Addressing sex and gender in cardiology care

Addressing sex and gender in cardiology care
© iStock/dragana991

Lorna Rothery spoke to Professor Angela Maas, an internationally recognised expert in women’s cardiology care, about why we must approach cardiovascular care differently for men and women.

No two people are the same, and in cardiology, accounting for sex and gender-based differences is hugely important for understanding symptom presentation and ensuring patients receive timely and appropriate treatment. Unfortunately, gender-sensitive cardiology care is not widely recognised and as a result, women have bore the brunt of shortcomings in care and are twice as likely to die of coronary heart disease compared to men. Misdiagnosis, inadequate treatment, and delays in seeking help are some of the reasons behind high rates of cardiovascular-related mortality among the female population.

Though an increasing body of research is helping physicians become more aware of biological and gender-based differences, low representation and participation of women in clinical trials often mean healthcare workers are diagnosing and treating patients based on evidence collated predominantly from men.

Understanding women’s susceptibility to cardiovascular diseases, and how this informs diagnosis and treatment has long been a focus for Professor Angela Maas, a leading cardiologist who specialises in women’s heart disease and set up the first outpatient clinic for women’s cardiology care in the Netherlands in 2003. She was elected as a UN Women representative in 2020 and in the same year released her book A Woman’s Heart: Why female heart health really matters (Aster) which drew on the importance of acknowledging female-specific risk factors in cardiology care. She spoke to Lorna Rothery about the impact of sex and gender disparities in cardiovascular care and why female-specific risk factors for heart disease must form part of medical education and cardiology training.

Women are twice as likely to die of coronary heart disease. What are the key differences between men and women in terms of their risk factors for cardiovascular conditions?

There are well-known lifestyle factors and traditional cardiovascular risk factors like hypertension, and diabetes, which we know affect men and women differently. Smoking, for instance, specifically in the younger age group (below 60) is twice as likely to cause cardiovascular events in women.

Regarding hypertension, there is a shift in blood pressure during the life course; men often experience greater hypertension under 50, but after menopause and beyond the age of 55, there is a steep rise in blood pressure, specifically systolic blood pressure, among women. There are also differences in lipids between the ages of 50 and 60; lipids increase by at least 15% in women whereas there is little change among men in the same age group.

Women also have female-specific risk factors; migraines starting in their teens or 20s, prior hypertensive pregnancy, or severe hypertensive pregnancy disorders like preeclampsia can double the risk of coronary heart disease and heart failure later on, and even dementia in older age.

Discussions are now taking place about whether in the future, we should aim to have lower thresholds for normal blood pressure in women compared to men because the impact of hypertension is greater in women. For older adults specifically, we see more myocardial stiffness with diastolic heart failure in women compared to men so it may be that we need to have lower blood pressure values for them.

We know that treatment with statins in secondary prevention, but also in primary prevention, is less strict in women compared to men. Women have more adverse effects to medication and also more aversion to lipid-lowering therapy. This leads to a bit of indifference in doctors because they so often get complaints about statins, but there are other options. For instance, you can have a statin a few times a week, it is better than nothing. Sometimes you have to be more creative in treating women than men. When you consider heart failure, for instance, dosages of medication can be lower for women than men because of the side effects that can occur.

Focusing on menopause, how does this affect your heart?

All women experience menopause differently and about 80% will have shorter or longer periods of vasomotor symptoms – sleep disturbances, hot flashes, night sweats – which start a few years before the onset of menopause. In 20% of women, these may last for ten years or even longer, and for those women, it may be a good idea to have hormonal replacement therapy for several years.

Early menopause – before the age of 40 – is a risk factor in women and physicians need to be aware of this when treating female patients.

© iStock/Adene Sanchez
It is still not obligatory for medical students to learn about sex and gender differences in cardiovascular disease, and also other diseases. There are still many guidelines that refer to women as a specific subset of patients, and we are not a subset of patients, we are half of the population

Does hormone replacement therapy (HRT) affect your risk of cardiovascular disease?

Since the publication of the Women’s Health Initiative studies 20 years ago, there has been much discussion and aversion around hormonal replacement therapy. Nowadays there is much more choice, for instance, transdermal applications and implants, and we can better identify which women are at high risk, and which women are not. The risks associated with hormonal therapy are not the same in every woman. It can be really very important for quality of life in many women who have a lot of vasomotor symptoms, so I think an individual approach is important.

What about non-hormonal therapy, what helps?

Everything starts with a healthy lifestyle, but it is not always easy. Of course, limiting the intake of alcohol, not smoking, eating healthily, and taking regular physical exercise helps, but still, many women will have vasomotor symptoms. Healthy women may need hormonal therapy for a short or perhaps longer periods of time.

At the same time, many women who start having migraines in their teens or have multiple miscarriages, pregnancy problems, hypertension, or cardiovascular disease in their family will have an elevated risk, and you are not going to change that with a healthy lifestyle. It is important to identify women who are prone to a higher cardiovascular risk early on, because you have to pay more attention to their blood pressure, perhaps to their lipid changes. We need to learn to discriminate early on whom is at the highest risk, family history is very important for this.

When you consider other gender-related factors like socioeconomic position and poverty, which nowadays are more and more important, we know that a lower socioeconomic status and poor education go hand in hand with a higher cardiovascular risk, and poorer treatment when cardiovascular problems arise.

Education and financial independence for women are important for healthy ageing. It is a complex topic, if you have money stress the impact of this is not so easy to solve and as doctors, we cannot do anything about it.

What is the significance of accounting for sex and gender-based differences in CVD risk factors in terms of symptom presentation and approaches to diagnosis and treatment?

Women have a different pattern of coronary artery disease and a higher rate of non-obstructive coronary artery disease, yet all cardiology care has been built on the male model of obstructive coronary disease. From this model, we have developed Percutaneous Coronary Intervention (PCI) stents, and coronary bypass surgery, but if you look at the big data sets of patients, you see a majority of men and only a minority of women. So, women have more non-obstructive diseases, for which a PCI is not a solution.

Women have more spasms in their larger and smaller coronary arteries, and also more microvascular disease, with higher vascular resistance, and this is still extremely underdiagnosed. If a woman has a coronary spasm, there is more fluctuation in her symptoms, and thus different symptom presentations because the underlying problem is also different. Women not only communicate differently, but they also have different pathophysiology of the underlying disease and that makes symptoms different from what we have also always learned from the male patient.

Given these sex and gender disparities, what changes would you like to see at a policy level to ensure more gender-sensitive cardiology care?

It is still not obligatory for medical students to learn about sex and gender differences in cardiovascular disease, and also other diseases, and it should be. There are still many guidelines that refer to women as a specific subset of patients, and we are not a subset of patients, we are half of the population.

Cardiologists also need to collaborate more with other disciplines. Because in medicine, we examine patients and operate within our silos but of course across the patients’ life course, they will be treated by a range of people working within different disciples so I think the whole concept of healthcare should change, and it needs to change quickly.

Women must demand good answers from their doctors when they have symptoms and take care not to be sent home with a vague diagnosis of stress for instance. For doctors, we have to keep in mind that there is a lot still to learn and that we do not understand cardiovascular disease at the moment as we should.

Professor Angela Maas, FESC MD PhD
Radboud University Medical Center,
the Netherlands

This article is from issue 23 of Health Europa Quarterly. Click here to get your free subscription today.


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