In a nutshell
- People used to focus mainly on the classic, typically male heart attack: a narrowing of the major blood vessels in the heart that manifests as chest pains.
- Today we know that heart attacks in women can look very different in terms of causes, manifestation and treatment.
- But even in 2023, more awareness is needed when it comes to women-specific risk factors and follow-up.
Emeline Van Craenenbroeck is a professor of cardiology at UAntwerp and a heart failure specialist at Antwerp University Hospital. In this column, she explains how knowledge about the female heart has evolved. She discusses important differences between heart attacks in men and women, ranging from causes and symptoms to treatment.
The 'classic' heart attack
We meet Professor Van Craenenbroeck in her office at Antwerp University Hospital. On her laptop, she shows us a drawing from the 1980s, by medical illustrator Frank Netter.
'Several generations of medical students will recognise Netter's illustrations from their courses,' Van Craenenbroeck says. 'In this image, we see a man leaving a restaurant, stepping out into the cold, and reaching for his heart. The classic picture of a heart attack.' But that picture needs some adjusting: 'It's a wonderful drawing and it's still accurate, but only for a certain group of patients, namely men. In women, it can look very different.'
A heart attack, technically a myocardial infarction (MI), can manifest differently in men and women, Van Craenenbroeck explains. 'The main symptom for all genders is chest pain. This pain often also radiates outward to the arm, or even the jaw or the teeth. But what many people don't realise is that women often have vaguer, more diverse symptoms. For example, they may suddenly feel nauseated, dizzy, tired or short of breath, and these are all possible indications of a heart attack. The danger lies in the fact that such symptoms are typically considered less urgent. Patients brush them off or decide to wait and see, not knowing that a heart attack might be imminent.'
Pregnancy complications and hormonal influences
The causes of myocardial infarctions can also differ between men and women. 'The classic risk factors apply to everyone,' says Van Craenenbroeck. 'These are usually lifestyle-related: smoking, obesity, lack of exercise ... They cause the large blood vessels in the heart to clog up, which can result in the classic infarction as seen in the Netter image. But only in men is this the number one cause. In women, a narrowing or contraction of the small blood vessels is actually more common. Lifestyle plays less of a role in this than gender-specific risk factors, including hormonal influences and pregnancy. Complications such as preeclampsia can eventually lead to heart problems, and are often early signs of an underlying vascular disease.'
No 'one-size-fits-all' treatment
Asked whether sufficient distinction is made between men and women when treating a heart attack, Van Craenenbroeck shakes her head. The problem is already apparent in medical studies into the effects of rehabilitation and medication. Up to ninety per cent of subjects in these studies are male. 'Women are less likely to participate in medical studies. Sometimes the reasons for this are practical in nature, like having a household to take care of.' This underrepresentation absolutely needs to be addressed, stresses Prof. Van Craenenbroeck. 'Every possible barrier must be removed to actively recruit female participants. As it stands, we don't really know to what extent the results seen in men also apply to women, for instance when it comes to the right medication or dosage.'
Invasive treatments are not blanket solutions either. 'Many people associate heart attacks with stents, which are put in place to keep narrowed blood vessels open. But that only works on major blood vessels that have narrowed. Often it's only on the operating table that doctors see that the problem isn't there. So they end up not placing the stent and the case is closed, end of story.' But it shouldn't end there: 'Ideally, the proper functioning of the small blood vessels should then be tested, especially in women. Unfortunately, that's not standard practice yet.'
Number one cause of death in women
Better detection and follow-up of heart problems in women is literally a matter of life and death. 'Heart disease is the world's leading cause of death in women, too, taking more lives than breast cancer,' says Van Craenenbroeck. Fortunately, awareness around women-specific medicine is increasing. For cardiology, there was a tipping point about two decades ago. 'It was around the time that we saw an increase in female cardiologists,' Van Craenenbroeck notes. 'Things are going in the right direction, but we're not there yet. Take the current European health guidelines, for instance. There's a separate section on heart attacks in women, which is great. But when you read on, women are described in it as a 'special population'. This clearly shows that there's a lot more awareness raising to be done.'