Recognizing the Signs of Heart Disease in Women, Part 1
Heart disease is not just a disease of older women; in fact, even pregnancy can place younger women at risk for heart-related conditions. This 3-part series will help guide nurses in the recognition and management of the number 1 killer of American women—heart disease.
This information was presented at the 2010 Association of Women’s Health, Obstetric and Neonatal Nurses meeting by Carolyn Strimike, RN, MSN, CCRN, APN-C, of the Women’s Heart Center at St. Joseph’s Regional Medical Center, Paterson, NJ. Ms Strimike is an acute care nurse practitioner and cofounder of Heartstrong, LLC (www.heart-strong.com). With her colleague Margie Latrella, she has coauthored 3 books, including Take Charge: A Woman’s Guide to a Healthier Heart (2008).
So, You Think You Know the Risk Factors?
“There has been an alarming increase in mortality from heart disease among women, possibly because they are more ‘complex’ than men,” Ms Strimike said. Women have hormones that play critical roles in heart health. Declining estrogen makes menopause the greatest risk factor for heart disease.
Other risk factors—including heredity, overweight/obesity, physical inactivity, smoking, hypertension, abnormal lipids, and diabetes/metabolic syndrome— are well established, but less recognized risks include:
- Emotional stress
- Gum disease
- Inflammation
- Sleep apnea
- Depression
- Resting heart rate >76 beats per minute.
In addition, the following risk factors are specific to women:
- A female first-degree relative with heart disease conveys a stronger risk than a male relative
- Smoking is linked to heart attacks/ strokes at a younger age in women than in men
- Pregnancy-induced high blood pressure (BP) that later becomes normal increases the risk
- High systolic BP
- Abnormal lipids: low high-density lipoprotein cholesterol and triglyceride levels, as well as diabetes, are more robust risk factors in women
- Hypo/hyperthyroidism is particularly relevant in women.
Risk factors “cluster” by race to some degree. The presence of ≥2 risk factors has been found in 60% of black women and only 30% of white women; ≥3 risk factors are found in 30% and 10% of these populations, respectively. Nearly 30% of white women, but <10% of black women, have no risk factors for heart disease.
Much of this difference stems from a higher presence of elevated BP in blacks. “African American women develop hypertension earlier in life, often in their 20s,” Ms Strimike said. “We need to be very aggressive in treating this.”
Heart Attack: Men versus Women
“The TV movie symptoms of a heart attack—severe, crushing chest pain, nausea, shortness of breath—are derived from clinical observations in men,” she noted. Women may demonstrate these symptoms, but they may also have:
- Odd chest sensations
- Shoulder-blade pain
- Hot flushes/cold sweats
- Dizziness
- Unusual fatigue/weakness.
Once myocardial infarction (MI) occurs, outcomes are generally worse for women than for men (Table), through around age 70, when the rates become comparable. When women undergo cardiac bypass surgery, they have increased length of hospital stay, increased postoperative complications, and higher operative mortality compared with men.
It is a tragedy—and often a fatal one —when the signs and symptoms of an MI are not recognized, but these are not the only signs ignored by clinicians, Ms Strimike noted. Women are often diagnosed with anxiety rather than heart disease, when in fact they are having signs of MI, she said. Women who report chest pain, shortness of breath, and palpitations, along with high levels of life stress, tend to be diagnosed with anxiety rather than heart disease. In many studies, a diagnosis of heart disease was made in 15% of women with such signs compared with 56% of men. The sex differences disappeared when no life stress was reported.
Arteries Are Different in Women and Men
Finally, heart disease may be missed in women because abnormalities of the coronary arteries—the hallmark sign— may be lacking, she said. In the major coronary intervention studies, “normal” coronary arteries were documented in 20% to 30% of women with heart disease compared with just 7% to 14% of the men.
“In women who reported symptoms consistent with heart disease, 50% did not have their disease detected on cardiac catheterization, or had only minimal narrowing of blood vessels,” she said, “but 17% of them went on to have severe coronary artery disease at 5 years. In women, we have to pay attention to mild narrowing of the arteries.”
In contrast, women are more likely to have “small-vessel disease,” which in cludes spasm, edema, and small blood clots. Rather than a focal area of obstruction and obvious narrowing, in women a layer of plaque may line the entire vessel.
“Women have a more diffuse type of disease, and this may be related to hormones,” she said. “Blockage in the female coronary artery often will not show up on a stress test or heart catheterization. This is why we need additional tools, such as intravascular ultrasound, which can reveal arterial disease, to diagnose heart disease in women.”
Watch for the Symptoms
Nurses can help to identify women at risk by the presence of symptoms and family history, as well as when a physical examination reveals elevated BP, abnormal lipids, excess weight or body fat (waist/hip/neck measurement, waistto- hip ratio, body mass index, and body fat analysis are recommended), and diabetes or metabolic syndrome. If this screening indicates an intermediate risk of heart disease, a woman should be encouraged to undergo additional cardiac testing.