Heart diseases in women2

Heart Diseases in Women- The Unnoticed and Silent Killers

Cardiovascular Diseases: Explaining the Magnitude

Along with cancer and diabetes, cardiovascular diseases (CVDs) are non-communicable diseases and refer to a heart- or blood vessel-related illness. They include a number of ailments, such as peripheral artery disease, heart failure, and heart attack, among others.
According to studies, these conditions can lead to serious complications and are associated with lifestyle risk factors such as smoking, drinking alcohol, maintaining poor levels of physical activity, and an unhealthy diet. Blockage of your blood vessels (atherosclerosis), coronary artery disease, and high blood pressure (arterial hypertension) are the main contributors to heart diseases as a result of poor lifestyle decisions. 1,2 Especially, high blood pressure has been discovered to be a distinct risk indicator for acute heart attack and stroke, particularly in the elderly population.3
Cardiovascular diseases are the major cause of mortality worldwide, accounting for over 17.9 million deaths annually. 4 It is estimated that 85% of the deaths around the globe are caused by heart attacks and strokes.5
Despite reports from international research indicating heart-related illnesses affect men more frequently than they do women, they remain the most prevalent reason of mortality for females.6
According to a recent Indian study from 2022, 29.4% of adults over 45 in India claimed to have a diagnosed cardiovascular disease. Besides advanced age, also gender affects the risk of CVD: 11,476 Women (32.4%) suffered from heart-related diseases, in contrast to 7,812 Men (25.9%). Additionally, the study identified the three primary risk variables for developing heart- related disorders including high blood cholesterol levels, diabetes, and lack of exercise.3
Furthermore, Studies have also shown that women are undertreated despite the fact that they are more likely than males to have cardiac diseases, have a higher mortality rate, and have a worse prognosis.6,8
In this blog we will focus on heart-related illness and discuss why women are at higher risk to develop cardiovascular diseases and shed light on possible risk factors.

Identifying the Problem

Cardiovascular diseases are an umbrella term for a variety of conditions that affect the heart and blood vessels, such as blood vessel blockage (coronary artery disease), irregular heartbeats (arrhythmias), birth defects of the heart, diseases of the heart muscle, or its valves.
As mentioned before, there are several heart-related conditions that can be life-threatening on their own, however, they are often accompanied by other diseases that can be just as serious and worsen the overall situation. Due to the centric and crucial importance of our heart and its functions, any illness can affect its ability to pump blood and oxygen through the rest of the body and therefore has a major impact on our health.
Pain in the chest and/or discomfort in other, more distal locations, such as the arms, shoulder, elbows, jaw, or back, are the main signs of a heart attack. Furthermore, breathing issues, nausea, vomiting, dizziness or fainting, sweating, and turning pale are frequently mentioned along with heart-related issues.5
Depending on the underlying diseases, symptoms differ from patient to patient. Swollen legs, ankles, or feet are typical reported signs of a damaged heart muscle (cardiomyopathy), as well as difficulty in breathing while sleeping during the night, irregular and fast heartbeats, and shortness of breath.9
Men and women frequently experience different heart disease symptoms, and it has been demonstrated that failing to recognise this can have negative effects. Particularly, women appear to be more likely than males to develop untypical symptoms such as anxiety, body pain in areas including the back, shoulder, or face, feeling sick and vomiting, in the event of a heart attack. Rather than genuine physical exertion, they are more prone to experience emotional distress as the acute trigger for a heart attack.5,6
A number of studies have also shown that women were more likely than males to have an inaccurate first diagnosis when they were admitted to the hospital due to heart-related problems.6,7 Consequently with the wrong diagnosis, women also receive a lower rate of correct diagnostic tests for the heart, such as angiograms, and interventional procedures compared to men and have therefore a higher mortality risk.8
After understanding the sex-specific differences of the symptoms and their importance, we should also investigate further differences between men and women in regard to cardiovascular diseases.

Focus on Women

According to a meta-analysis of well-known indicators of risk for cardiovascular diseases, women are more negatively impacted by smoking, diabetes, arrhythmia, and poor social and economic standing than men. The study reported that the only factor that affected males more than women in terms of the onset of cardiovascular illnesses was total cholesterol levels. Higher blood pressure or body mass index was affecting both the genders equally. Although each of these cardiovascular risk variable increase the chance of heart diseases in both genders, some are more harmful to one sex than the other.6
But how comes that there is so much of difference? While considering the differences of the genders in cardiovascular diseases, it’s important to keep in mind that estrogen, a predominant female hormone, is frequently acknowledged for its heart-protective effect and is thought to contribute to the reduced incidence of heart diseases in younger women when compared to age-matched males.
Consequently, the progressive drop in estrogen levels of men after puberty would explain the fact that men experience heart disease 10-15 years earlier than women.10
On the other hand, oestrogen reduction during the menopause enhances the risks of women with the age of 50+ and increases the risk of heart-related illness by 2–4 times.11
Menopause may also be related to an elevated risk for high LDL cholesterol, diabetes, high blood pressure, and obesity, all of which increase one’s probability of developing a cardiovascular disease.12
As one of the most common bad lifestyle choices decreasing heart health, smoking has been proven to be more harmful to women than males (> 50 years). A study showed that smoking resulted in enhanced risk for a heart attack in women: For female non-smokers the average age to experience a heart attack was 80.7 years, whereas women who smoked experienced their first heart attack 14.4 years on average earlier with approximately 66.2 years. In comparison, smoking did not had such a strong effect in men: male non-smokers had their first heart attack approximately with 72.2 years, whereas smoking men experienced it 8.3 years earlier with 63.9 years. In summary, this study showed that women almost lose double so many years due to smoking.13
A possible explanation for this surprising difference could be that nicotine lowers circulating estrogen levels and therefore reduces the protective effects of estrogen on the blood vessel walls.14 Furthermore, it also leads to early onset of menopause in women, which is also known to increase risk factors for heart-related diseases.15
Similarly, stroke is one of the most prevalent causes of death and sickness globally and has a higher mortality rate in women than in men.5 Women are more likely than males to suffer a stroke, and they also tend to have repeated strokes more frequently, mainly due to their longer life expectancy.
As is the case with other cardiovascular illnesses, women are more vulnerable to suffer a stroke due to female-specific risk factors including menopause, oral contraceptives, pre-eclampsia, pregnancy-related diabetes, migraines with aura, and hormone replacement therapy.16
Let us have a look at some of the factors contributing to a higher risk of cardiovascular diseases in women, so that we can have a better understanding of the danger of it.

Risk of Cardiovascular Diseases and Adverse Pregnancy Outcomes

In their guidelines, the American Heart Association emphasizes especially that adverse pregnancy outcomes, such as hypertensive disorders of pregnancy (pre-eclampsia), preterm delivery or pregnancy-related diabetes can have harmful influence on women’s health, especially on heart health. Furthermore, a woman’s chance of acquiring cardiovascular disease risk factors and consequent illnesses including coronary heart disease, stroke, peripheral vascular disease, and heart attack can also increase after placental abruption or pregnancy loss.17
Especially pre-eclampsia and repeated miscarriages are associated with hampering the blood vessels function, causing severe vascular problems in affected women, but also act as a prognostic indicator of potential cardiovascular disease.18
Interestingly, research suggested that race may be an additional factor: Black and Asian women are more likely than White women to suffer from unfavourable pregnancy outcomes, including more severe conditions and less favourable prognosis.17
However, among all those increased risks during pregnancy, there are also good news for pregnant ladies: Lactation and breastfeeding may have a beneficial influence on women’s likelihood of developing heart-related diseases.17 In order to reduce the risk of heart illness, healthcare professionals also urge women with problems during their pregnancy to adopt healthy lifestyle practises, such as eating a heart-healthy diet and increasing their physical activity, beginning after the baby is born and continuing for the rest of their lives.
After discussing pregnancy-related conditions as major contributors to cardiac diseases, let us also explore other diseases, which can negatively influence our heart health.

The Connection of Heart Health and Diabetes

Since high blood sugar can negatively impact and harm blood vessels and the nerves that regulate our heart, a substantial link was found between diabetes and heart failure as often co- occurring conditions.19 The prevalence of type 2 diabetes in patients with heart failure ranges up to 30%.20 Detailed results of the study again indicate that women are at higher risk for heart diseases in combination with type 1 diabetes (47% higher risk than in comparison to men). Similar, type 2 diabetes was linked with a 9% higher excess risk for females.
Additionally, diabetes is also a risk factor for stroke: Women had a 27% greater relative risk of stroke than men, according to a pooled analysis.16,21
Sex differences in the management of diabetes, undertreatment for diabetic women and the fact that females often have a longer duration of prediabetes than men, could contribute to gender- specific development of heart-related problems.20

Association of Heart Diseases and Non-alcoholic Fatty Liver Disease

However, as mentioned before, Diabetes is not the only frequent reported lifestyle diseases, which is associated with poor heart health. High blood cholesterol levels also increase the risk for heart-related diseases, because too much LDL (“bad”) cholesterol can damage your blood vessel walls and form obstacles inside your arteries, hampering your health.19
Therefore, it is not surprising that cardiovascular diseases are frequently the cause of death in patients with non-alcoholic fatty liver disease (NAFLD), which results from a built up of fat in the liver. Studies found a significant higher prevalence of heart-related illness among non- alcoholic fatty liver disease patients, almost 45% suffered from both.22 The degree of severity further influences the prevalence: more patients suffer from heart diseases while having a moderate to severe liver condition than those with a mild stage. This highlights the importance of early treatment and the management of cholesterol levels.
Regarding gender, studies have reported that men suffering from NAFLD had significantly lower likelihood of developing heart-related diseases, whereas women had a 2-fold increased risk.23
Besides gender, also the diabetic status had a major influence: Patients with diabetes were twice as likely to suffer from cardiovascular diseases compared with the non-diabetics.22

Conclusion

In this blog we have discussed the elevated risk of cardiovascular diseases in women, in connection with woman- specific risk factors and higher mortality rates than men. We have explored the hormonal influences on protective as well as harmful outcomes and summarised the most important cooccurring diseases.
Healthcare experts generally advise to keep high blood pressure under control and maintain low blood cholesterol levels with a healthy diet and regular exercise. By avoiding alcohol and smoking you can furthermore support your heart and keep it healthy a long time. Especially for women, it is important to immediately seek medical help even when in doubt due to not-typical symptoms. More research studies should address the differences between male and female cardiovascular health so we can better understand these diseases and take action to prevent it.

1. Frąk W, Wojtasińska A, Lisińska W, Młynarska E, Franczyk B, Rysz J. Pathophysiology of Cardiovascular Diseases: New Insights into Molecular Mechanisms of Atherosclerosis, Arterial Hypertension, and Coronary Artery Disease. Biomedicines. 2022;10(8). doi:10.3390/biomedicines10081938

2. Cheung AK, Sarnak MJ, Yan G, et al. Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int. 2000;58(1):353-362. doi:10.1046/j.1523-1755.2000.00173.x

3. Kundu J, Kundu S. Cardiovascular disease (CVD) and its associated risk factors among older adults in India: Evidence from LASI Wave 1. Clin Epidemiol Glob Heal. 2022;13(October 2021):16-20. doi:10.1016/j.cegh.2021.100937

4. Noncommunicable diseases, available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases, accessed on: 04/07/2023.

5. Cardiovascular diseases (CVDs), available at: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds), accessed on: 04/07/2023.

6. Woodward M. Cardiovascular disease and the female disadvantage. Int J Environ Res Public Health. 2019;16(7). doi:10.3390/ijerph16071165

7. Wu J, Gale CP, Hall M, et al. Editor’s Choice - Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study. Eur Hear journal Acute Cardiovasc care. 2018;7(2):139-148. doi:10.1177/2048872616661693

8. Gao Z, Chen Z, Sun A, Deng X. Gender differences in cardiovascular disease. Med Nov Technol Devices. 2019;4:100025. doi:https://doi.org/10.1016/j.medntd.2019.100025

9. Heart disease, available at: https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms- causes/syc-20353118, accessed on: 05/07/2023.

10. Baker L, Meldrum KK, Wang M, et al. The role of estrogen in cardiovascular disease. J Surg Res. 2003;115(2):325-344. doi:https://doi.org/10.1016/S0022-4804(03)00215-4

11. Xiang D, Liu Y, Zhou S, Zhou E, Wang Y. Protective Effects of Estrogen on Cardiovascular Disease Mediated by Oxidative Stress. Oxid Med Cell Longev. 2021;2021. doi:10.1155/2021/5523516

12. Rodgers JL, Jones J, Bolleddu SI, et al. Cardiovascular risks associated with gender and aging. J Cardiovasc Dev Dis. 2019;6(2). doi:10.3390/jcdd6020019

13. Grundtvig M, Hagen TP, German M, Reikvam Å. Sex-based differences in premature first myocardial infarction caused by smoking: Twice as many years lost by women as by men. Eur J Prev Cardiol. 2009;16(2):174-179. doi:10.1097/HJR.0b013e328325d7f0

14. d’Adesky ND, de Rivero Vaccari JP, Bhattacharya P, et al. Nicotine Alters Estrogen Receptor-Beta-Regulated Inflammasome Activity and Exacerbates Ischemic Brain Damage in Female Rats. Int J Mol Sci. 2018;19(5). doi:10.3390/ijms19051330

15. Kim JM, Yang YS, Lee SH, Jee SH. Association between Early Menopause, Gynecological Cancer, and Tobacco Smoking: A Cross-Sectional Study. Asian Pac J Cancer Prev. 2021;22(10):3165-3170. doi:10.31557/APJCP.2021.22.10.3165

16. Yoon CW, Bushnell CD. Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes. J Stroke. 2023;25(1):2-15. doi:10.5853/jos.2022.03468

17. Parikh NI, Gonzalez JM, Anderson CAM, et al. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation. 2021;143(18):E902-E916. doi:10.1161/CIR.0000000000000961

18. Okoth K, Chandan JS, Marshall T, et al. Association between the reproductive health of young women and cardiovascular disease in later life: Umbrella review. BMJ. 2020;371. doi:10.1136/bmj.m3502

19.Diabetes and Your Heart, available at:https://www.cdc.gov/diabetes/library/features/diabetes-and heart.html#:~:text=Over%20time%2C%20high%20blood%20sugar,and%20can%20damage%20artery%20walls, accessed on: 06/07/2023.

20. Ohkuma T, Komorita Y, Peters SAE, Woodward M. Diabetes as a risk factor for heart failure in women and men: a systematic review and meta-analysis of 47 cohorts including 12 million individuals. Diabetologia. 2019;62(9):1550-1560. doi:10.1007/s00125-019-4926-x

21. Peters SAE, Huxley RR, Woodward M. Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes. Lancet (London, England). 2014;383(9933):1973-1980. doi:10.1016/S0140-6736(14)60040-4

22. Toh JZK, Pan XH, Tay PWL, et al. A Meta-Analysis on the Global Prevalence, Risk factors and Screening of Coronary Heart Disease in Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol. 2022;20(11):2462- 2473.e10. doi:https://doi.org/10.1016/j.cgh.2021.09.021

23. Khalid YS, Dasu NR, Suga H, et al. Increased cardiovascular events and mortality in females with NAFLD: a meta-analysis. Am J Cardiovasc Dis. 2020;10(3):258-271.

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