Cardiovascular disease affects both men and women, but women tend to have more atypical symptoms of acute myocardial infarction (MI). Physicians need to understand these potential differences in presentation in order to improve outcomes, according to the first scientific statement on the topic from the American Heart Association (AHA), published online on Jan. 25 by Circulation. ACP Hospitalist spoke with lead author Laxmi S. Mehta, MD, the director of the women's cardiovascular health program and an associate professor of medicine at the Ohio State University Wexner Medical Center in Columbus.
Q: What are some of the key differences in symptom presentation between men and women that hospitalists should know?
A: When we think of MI, we frequently think of a substernal chest pressure that's radiating down the left arm, associated with some shortness of breath and diaphoresis. While women can have atypical symptoms, they still could present the same way as men with all those [classic] symptoms. Chest pain can be atypical in women and can be chest pressure, sharp pain, pleuritic pain, or reproducible kind of pain, and it doesn't necessarily need to be left-sided. If women present with chest pain, but it doesn't sound quite like the classic symptoms and it's new for them, then I think it warrants further investigation and, at bare minimum, an EKG if presenting with acute symptoms. Women might not even have chest pain—they could have shoulder pain or intense fatigue, generalized weakness, flu-like symptoms, back pain, indigestion, palpitations. Many women experience atypical symptoms, which can make diagnosis a challenge. Questioning how acute the symptoms are and if the symptoms change with exertion is a helpful tool in gauging if it's something potentially related to the heart.
Q: How might that differ from past approaches?
A: In the past, women were being undertreated, there were delays in women presenting to the hospital, and then physician and nursing staff underdiagnosed women with heart attacks. Nowadays, a lot of hospitals end up doing EKGs on anyone with a symptom from the waist up, so at least we can capture major heart attacks if they're occurring. But the atypical symptoms or nature of those symptoms can really be perplexing and can certainly lead you down a pathway that might not be heart-related.
Q: The paper notes some racial and ethnic differences in women's presentation and risk factors, as well as higher mortality among younger women (about 45 to 55 years) compared to older women. What should hospitalists keep in mind when treating women who fit into these categories?
A: Minority populations have several risk factors [e.g., more comorbidities such as diabetes, hypertension, heart failure, and obesity] at the time of presentation with [acute] MI, so paying attention to those risk factors and managing those risk factors is going to be key. Paying attention to some of the psychosocial issues that go along with being younger or being a racial minority with heart disease is also important. That's where a team-based approach is imperative.
It's perplexing why the mortality rates are higher in younger women, and there's a lot more to learn. In younger women with MI, what happens is they tend to have a lot of competing roles, especially if they're young and still have children at home, and that can sometimes be a burden on them taking care of themselves or continuing cardiac rehabilitation or some of the other necessary [treatments]. Many of the young women who present with heart attacks are smokers, so working really hard to engage them to quit the smoking and looking at what kind of hormonal replacement or birth control pills they're on is going to be key. Diabetics and especially diabetic women can present at a younger age, so modifying diabetes and having tight glucose control is imperative, as well.
Q: What do we know about the proper course of treatment for women with acute MI? Does it differ from male patients?
A: What we know about treatment is based on research. However, women have only comprised 25% to 30% of the cohort in research studies, so they are a minority. We've taken what we've learned from the research predominately in men and have [applied] it to women and said, ‘That's the treatment.’ From the data we have, we're still recommending similar treatment in terms of aspirin, beta-blockers, [angiotensin-converting enzyme] inhibitors, and statins, and we're still recommending cardiac catheterizations. Women continue to have twice the bleeding rates as men. Some of it is related to their body weight, kidney function, and adjustment of dosing guidelines. If anticoagulants are given, we do recommend some titration of doses based on weight because in the past, [clinicians] weren't taking weight [into account], and women are smaller.
What we see, though, is that women are still under-referred for some of these pharmacologic treatments in hospital, at discharge, and after discharge. Some of that is due to provider bias of not getting those patients on the medications, some of that is also due to patients' nonadherence to taking medications or refusal to take the medications. We also know that women who have nonobstructive coronary heart disease are less likely to be treated with medications compared to those who have obstructive disease. That's where some of the disparities occur in outcomes. An important part of the treatment of MI besides revascularization and medications is cardiac rehabilitation. Women are under-referred for cardiac rehabilitation. Even if they are referred, their attendance rates of going to cardiac rehabilitation are poor compared to men, despite it being an important treatment. Additionally, women suffer from more depression than men at baseline and after a cardiac event, so working on depression management is going to be imperative for the recovery of the patient's health.