Maybe it was fate. Way back in 1991, a leading cardiologist coined a term for a dispiriting fact of medical care: If a woman suffers a heart attack she is not taken as seriously or given the same life-saving treatment as a man unless her symptoms look like a man’s, much as the title character of the 1983 film Yentl was afforded educational opportunities only when she disguised herself as someone with a Y chromosome. Cardiology’s “Yentl Syndrome” was born and, soon after, so was a medical activist: actor, singer, and director Barbra Streisand, who played the cinematic Yentl.
“It’s gender discrimination that makes me crazy,” Streisand has said. Infuriated that women were being shortchanged in both medical care, where the Yentl Syndrome persists, and the lab, where cardiovascular researchers have historically studied men much more than they have women (and even male mice more than female mice), Streisand threw herself into the fray. Over the years, she has donated $22 million to what is now the Barbra Streisand Women’s Heart Center at Cedars-Sinai medical center in Los Angeles, and she has bent the ear of every politician, doctor, and woman who will listen: a woman’s cardiovascular disease is different from a man’s, and unless we recognize and explain that, and battle what Streisand calls the “misconception that heart disease is mostly a man’s disease,” women will continue to die unnecessarily.
Cardiovascular disease (CVD), the leading cause of death in both sexes in the U.S., kills more women than men every year (400,000 vs. 387,000 in 2010, the latest data available, according to the American Heart Association). Although the overall rate of CVD is slightly lower for women, “a woman is more likely to die from her heart attack than a man, especially a younger woman,” said cardiologist Holly Andersen of Weill Cornell Medical Center in New York.
One reason is that heart attacks look different in women. Men have “Hollywood heart attacks”: atherosclerotic plaque buildup in a major coronary artery leads to a blockage that triggers intense pain in the chest and down the left arm. Women can suffer that kind of heart attack, too, but often they experience something quite different: narrowing of the heart’s small arteries and blood vessels, causing the heart to not get enough blood. The symptoms are also different, typically extreme fatigue, shortness of breath, indigestion, and discomfort or pain in the neck, jaw, throat, upper abdomen, or back.
As a result, women suffering heart attacks often fail to recognize them, and EMS teams are 50 percent more likely to delay getting such women to the hospital, Andersen said. Once there, the Yentl Syndrome continues: ER personnel wait an average of 13 minutes longer to give a woman life-saving treatment (such as a stent) compared to a man, and are less likely to give her a blood test to diagnose a heart attack. Overall, women with chronic heart disease are less likely than men to be prescribed aspirin, ACE inhibitors, and beta-blockers—all shown to reduce the risk of fatal heart attacks. Women are less likely to be given stents or coronary artery bypass grafts, or, when discharged, to be given appropriate prescriptions or be sent to cardiac rehab. No wonder the CVD mortality rate in men has fallen more sharply than it has in women.
Another reason women are dying unnecessarily is that their heart disease is more difficult to diagnose. Those blockages of narrow coronary arteries—it’s called coronary microvascular disease—can be difficult to see in imaging tests, Andersen said, impeding accurate diagnosis: angiograms are simply better at detecting big atherosclerotic blockages in large arteries. A women is more likely to be told she is at low risk for heart disease despite the presence of coronary microvascular disease, another manifestation of Yentl Syndrome: if it doesn’t look like a man’s heart disease, which researchers have long viewed as the standard, don’t treat it as heart disease.
Although the sexes share many risk factors for heart disease—smoking, obesity, poor diet, inactivity—women have additional ones. Those 50 and younger who have already suffered one heart attack are more likely than comparable men to have myocardial ischemia, or reduced blood flow to the heart, after an emotional stressor, found the 2013 Myocardial Infarction and Mental Stress Study, led by epidemiologist Viola Vaccarino of Emory University. That may reflect women’s relative overload of poverty, depression and other sources of stress. And it may be one reason women younger than 50 are, compared to men of the same age, twice as likely to die if they have a heart attack despite having less severe heart disease: stress is constricting their (smaller-than-men’s) coronary arteries.
If some of this sounds speculative, that’s because it is: women’s heart disease has been a stepchild of scientific research for so long that there are more mysteries than explanations. Women have a higher rate of angina (chest pain) than men, notes Cedars-Sinai cardiologist C. Noel Bairey Merz, yet lower rates of obstructive coronary artery disease—supposedly the cause of angina. And despite less obstructive disease, women have a worse prognosis compared with men. Without more research on women’s heart health, we’ll never know why.
Although awareness of heart disease as a women’s issue has increased, it pales beside breast cancer. “Women don’t talk about their heart disease for fear they’ll be judged” as somehow responsible for it, Andersen said, perhaps because of smoking, an unhealthy diet, or lack of exercise. Breast cancer suffered a similar stigma until the 1970s, when First Lady Betty Ford went public about her double mastectomy. “Women’s heart disease needs its Betty Ford,” Andersen said.
Until then, it has pioneers like Andersen and Streisand.
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