How Is Heart Failure Different in Women?

What any woman with heart failure should know

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Heart failure is a major cause of death and disability in both men and women. Over the past few decades significant resources have been dedicated to understanding the causes of heart failure, and to developing more effective treatments for it. And in these efforts we have made significant strides.

One thing we have discovered in this effort is that most aspects of heart failure are not very different between men and women.

For both sexes, heart failure develops most often as a result of coronary artery disease (CAD) or longstanding hypertension (high blood pressure). And usually, the symptoms of heart failure, and the optimal treatment of it, are quite similar in women and in men.

But there are differences. There are a few aspects of heart failure that pertain especially to women. These include the causes of heart failure in women, the age of women who develop heart failure, the symptoms caused by heart failure, and how doctors treat heart failure in women. If you are a woman who has heart failure, you should be aware of these differences.

Causes of Heart Failure That Are Especially Important in Women

Hypertension: The most common medical problems that lead to to heart failure are hypertension and CAD. Of these, hypertension is the leading cause in both men and women. But hypertension is substantially more likely to cause heart failure in women than in men.

Hypertension increases the risk of developing heart failure by 300 percent in women, but "only" by 200 percent in men. Among women with heart failure, hypertension turns out to be the underlying cause in 59 percent (compared to 39 percent in men). So, while it is very important for anyone with hypertension to be adequately treated, it seems especially important in women.

Diastolic Heart Failure: In diastolic heart failure, cardiac function deteriorates because the heart muscle becomes stiff, and the heart has a difficult time filling adequately with blood in between heart beats. Consequently, the amount of blood that is being pumped with each heart beat is relatively reduced (producing fatigue and poor exercise tolerance), and blood that is unable to fill the heart "backs up" into the lungs (producing pulmonary congestion).

While diastolic heart failure can occur in anyone, this condition is more prominent in women than in men.

Diabetes: Diabetes itself doesn't produce heart failure, but people with diabetes have a high incidence of conditions that do—specifically, CAD and hypertension. And for reasons that are not understood, women with diabetes are twice as likely to develop heart failure as men with diabetes.

Obesity: Women who are obese have a risk of developing heart failure that is 50 percent higher than women of normal weight. Obese men also have a higher risk of heart failure, but the excess risk from obesity is not thought to be as high in men as it is in women.

Chemotherapy: Certain chemotherapy drugs (especially doxorubicin, or Adriamycin) can cause cardiac toxicity that can lead to heart failure.

Women tend to be exposed to these chemotherapy agents more often than men, in particular, for the treatment of breast cancer.

Postpartum cardiomyopathy: Postpartum cardiomyopathy is a type of heart failure associated with childbirth. While this condition usually resolves with aggressive treatment, it produces a long term high risk of developing heart failure in the future, especially with future pregnancies.

Stress cardiomyopathy: Stress cardiomyopathy, also called “broken heart syndrome,” is a form of sudden, severe heart failure triggered by extreme emotional trauma. While this condition can be seen in either sex, it is far more common in women, and may be related to microvascular angina—a condition that is also much more common in women.

Age of Women With Heart Failure

Women who develop heart failure tend to do so at an older age than men who develop heart failure. Unfortunately, because clinical trials in the past tended to exclude “elderly” people (people 65 or older), this means that relatively little data has been generated from clinical trials showing how women with heart disease respond to treatment. Recently, researchers have taken more care to enroll a sufficient number of women in clinical trials, and this shortcoming is being gradually rectified.

Symptoms of Heart Failure in Women

As mentioned earlier, the symptoms of heart failure in men and women are largely the same—gradually worsening fatigue, exercise intolerance, dyspnea, and edema (swelling). However, some clinical studies seem to suggest that women with heart failure are more likely to experience significant dyspnea and edema than men.

Response to Treatment in Women

As noted, clinical trials evaluating the treatment of heart failure have enrolled substantially fewer women than men. Nonetheless, the available data strongly suggests that women respond to heart failure treatment—in particular, to ACE inhibitorsbeta blockers, and diuretics—just as favorably as men. Furthermore, the aggressive treatment of heart failure in men or women is important in minimizing the risk of death.

Differences in How the Hearts of Men and Women Respond to Cardiac Stress

In research with animals and in clinical trials, evidence is accumulating to suggest that the heart muscles of men and women react differently to various kinds of physiologic stress.

Several animal studies have looked at how the hearts of males and females react to experimental conditions designed to produce heart failure. These studies have consistently shown that female cardiac muscle tends to respond by making various adaptions that help to stave off heart failure, whereas male cardiac muscle fails more quickly.

Clinical trials in people have suggested the same thing. In people with aortic stenosis (a narrowing of the aortic valve, which greatly increases the pressure and the stress within the left ventricle), premenopausal women develop cardiac hypertrophy (thickening of the heart muscle) more readily than men. This hypertrophy reduces wall stress, and delays the onset of dilated cardiomyopathy and thus, of heart failure. Interestingly, postmenopausal women do not show this same protective adaptation to aortic stenosis, and they develop heart failure at the same rate as men, suggesting that female hormones may have a protective effect. However, clinical trials evaluating the effect on heart failure of hormone replacement therapy in postmenopausal women have given contradictory results.

These findings may help to explain why women develop heart failure at a later age than men, and why women with heart failure tend more often to have diastolic heart failure (a condition often associated with cardiac hypertrophy) than men.

Still, all we can say with any confidence today is that the hearts of men and women respond somewhat differently to various kinds of physiologic stress. Unfortunately we do not yet know how to exploit those differences to benefit either women or men.

Outcome of Heart Failure in Women

Evidence suggests that, despite the fact that they tend to develop heart failure at a substantially later age than men, women with heart failure survive longer than men.

This relatively good news for women with heart failure is counter-balanced by at least some clinical evidence suggesting that doctors tend not to be as aggressive in treating women with heart failure as they are in treating men, and that if women were treated more appropriately they would do even better. One reason for this apparent discrepancy in therapy may be that (as some studies suggest) women may tend to minimize their cardiac symptoms when talking to their doctors. Doctors who do not take the time to press for a full accounting of symptoms may be unaware of just how sick and disabled their women patients actually are.

It is important for anyone, woman or man, who has symptoms suggestive of heart failure—especially worsening fatigue or dyspnea—to make sure their doctor knows all about it. But perhaps women need a little extra reminding of how important this is.

If you have heart failure you should thoroughly familiarize yourself with the symptoms that can be caused by heart failure, and report any changes in those symptoms to your doctor. Give your doctor a chance to treat you the way you deserve to be treated.

A Word From Verywell

While heart failure has similar causes, and produces similar symptoms, in men and women, there are still some important gender-related differences in heart failure. If you or a loved one are a woman with heart failure, it is worthwhile to keep some of these differences in mind, and make sure your doctor is taking them into account in managing your condition.

Also, as important as lifestyle changes are in anyone with heart disease or an elevated risk of heart disease, those changes—especially changing your lifestyle to get to a healthy weight, getting the exercise you need, getting on a healthy diet, and optimizing your control of hypertension and diabetes—are especially important if you are a woman with heart failure.

Sources:

Frazier CG, Alexander KP, Newby LK et al.: Associations of Gender and Etiology With Outcomes in Heart Failure With Systolic Dysfunction: a Pooled Analysis of 5 Randomized Controlled Trials. J. Am. Coll. Cardiol. 49, 1450-1458 (2007).

O'Meara E, Clayton T, McEntegart MB et al.: Sex Differences in Clinical Characteristics and Prognosis in a Broad Spectrum of Patients with Heart Failure: Results of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program. Circulation 115, 3111-3120 (2007).

Shah RU, Klein L, Lloyd Jones. Heart Failure in Women: Epidemiology, Biology and Treatment. Women’s Health. 2009;5(5):517-527.

Skavdahl M, Steenbergen C, Clark Jet al.: Estrogen receptor-β Mediates Male-Female Differences in the Development of Pressure Overload Hypertrophy. Am. J. Physiol. Heart Circ. Physiol. 288, H469-H476 (2005).

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