When symptoms are missed, dismissed or delayed …
Cardiovascular disease is the leading cause of death for women worldwide yet it’s still under-diagnosed and under-treated. While women are almost 50 per cent more likely than men to be misdiagnosed after a heart attack, heart disease is often considered to be a ‘male issue’. To understand why this gap still exists, Dr Caoimhe Hartley, Clinical Lead Women’s Medicine and GP at Blackrock Health Womens Health Centre, and Consultant Cardiologist Dr Sorcha Allen discuss the issue in a new podcast, Heart Health In Women.
The Awareness Gap
Dr Allen: If you polled people on the street, very few would know that more women die of heart disease every year than men. Historically, the very large clinical trials conducted over the last 20 to 30 years predominantly focused on men. Consequently, medical training was built on the foundation that heart disease impacts men over the age of 55 with specific, “typical” risk factors. This has led to the misconception that heart disease isn’t a “woman’s issue” in the same way as breast cancer or menopause. We are taught to look out for typical heart disease symptoms such as central, crushing chest pain radiating to the jaw or left arm. While some women do experience this, the vast majority present with much more subtle symptoms. Because they don’t look like the “classic” male presentation, they can be dismissed or result in delayed diagnosis. In cardiology, we are trying to move away from these terms because “atypical” symptoms are completely typical for half the population.
Recognising The Symptoms
Dr Allen: The single biggest symptom I hear from women is profound fatigue and a decrease in exercise tolerance. For example, suddenly finding themselves incredibly breathless on a walk they used to do easily. Shortness of breath and sleep disturbances are also highly common, particularly in the two weeks leading up to a heart attack. When women do experience chest discomfort, they often describe it not as crushing pain, but as a band-like pressure, or even as something resembling indigestion or heartburn in the upper abdomen.
Dr Hartley: We know from research that more than half of women presenting with heart attack symptoms are misdiagnosed. What are these symptoms usually mistaken for?
Dr Allen: Women are far more likely to have their symptoms dismissed or attributed to anxiety, gastrointestinal issues like indigestion, or musculoskeletal pain. If heart disease isn’t at the forefront of a doctor’s mind, their clinical assessment will be skewed. Because of this, women often have to present to emergency departments or clinics multiple times before getting the correct diagnosis, which can contribute to worsened outcomes in the long-term outcomes.
Pregnancy And Menopause Risk Factors
Dr Hartley: Are the standard cardiovascular risk calculators we use in general practice suitable for women?
Dr Allen: Traditional risk calculators do a good job of assessing shared risk factors like high blood pressure, cholesterol, smoking, age and ethnicity. However, they fail to consider female-specific risk profiles. We are missing a standardised, gender-specific risk calculator. Because of this, we aren’t screening women as thoroughly as we should be.
Dr Hartley: For female-specific risks, what should we be looking out for in a woman’s pregnancy history?
Dr Allen: There are three critical red flags in pregnancy history that significantly increase cardiovascular risk later in life:
1. Preeclampsia, eclampsia or gestational hypertension: Women who have high blood pressure during pregnancy are at a significantly higher risk of developing chronic hypertension and heart failure down the line.
2. Gestational diabetes: This incurs a high risk of developing Type 2 diabetes and general cardiovascular disease later in life.
3. Preterm delivery: Delivering a baby before 37 weeks is directly linked to a higher risk of coronary artery disease and heart attacks.
Medical guidelines actually state that any woman who experience these pregnancy-related complications should receive a cardiovascular screen about six months after delivery.
Dr Hartley: What about the menopause transition, how does the loss of oestrogen impact a woman’s heart?
Dr Allen: Oestrogen is naturally protective against cardiovascular disease, which is why women often seem protected during their younger years. However, during perimenopause and menopause, oestrogen levels drop, and that protection declines.
Managing Symptoms
Dr Hartley: Heart palpitations are incredibly common during perimenopause. When are they just a benign symptom of hormone changes and when are they a “red flag”?
Dr Allen: Palpitations during menopause are often part of benign vasomotor symptoms (like hot flushes). However, they become red flags if they are accompanied by dizziness, light headedness, chest tightness or chest pain. If palpitations last for a long time and don’t resolve quickly, they need to be checked out to rule out an underlying heart rhythm issue.
Statins And Preventative Care
Dr Hartley: Statins are highly effective, but some women can be reluctant to take them due to fear of side effects. How can we address these concerns?
Dr Allen: Statins can have a bit of a bad reputation, particularly in relation to muscle aches and risk of liver damage. Severe muscle inflammation from statins is incredibly rare. Furthermore, statins do much more than just lower cholesterol. They stabilise existing arterial plaque, act as an anti-inflammatory on the blood vessels and actively prevent the plaque ruptures that cause heart attacks. If started at a low dose and up-titrated slowly, many people tolerate them perfectly. The benefits of statins far outweigh the risks.
Heart Health For Women Over 40
Dr Hartley: If a woman in her 40s or 50s wants to be proactive about her heart health, what should she do?
Dr Allen: I recommend a three-step approach:
1. Get your blood pressure checked regularly. Do not write off high readings as “white-coat hypertension” – if it’s high, it needs to be managed.
2. Talk to your doctor about your family history of early heart disease, any pregnancy complications you experienced and any autoimmune/inflammatory conditions (like rheumatoid arthritis or lupus) you may have.
3. Focus on eating whole, fresh foods 80 per cent of the time and avoid ultra-processed foods. When it comes to exercise, consistency is key. You don’t need to run marathons; 20 to 30 minutes of brisk walking five times a week is phenomenal. Additionally, include weight-bearing or resistance exercise to protect your bones and muscles.
Most importantly, listen to your body and advocate for yourself. Women are highly prone to minimising their symptoms because they are busy caring for children, careers and aging parents. Don’t dismiss it if you feel exhausted, breathless or just “off”. If you feel like your concerns are being brushed aside by a doctor, seek a second opinion. No-one will ever fault you for ruling out a serious cardiac issue.
