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Getting to the heart of women’s cardiovascular health

Dr. Jasmine Grewal is director of the Cardiac Obstetrics Clinic at St. Paul’s Hospital. (Photo taken prior to COVID-19)

Heart health is important for everyone, but there are several significant aspects of women’s cardiovascular health, including sex-specific risks of developing heart disease, unique symptoms, and the impact of pregnancy on preexisting heart conditions.

Gaps in diagnostics, care and understanding

While heart disease is the leading cause of death in women, a new report from the Heart & Stroke Foundation of Canada identified gaps in diagnostics, care and understanding of women’s heart disease.

Dr. Karin Humphries, program head of cardiovascular health, CHEOS

 “Probably the most important contribution to the gap in diagnosis, and why women are under-diagnosed, is they frequently present with different symptoms,” says Dr. Karin Humphries, the program head of Cardiovascular Health at the Centre for Health Evaluation and Outcome Sciences (CHEOS).

Women have different symptoms

Women often present with different heart-attack symptoms than men that may not always be recognized. Women may not experience chest pain at all, and if they do, they may describe it as more of a pressure or heaviness.

They are also more likely to have multiple symptoms, which can include shortness of breath, nausea, vomiting and sweating, and back, stomach, neck, jaw, or shoulder pain.

“By and large, men will present with chest pain, end of story. Women almost always present with multiple symptoms,” says Dr. Humphries. This can complicate diagnosis, but that makes it all the more important for the health care system to be aware of how heart attacks may present in women.

Women face sex-specific risk factors for heart disease, such as pregnancy. A pregnant woman who develops gestational diabetes or hypertension is at greater risk of developing those conditions fully in the future, increasing their risk of cardiovascular disease. Additionally, many factors that increase risk for everyone have a greater impact on women, such as smoking.

Women may experience chest tightening or pressure while men experience chest pain, “end of story,” says Dr. Humphries.

Diagnostic methods not made for women

Because women have been underrepresented in the clinical trials used to guide cardiovascular care, some methods used to diagnose heart attacks were not made with women in mind. One such method is measuring cardiac troponin, a protein released when the heart muscle is damaged, using a single threshold for diagnosis.

 “In the last decade, we have developed a very sensitive cardiac troponin test and that has allowed us to finally appreciate that women do not produce as much cardiac troponin as men. So using that same threshold disadvantages women,” says Dr. Humphries. She is running a clinical trial, CODE-MI, which is testing to see if using a female-specific lower troponin threshold will help healthcare professionals diagnose women having heart attacks. Read about the study in this Daily Scan article.

Pregnancy in women with pre-existing heart conditions

Pregnancy can effect the outcomes of women with pre-existing heart conditions.

Dr. Jasmine Grewal is the director of the Cardiac Obstetrics Clinic at St. Paul’s Hospital, and the recently appointed head of UBC’s Department of Cardiology. She is engaged in clinical research in the areas of pregnancy and heart disease and congenital heart disease. Her research focuses on improving patient outcomes and finding ways to identify women who are high risk of having a cardiac event during pregnancy so their care can be personalized.

Most of the patients that come through her clinic already have a cardiac diagnosis. A cardiac disease and pregnancy registry enrolls women who come through her cardiac obstetrics program. That lets researchers track their outcomes over time.

One focus of current research is on how pregnancy affects cardiac conditions in the long term. Data suggest it varies between conditions – for some, a patient may go back to “baseline” after pregnancy. For others, it may have a longer impact.

Risk levels vary for women with cardiac disease in pregnancy

Not all pregnant women with cardiac disease are at high risk of negative outcomes. The counseling a woman receives regarding her risk can have a significant impact.

Ideally, someone who is, or is considering becoming, pregnant with a cardiac condition would go to her family doctor, who would refer them to an expert for a risk assessment. The expert could reassure someone who is low-risk that, likely, nothing special needs to happen during their pregnancy. Conversely, they could advise someone who is high-risk that she may require more intensive care through her pregnancy and delivery.

Closing the gaps

While the Heart & Stroke Foundation of Canada identified gaps in their report, researchers like Dr. Humphries and Dr. Grewal are making strides in the understanding and treatment of women’s heart health.

“I think the momentum will pick up, especially as awareness amongst the public also increases,” says Dr. Humphries. It is important to raise awareness, both in the public and in healthcare practitioners, about these aspects of women’s heart health, so that they can receive appropriate treatment.

Story by Grace Jenkins, Providence Research