Heart Disease: Men vs. Women

Surprising Differences Due to Gender

Illustration of man and woman showing the location of their hearts
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A woman’s heart looks just like a man’s, but there are significant differences. For example, a woman’s heart is usually smaller as are some of its interior chambers. The walls that divide some of these chambers are thinner. A woman’s heart pumps faster than a man’s, but ejects about 10 percent less blood with each squeeze. When a woman is stressed, her pulse rate rises and her heart ejects more blood.

When a man is stressed, the arteries of his heart constrict, raising his blood pressure.

Why do these differences matter? They matter because gender plays a role in the symptoms, treatments, and outcomes of some common heart diseases.

Coronary Artery Disease (CAD)

CAD, the leading cause of heart attack, is the same process in men and women. Extra fats circulating in the blood are deposited in the walls of the heart’s arteries, forming deposits called plaques. When these plaques grow slowly, they become hard and gradually narrow the artery, interfering with blood flow. More often the plaques remain soft and become unstable and rupture. This triggers a cascade of events that produces a blood clot that stops blood flow. Either way, the result is a heart attack.

Despite this process, women have risk factors for CAD that men don’t have. They also tend to have different symptoms of heart attack. When symptoms appear, CAD may be more difficult to diagnose using conventional testing methods.

After a heart attack, women don’t always do as well as men. Sometimes, it’s because women don’t always receive the best treatment for their disease. Other times, it’s because they didn’t know they were at risk until it was too late. Here are six ways that CAD differs in men and women:

  1. Women have risk factors men don’t have. Certain diseases found only in women increase the risk of CAD. These include endometriosis, polycystic ovary disease (PCOS), diabetes, and high blood pressure that develops during pregnancy. Endometriosis has been found to raise the risk of developing CAD by 400 percent in women under age 40. Women also share traditional risk factors with men, such as high blood pressure, high blood sugar levels, high cholesterol levels, smoking, and obesity. Like men, women can be impacted by a family history of heart disease, particularly when a father or brother was diagnosed with CAD before age 55 or a mother or sister was diagnosed before age 65.
  1. Women are generally older when they have their first heart attack. Men are at risk for heart attack much earlier in life than women. Estrogen offers women some protection from heart disease until after menopause, when estrogen levels drop. This is why the average age for a heart attack in women is 70, but 66 in men.
  2. The symptoms of heart attack can be different in women. Chest pain (also described as a crushing weight on the chest) is the most common symptom of heart attack in men. Some women also experience chest pain, but they are more likely to have different symptoms. Unlike the dramatic, chest-clutching pain seen in the movies, women often experience subtler symptoms for three or four weeks before a heart attack. Red flags include:
    • New or dramatic fatigue. You aren’t exerting yourself, but you feel deeply fatigued, but can't sleep, or have a “heavy” chest. For example, a simple activity like making the bed makes you feel unusually tired or you are suddenly worn out after your normal exercise routine. 
    • Shortness of breath or sweating. Look our for when either symptom occurs without exertion, is accompanied by a symptom such a chest pain or fatigue, worsens over time after exertion, or sparks a cold, clammy feeling that occurs without cause. Also, if shortness of breath worsens when lying down and is relieved when you sit up. 
    • Pain in the neck, back, or jaw. Look out for when there is no specific muscle or joint that aches or when the discomfort worsens when you are exerting yourself and stops when you stop. The pain can be in either arm, whereas it’s usually the left arm in men. Also, pay attention to pain that starts in the chest and spreads to the back, pain that occurs suddenly and may awaken you at night, or pain in the lower left side of the jaw.
  1. CAD in women is sometimes hard to diagnose. An X-ray movie (angiogram) taken during a cardiac catheterization is the gold standard test for finding narrowings or blockages in the heart’s large arteries. But CAD in women often affects the small arteries which cannot be clearly seen on an angiogram. That’s why any woman who is given the “all clear” signal after an angiogram and continues to have symptoms should see a cardiologist who specializes in women with heart disease.
  2. A heart attack is harder on a woman than a man. Women don’t tend to do as well as men after a heart attack. They often require a longer hospital stay and are more likely to die before leaving the hospital. This may be due to the fact that women who suffer a heart attack have more untreated risk factors, such as diabetes or high blood pressure. Sometimes, it’s because they put their families first and don’t take care of themselves.
  1. Women don’t always get the proper medications after a heart attack. After a heart attack, women are at greater risk of developing a blood clot that can cause another heart attack. For unknown reasons, they are not as likely to be given a drug to prevent such blood clots. This could explain why women are more likely than men to have a second heart attack within 12 months.

Heart Failure

Heart failure in men is usually caused by damage from a heart attack that prevents the muscle from contracting as forcefully as it should. On the other hand, women are more likely to develop heart failure when high blood pressure, chronic kidney disease, or other condition prevents their heart muscle from relaxing properly between beats. Women with this type of heart failure generally live longer than men with heart failure. But, they need frequent hospitalizations for shortness of breath, have limited physical ability, and are more likely to need nursing home care.

Atrial Fibrillation

Atrial fibrillation (afib) is a condition that causes the heart to beat in an irregular, often rapid, rhythm. Recent studies have found that women with afib have more symptoms, a worse quality of life, a higher likelihood of stroke, and worse outcomes than men. They also are more likely to be treated for afib with catheter ablation, but more likely to be re-hospitalized for afib after the procedure than men. Despite these problems, women who receive treatment for afib are more likely to survive longer and are less likely to die from a heart problem than men with afib.

Protect Yourself

Whether you are a man or a woman, it’s never too late to lower your chance of experiencing a heart attack. Here is what you need to do:

  • Quit smoking or don’t start
  • Get regular exercise (at minimum, walk 30 minutes a day)
  • Eat a diet high in fruits, vegetables, whole grains, and fish and low in animal products, simple carbohydrates, and processed foods
  • Maintain a normal weight, blood pressure, blood lipid, and blood sugar levels.

Dr. Cho is a cardiologist and section head at Cleveland Clinic's Tomsich Family Department of Cardiovascular Medicine. She is also the Director of the Women's Cardiovascular Center.

Sources

Mu F, Rich-Edwards J, Rimm EB, et al. Endometriosis and risk of coronary heart disease. Circ Cardiovasc Qual Outcomes, 2016:9(3):257-264. 

McSweeney JC, Rosenfeld AG, Abel WM, et al. Preventing and experiencing ischemic heart disease as a woman: State of the Science. Circ, 2016;133(13):1302-1331.

Mehta LS, Beckie TM, DeVon HA, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circ, 2016; 133(9):916-947.

Piccini JP, Simon DN, Steinberg BA, et al. Differences in clinical and functional outcomes of atrial fibrillation in women and men: Two-year results from the ORBIT-AF registry. JAMA Cardiol, 2016;1(3):282-291.

Kaiser DW, Fan J, Schmitt S, et al. Gender differences in clinical outcomes after catheter ablation of atrial fibrillation. JACC Clin Electrophysiol, 2016;DOI:10.1016/j.jacep.2016.04.014.

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