised to help the medical community better understand the fundamental differences in women's heart health. Physiological, hormonal, and sociocultural factors all contribute to how women develop, diagnose, and manage heart disease. All cardiologists should consider these factors and use all tools available, including ECG, to make the best clinical decisions possible.

REFERENCES

Centers for Disease Control and Prevention. "Women and Heart Disease." CDC.gov. https://www.cdc.gov/heartdisease/women.htm. Accessed February 23, 2022.
Maas A. "The clinical presentation of 'angina pectoris' in women." European Society of Cardiology. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/The-clinical-presentation-of-angina-pectoris-in-women. Accessed February 23, 2022.
Cleveland Clinic. "Estrogen & Hormones." https://my.clevelandclinic.org/health/articles/16979-estrogen--hormones#:~:text=When%20estrogen%20levels%20decline%2C%20levels,to%20heart%20attack%20and%20stroke. Accessed February 24, 2022.
American Academy of Family Physicians. "Insulin Resistance." familydoctor.org. https://familydoctor.org/condition/insulin-resistance/. Accessed February 24, 2022.
Barroso A and Brown A. "Gender pay gap in U.S. held steady in 2020." Pew Research. https://www.pewresearch.org/fact-tank/2021/05/25/gender-pay-gap-facts/. Accessed February 23, 2022.
Livingston G. "The Changing Profile of Unmarried Parents." Pew Research. https://www.pewresearch.org/social-trends/2018/04/25/the-changing-profile-of-unmarried-parents/#:~:text=This%20trend%20has%20boosted%20the,as%20were%2088%25%20in%201968. Accessed February 22, 2022.
American Heart Association. "Environment, culture, other social determinants play big role in heart health." https://www.heart.org/en/news/2019/03/21/environment-culture-other-social-determinants-play-big-role-in-heart-health. Accessed February 22, 2022.
American Heart Association. "Warning Signs of a Heart Attack." https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack
U.S. Department of Health & Human Services. "Heart disease and women." Office on Women's Health. https://www.womenshealth.gov/heart-disease-and-stroke/heart-disease/heart-disease-and-women. Accessed February 22, 2022
American Heart Association. "Coronary Microvascular Disease (MVD)." https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain/coronary-microvascular-disease-mvd. Accessed February 22, 2022.

Sarah Handzel, BSN, RN has been writing professionally since 2016 after spending over nine years in clinical practice in various specialties.

The opinions, beliefs, and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs, and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.