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Women and Heart Health by Nicole Harkin, MD, FACC

What’s the primary cause of death for women in the United States? If you guessed breast cancer, you’re not alone. It’s actually cardiovascular disease. And most women don’t know that. While death due to cardiovascular disease has declined over the last couple of decades, the annual mortality rate is, in fact, higher for women than men. This means that every year, more women than men die of heart disease. So, what’s going on? Are women just tiny men, or are we different? Here’s what we need to know.

Heart disease is not a “man’s disease”

About one in three American women will die from heart disease (that’s compared to one in 31 from breast cancer). Heart disease is responsible for more deaths than all cancers combined. So, no, it’s not a man’s disease! In fact, 45% of women over the age of 20 already have some form of cardiovascular disease!

Atypical symptoms of heart disease in women

While women often experience the classic symptom of chest pain when they have a heart attack (which may be experienced as crushing, pressure or tightness), they are more likely than men to have atypical symptoms such as shortness of breath, extreme fatigue with walking, nausea/vomiting, intense anxiety, back pain or jaw pain. Women are also more likely than men to have symptoms brought on by stress or while they sleep. And, unfortunately, more than half of the women who die suddenly from heart disease will have had no prior symptoms whatsoever.

Unique risk factors While the top risk factors for heart disease are the same in women as they are in men—high blood pressure, high cholesterol, family history, diabetes, above-ideal body weight, smoking, standard American diet, strong family history and not enough exercise—several risk factors are unique to women. While many of the risk factors cannot be modified specifically, they are essential to recognize in order to have a more complete understanding of our overall cardiovascular risk. They also help us make treatment decisions, whether lifestyle- or medication-related.

  • Pregnancy-related risk factors: Pregnancy-related complications, including gestational hypertension or preeclampsia, gestational diabetes, recurrent miscarriages and premature delivery, increase the risk of future cardiovascular events by as much as two- to four-fold. This is a significant risk factor for women, given that adverse pregnancy outcomes occur in 10 to 20% of all pregnancies. Of these complications, preeclampsia (particularly if it occurs early) has the strongest association with increased cardiovascular risk.

  • Early menopause: Before menopause, women have a lower risk of heart disease than men in their age bracket. The risk for cardiovascular disease increases dramatically in women after menopause, who then assume the same risk of heart disease as similarly aged men. Premature menopause, typically defined as occurring before age 40, increases cardiovascular disease risk compared to women who reach menopause later in life.

  • Other hormonal factors: Estrogen-containing oral contraceptives (AKA birth control pills) are associated with an increased risk of heart attack and stroke. While the overall risk is relatively low in average-risk women, it is not the best choice for women with heart disease or multiple risk factors (particularly smoking). Polycystic ovary syndrome (PCOS), a common hormone disorder that often results in infertility, insulin resistance and abnormal cholesterol, is also associated with increased risk for heart disease.

  • Inflammatory and autoimmune diseases: Women are much more likely than men to have an inflammatory or autoimmune disease, which increases the risk for heart disease. Lupus, in particular, is quite common in women and was associated with up to a 50-fold increased risk of heart attack in one study. Other conditions that may be associated with higher risk include rheumatoid arthritis, psoriasis and inflammatory bowel disease (IBD).

  • Psychologic stress: Anxiety, depression, acute and chronic emotional stress, post-traumatic stress disorder (PTSD) and early-life adversities, while not unique to women, are more common in women than in men and are particularly strong risk factors for heart disease in women.

What you can do Women must recognize that heart disease can affect them. Many women don’t seek care for concerning symptoms because they mistakenly think that heart disease can’t or won’t happen to them. Do not ignore heart attack indicators, such as new chest pain, shortness of breath, strange jaw or back pain, or other new, worrying symptoms. If a symptom is concerning to you and you don’t feel heard, find a healthcare provider who will listen. Heart attacks are more likely to be missed in women. And risk factors are more likely to be under-diagnosed and under-treated in women. We need to be our own advocates, and in turn, advocate for our friends and family. While some factors are out of our control, like age and family history, there is still plenty that can be done to prevent heart disease. Start by recognizing your own risk factors, including those that are unique to us as women. Next, create a plan to work on the changes that you can do something about.

  • If you have any traditional or non-traditional risk factors, be sure that your doctor is aware of them. Discuss your overall cardiac risk with them and develop a game plan to mitigate those risk factors. You can calculate your 10-year risk of heart disease and stroke using the ACC/AHA Calculator. Just keep in mind that many of the risk factors discussed in this post are not accounted for with this calculator.

  • Know your numbers: your blood pressure, cholesterol levels, glucose and body mass index (BMI). Talk to your doctor about whether you should have additional testing done, including measures of inflammation or heart imaging like a CAC (a coronary artery calcification score, a type of CT scan that measures the calcium in the arteries of the heart).

Take stock of your lifestyle habits—from your nutrition to your exercise, stress and sleep patterns. Determine where you can optimize, and select just one or two small, achievable goals to work on at a time.

  • If you aren’t already doing it, make it a priority to fit in 150 minutes of moderate-intensity exercise each week. If stress is looming large, give yoga or meditation a try.

  • Aim for seven to eight hours of sleep each night.

  • If you smoke, please work with your healthcare provider to quit.

We’ll be discussing nutrition in more detail in the next post, so please stay tuned for that.


Nicole Harkin, MD, FACC

Nicole Harkin, MD, FACC, is board-certified in Internal Medicine, Cardiology, Echocardiography, Nuclear Cardiology, and Clinical Lipidology. After graduating from Boston University School of Medicine, she attended Columbia University for her Internal Medicine residency and New York University for her Cardiology fellowship. She also served as a chief fellow and an assistant attending. She is a fellow of the American College of Cardiology and a member of the National Lipid Association and American Society for Preventive Cardiology.

Dr. Harkin helped countless patients treat and prevent their heart disease in her private cardiology practice in Manhattan. She recently moved to San Francisco with her family and founded Whole Heart Cardiology, a preventive telecardiology practice with the mission of providing patient-centered cardiac care, evidence-based nutritional guidance and personalized lifestyle plans for her patients in a modern setting. She takes pride in helping her patients achieve their goals, feel better and thrive.

When not doctoring, she spends the majority of her time with her three young children. She also enjoys cooking, yoga, Pelotoning, hiking and traveling.

Instagram: @nicoleharkinmd

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