Women and heart disease: It's not a democracy

 I once made a television anchor person very angry. She drove down to Glasgow, KY to interview me about "Women and heart disease." She placed the microphone near my face with a camera rolling and said, "Tell us how women are different when it comes to heart attack symptoms."

"Well, actually everyone should be considered 'different,' " I started.

She frowned. "Let me put it this way. Aren't women often misdiagnosed with other illnesses when really it's heart related?" she pressed.

"Yes, but so are men. I find that both genders have often been told they have an ulcer, GERD, musculoskeletal pain, so my point is—"

She interrupted me, turned to the camera guy and said "Hold up," a bit stressed by her deadline. Then, with dogged determination, she said, "I've really come down here to talk about women."

"Yes, I know," I insisted, "But I have to give you facts, and I'm getting to the facts."

She finally allowed me to explain myself and we got through the interview. I could tell she was a little miffed. Needless to say, I don't think I'll be hearing from her again anytime soon.

That interview isn't the first time I've made the point that a risk-factor profile should reign as king when one is querying a patient about cardiovascular symptoms. I've never bought into the gender-difference thing when it comes to heart-attack presentation. Women have jaw, above the belly button, arm, ear lobe, upper back and tooth pain just like men do. I always teach my students that unless you believe that everyone is "guilty until proven innocent" in the cardiovascular world, you can really mess up, so proceed as if you have to prove their safety.

I once saw a patient in the ER for a sore throat. Just because he was a smoker, I did an ECG (as an intern in medicine doing an ER rotation) and called straight away for a cardiology consult with STs up and a CPK already out the roof. This poor guy had tried to get some kind of a diagnosis for days, going from the dentist to his doctor's office and finally to the university ER. The same thing happens with all sectors of our patient population.

When it comes to gender differences, I do buy into the notion that women used to be discriminated against. They were often told "It's not your heart, honey, it's your nerves" on many occasions. The discrimination was real but now less prominent than it used to be. Despite this newfound awareness that everyone can have a unique presentation of angina despite gender, we must be careful to acknowledge that there are differences in outcomes. More than one study has demonstrated that small stature, geriatric status, and female gender are all risk factors for complications of bypass surgery, anticoagulant use, and invasive procedures. However, with a little caution and preparation, we can minimize these differences in outcomes.

Nothing has served as a greater equalizer for cardiovascular risk in the young female population than smoking and obesity. I think that generalist physicians are starting to figure this out. Any cardiologist worth his or her salt would never evaluate a smoking female with chest pain without at least a stress exam and if symptoms are really typical and unstable or unresponsive to medical therapy, a cath. It is here that another trend is emerging: women are still starting to smoke at an early age and are continuing to die at an alarming rate, unchecked. Until we attack this at the root, with public smoking bans, we will not be successful in saving this generation of young women from the ravages of tobacco addiction.

What about the adage that "women are more fatigued with heart disease"? The answer is that "women are more fatigued, period." We are still the gender who tries to "have it all" and in order to do it, we have to work full-time, devote time to our progeny, nurture our romantic relationships, and do the laundry. We are lucky if we have a spouse that shares equally (and quickly I must admit here in this piece that I definitely do—thank you Mr. Tony Shirley for my life as I know it). There is no doubt that if one stood on the front porch of the local Walmart and polled the women coming out the door, about 99% of them would describe themselves as "fatigued." Ask any of them, "How many hours per week do you put in?" and their answer would likely be prefaced by the question "Do you mean at work or at home?"

So, dispense with the gender issues so far as the pathology. Anyone and everyone are guilty of having heart trouble until they have been adequately stratified. Put on a wig. Have a sex change. Wear your husband's jockey shorts or your wife's underwear. I really don't care what you do. If you are postmenopausal, have a family history, engage in high risk behavior like smoking or sedentary life style, are diabetic, obese, have untreated hypertension, or can't quote me a good LDL, you are GUILTY of having heart trouble until proven otherwise in my book.

The world of cardiovascular disease is NOT a democracy.    

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