Men and women differ at heart

Talk to most doctors about heart disease for long enough and one phrase is bound to come up: “It’s an equal-opportunity threat,” says Dr. Beth Abramson, a spokesperson for the Heart & Stroke Foundation of Canada and director of the cardiac prevention and rehab centre and women’s cardio division at St. Michael’s Hospital in Toronto. Today, just about the same number of men and women succumb to heart disease and stroke, about 36,000 annually. Yet “when people shut their eyes and think of someone having a heart attack, they think often of a man,” she says. “It’s perceived to be a man’s disease. It’s not.”

In fact, one in three Canadian women will die of heart disease and stroke—compared to one in 18 from lung cancer and one in 28 from breast cancer. By 2050, stroke mortality in the U.S. is projected to be 30 per cent higher for females than males. Despite the staggeringly high risks, the issue is only now gaining widespread recognition. “We noticed [female] patients were so surprised to have had a heart attack,” says Dr. Susan Bennett, director of the women’s heart program at George Washington University Hospital in Washington. The thinking was, “ ‘Everybody was checking my breasts and uterus, but nobody was talking to me about heart disease.’ ”

Every year, Maclean’s features its “How Healthy Are You?” series focusing on the well-being of Canadians. Of the initial 5,100 people who participated in an online survey of overall health called the Q-Gap, which is posted at www.macleans.ca/howhealthy, cardio-respiratory symptoms such as chest pain and breathlessness were the least reported ailments by men and women—even though “these symptoms are known to be acutely exhibited among people with sudden heart and vascular conditions,” says Dr. Elaine Chin, chief medical officer of Toronto’s Scienta Health, which created the test. This may also prove that heart disease just isn’t on a lot of people’s radar, especially among females.

That’s changing. Massive awareness movements are under way: the U.S. Women’s Heart Foundation doles out purple ribbons. Feb. 6 has been ordained “National Wear Red Day” by the American Heart Association. And the Heart & Stroke Foundation has launched “The Heart Truth” campaign—its official symbol is a red dress pin to boost education about female risk factors.

The campaigns are happening at the same time as research is accumulating. Groups such as the Genesis project, which was established in 2004 and is partly funded by the Canadian Institutes for Health Information, are identifying how diagnosis, treatment and perception vary between genders. Already there are stark contrasts. Women usually develop heart disease 10 years later than men, and sometimes suffer atypical symptoms. Congestive heart failure can look different between the sexes—in females, the heart gets thick and small; in males, it becomes enlarged. Women are also up to 30 per cent more likely to drop out of cardiac rehabilitation programs after a heart attack than men.

There’s still a lot to figure out. More than 30 years ago, twice as many men died of heart attack as women. It was a “man’s disease.” But since then, a perplexing trend has been observed: while male mortality rates for heart disease and stroke have been declining, women’s have risen, according to a report by the Heart & Stroke Foundation. Between 1973 and 2003, the number of men who died from heart disease and stroke dropped 19 per cent; during that same period, the number of female deaths rose by five per cent. For the first time in three decades, the mortality gap had closed in. (The latest Statistics Canada data shows the number of deaths from heart disease declining slightly in 2004.)

But over the years, another gap manifested. Because men were the primary population afflicted with heart disease, their way of articulating symptoms defined classic diagnostic criteria. Treatments were established according to how well they worked on men, who until recently made up the majority of participants in clinical trials. All this contributed to a gender bias among the public and health care professionals. Women downplayed symptoms, and doctors under-diagnosed them. Even after a heart attack, females have historically been under-referred to specialists and have had bypass surgery and angioplasty less often than men. One 2005 study showed that only 17 per cent of cardiologists in the U.S. knew that more American women die from heart disease each year than men.

The first step in fighting heart disease is, of course, recognizing symptoms—which isn’t always easy. Chest heaviness or pain is the most common indication of heart troubles among both sexes (along with suddenly feeling cold, clammy or short of breath), explains Abramson, but sometimes women articulate it as “an unusual burning.” Dr. Louise Pilote, principle investigator of Genesis and director of general internal medicine at McGill University Health Centre in Montreal says that instead of pain radiating down the shoulder and into the jaw, which is typical, some women feel it more in their neck and back. Others just experience nausea, dizziness, sleep disturbances or extreme fatigue. These atypical symptoms make diagnosis especially tough because even when a female seeks medical attention, heart disease “is not the first thing you think about when a woman says ‘I’m so tired,’ ” says Pilote.

The year Annie Bailey was 46, she used to get chest pains and they wouldn’t go away until she burped. She was a mom of seven then, and besides taking care of her own home, she had a job cleaning the local doctor’s office in rural Sydney Mines, N.S. Eventually, Bailey got around to telling him about her discomfort. The doctor diagnosed her with angina, which occurs when not enough blood is getting to the heart. “I said, ‘So?’ ” remembers Bailey, now 66. His reply was direct: “You could be having a heart attack and not even know it.” Bailey says she cried, got her pills, and pushed it out of her mind. “But I should have stopped and listened right then. I was just too busy to worry about it.”

Bailey, who since then has had five blocked arteries, open heart surgery, and two pacemakers, is representative of many women in that she minimized her risk of heart disease and downplayed her symptoms. Fortunately, her doctors and family took them seriously and she’s received prompt care along the way. But not everybody experiences such support. Abramson tells the story of two female patients, each who separately suffered symptoms of a heart attack but received different responses from their husbands. One was taken to ER immediately, the other told it was probably fine and to go back to sleep. “The first woman was diagnosed with a heart attack and had a successful angioplasty,” says Abramson. The other didn’t get timely medical attention and her health deteriorated. “I’m telling you this because women and men and their family need to be aware of the threat,” she adds.

That support system is also important in the aftermath of a heart event, when patients are sometimes referred to cardiac rehabilitation to improve their fitness, learn about nutrition and occasionally receive counselling. Chris Blanchard is a health psychologist at Dalhousie University in Halifax, studying 1,200 Maritimers to figure out why women are up to 30 per cent more likely to quit these programs than men. One of the big obstacles appears to be that females put themselves low on the totem pole of priorities. “They are caretakers for other people, and they undersell themselves,” he says. Out of a typical 20-session rehab program, men will attend 80 per cent of the time, compared to women who will make it 50 or 60 per cent of the time. If the sessions are home-based, male adherence stays the same, but that of women’s plummets to 30 per cent. “That the biggest gender discrepancy I’ve seen,” he says.

This is dangerous because just-published research shows that 30 minutes of physical activity a week leads to a 20 per cent increase in patient survival. “So if we know that women are doing less physical activity, then we know that they’re potentially placing themselves at increased risk for death and premature comorbidity,” Blanchard explains. “That’s a huge impact.”

Blanchard says his team has observed other differences between men and women when it comes to cardiac rehab. Many females don’t like to exercise in a regimented way. They’re also referred to these programs by physicians less often. When women do attend sessions, many say they don’t like working out alongside so many men—there’s often a one-to-five ratio. To address these issues, some health districts across the country have implemented automatic referrals to cardiac rehab and are offering female-only sessions.

For Natalie Cordiner, 44, cardiac rehab has proven a lifesaver. When her congenital heart problems flared up after giving birth to her youngest daughter a few years ago, she nearly died. Juggling a newborn plus two other children and a full-time job made exercising the least of her concerns. “But once things were organized with child care, work and daily life, I really looked forward to going,” says Cordiner from Halifax. “It was a short-term adjustment for a long-term gain.”

It’s understandable why many women are sometimes surprised by their heart disease compared to men. But that attitude persists, to some degree, in the world of cardiac research too. In 2006, a team of Toronto researchers led by Dr. Peter Liu were the first in the world to show how congestive heart failure—which happens when heart muscles get weak or stiff—often looks different in each sex. Men tend to suffer “systolic dysfunction” (systolic pressure is the top number when your blood pressure is taken). Their damaged hearts get bigger, explains Liu, scientific director of the Canadian Institutes of Health Research and a cardiologist at the Peter Munk Cardiac Centre. Women, on the other hand, often develop “diastolic dysfunction.” Their hearts shrink and become thickly layered with scar tissue. (Systolic dysfunction means the heart has trouble pumping blood out; diastolic dysfunction means the heart has trouble filling up with blood.) Today, “most of the treatments we have are geared toward the big heart because that’s what was commonly recognized and studied,” he says. But trials are under way to determine ways of dealing with the diastolic problems.

It’s worth noting, Liu adds, that when his initial findings were published in The New England Journal of Medicine, some critics suggested his study participants were unusual or the findings accidental. But they have since been replicated globally. Liu believes that when it comes to disease, gender differences are sometimes de-emphasized or overlooked. “We make certain assumptions, and to be socially correct we try to minimize differences,” Liu says. But Bennett believes understanding how illnesses manifest in each gender is “the first tier of personalized medicine.” Adds Liu, “I think it is very important to recognize that, in fact, men and women are different from the day the heart develops.” Until the day it stops beating.