What every woman should know about heart disease

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Challenges Facing Women

How had Susan reached the brink of a heart attack with basically no warning? Partially because of the difference in symptoms between men’s and women’s heart disease.

Susan, even with a major blockage, had gone undiagnosed for years due to lack of major symptoms. And while her blockage was detectable on a scan, some women’s arteries have no detectable plaque but still close from a spasm or a temporary constriction, sometimes even to the point of triggering a heart attack. Although it’s not known what causes these spasms, many doctors believe that fluctuations in estrogen levels contribute, and stress may play a role, too. These factors make heart disease in women problematic to treat. “If a man has a blockage,” says Susan’s doctor, Mehmet Oz, M.D., director of the Cardiovascular Institute at Columbia University in New York City, “you can ream it out with angioplasty or put a bypass over it, and it’s easy. But in the woman, the problem is more diffuse. How do you bypass a spasm?”

These challenges have resulted in women being underdiagnosed and undertreated, even though about the same number of women die each year of coronary artery disease (CAD) as men. In 2001, for example, 689,000 men had removal of a coronary artery obstruction with angioplasty or insertion of a stent, according to the Centers for Disease Control and Prevention, compared with 363,000 women. Similarly, 365,000 men had CABG, compared with 151,000 women.

But is the undertreatment of women all symptom-related? Or does bias play a role? Experts have different thoughts on the issue.

“The question of whether there is bias against women in heart treatment has been around for some time, and, in fact, our data do show a bias against giving women more aggressive therapy,” says Sujoya Dey, M.D., a cardiologist at the University of Michigan Cardiovascular Center. “But our findings also suggest that a small part of the difference in treatment may be understandable, because women’s CAD appears to be different, sometimes occurring in vessels too small for angiography, angioplasty, or bypass.”

The findings haven’t convinced Marianne Legato, M.D., professor of clinical medicine at Columbia University College of Physicians and Surgeons and founder/director of the Partnership for Gender-Specific Medicine at Columbia University in New York City. “The major percentage of bias against women and the lack of aggressive treatment when they have heart disease remains to be explained,” she says. “It’s not because women refuse care or treatment. That only accounts for 3–6 percent of the difference.”

Even when women are treated with heart surgery, they don’t do as well afterward, says Viola Vaccarino, M.D., a cardiovascular epidemiologist at Emory University in Atlanta. Women, particularly younger women, have as much as three times the risk of dying during or shortly after CABG than men do, she reported in a 2002 study in Circulation, a journal of the American Heart Association.

And women have a more difficult recovery than men after CABG, too, including more symptoms of anxiety and depression and a higher rate of infections and readmittance to the hospital for heart failure, according to her 2003 study published in the Journal of the American College of Cardiology. That may be explained, Oz says, by the fact that women often have more advanced conditions by the time they’re referred to a surgeon, “perhaps because they were not evaluated aggressively enough in the beginning.”

The Good News
But the outlook is not all bad for women with CAD, Oz adds. If angioplasty isn’t a possibility, as was the case for Susan, there are amazing new surgical techniques that are less invasive, cause less pain, and may allow faster and better recovery.

A few years ago, an exciting new way of doing surgery was developed. The operation is done while the heart is beating, with no need for a heart-lung machine to take over blood-circulation duties—thus, the surgery is called “off-pump.” In 2003, about 23 percent of all bypass surgeries—including Susan’s—were done off-pump, according to the Society of Thoracic Surgeons’ national cardiac database. Oz says that, understandably, it’s a little more difficult to operate on a slippery, beating heart than a still one. But once learned, this is a quick and efficient procedure that is less traumatic to patients’ bodies. Patients bleed less, Oz says, and they have less risk of heart attack during surgery.

Still, off-pump surgery has not yet been proven in studies to provide a major benefit in the incidence of short-term cognitive problems, which are often suffered by heart surgery patients. “I think that in some categories it is better, in older patients with hardened arteries, for example, and in people who have had prior strokes,” says Oz, who performs off-pump surgery in about one-third of his bypass cases.

For now, on- and off-pump techniques are viable, but questions remain. The answers may become clearer after a large ongoing study by the Department of Veterans Affairs is finished. Until then, experts recommend that if you’re going to have off-pump surgery, you go to a surgeon experienced in the technique—someone who has mastered the technical challenges.

In Susan’s case, she sailed through off-pump, double-bypass surgery. “I did not have any noticeable memory loss or confusion afterward,” she says. “But then, I didn’t expect to!”