Cover Story
A Woman's Heart
New evidence and increasing awareness are making cardiologists—and hospitals and clinics—pay attention to the heart health of women.
By Susan Gaines
A Waterfall gurgles soothingly in a lobby adorned with the work of local female artists. Soothing music drifts from discretely placed speakers, lulling visitors into a relaxed state as they settle into comfortable chairs. Aromatic eye pillows, body wraps, relaxation CDs, and other soothing products for sale are on display. Nothing is white; the rooms are decorated in soothing stylish taupes and greens. You can practically feel your heart rate slow the moment you enter this inviting suite.
This is not a new-age spa. It is the North Memorial Women’s Heart Clinic at WestHealth in Plymouth, a timely response to a growing body of evidence—and awareness—that heart disease can look, act, and feel differently in women than in men. It is one of a growing number of clinics—there are about 40 nationwide—that have made an attempt to play catch-up in preventing, diagnosing, and treating a disease that experts now say is 15 percent more likely to kill a woman than a man.
Public Enemy No. 1
A recent media blitz, including the American Heart Association’s (AHA) Go Red campaign, has called attention to the fact that heart disease is the No. 1 killer of women. And according to the AHA, while fewer men are dying of the disease, the mortality rate for women has increased during the last two decades. The numbers for minority women are even worse: The age-adjusted rate of heart disease for African American women is 72 percent higher than the rate for white women. And African American women 55 to 64 years old are twice as likely as white women to have a heart attack and 35 percent more likely to suffer from coronary artery disease, according to WomenHeart, the National Coalition for Women with Heart Disease.
Reaching women with both the message—that they need to be concerned about heart disease—and appropriate care is a challenge that hospitals and health systems in Minnesota are taking on. At North Memorial, Mercy Hospital in Coon Rapids, the Mayo Clinic in Rochester, and elsewhere, physicians and other providers are looking for ways to capture a health care consumer market that has been overlooked.
Cynics might posit that comfortable furnishings and the sound of falling water in a clinic lobby are just examples of medicine using a retail-driven strategy to cater to an untapped market, to transform a patient group—albeit an underserved one—into a profit-generating group of health care consumers. But for cardiologist and North Memorial clinic director, Pam Paulsen, M.D., running a women’s heart clinic requires more than putting “women” in the name and offering eye pillows and relaxing music, along with cholesterol tests.
Paulsen and her team are trying to transform cardiology care for women. They’ve attempted to create a full-service clinic that brings together experts focused on what is unique about heart disease in women and offers all the latest technologies for detection and treatment in an environment designed to make women feel at ease.
Although atmosphere is one factor that separates a women’s heart clinic from a gender-neutral facility, the main difference between such clinics is that women’s heart clinics pay greater attention to gender. “We take gender into account in decisions about prevention, diagnosis, and treatment of heart disease,” says Sharonne Hayes, M.D., a cardiologist and director of the Women’s Heart Clinic at Mayo.
Women Are Not Small Men
Medicine is just beginning to understand the extent of the differences between men and women, according to Paulsen. “The fact is, hormonally we’re completely different creatures,” she says. In 1991, the Women’s Health Initiative shattered the idea that women and men are the same, when it launched a 15-year research program that examined the most common causes of death, disability, and poor quality of life in postmenopausal women. The program included a series of clinical trials, which involved more than 161,000 generally healthy postmenopausal women. As the data started to come in, many scientists, including Paulsen, realized how little they really knew about women and, in particular, the role of estrogen in cardiovascular disease.
“We had presumed that estrogen was protective for the heart,” says Paulsen. “It turned out we had completely inadequate data. We only had retrospective data that was probably looking at healthy women. When they actually did a randomized trial, it turned out that estrogen was not only not beneficial but probably harmful. It really made us wake up as scientists.”
Not only are women different hormonally, but women also have more co-morbid conditions, says Paulsen. Women are more likely to be obese and have high cholesterol, high blood pressure, and diabetes. And they are more likely to be smokers than men. Not only do they have more risk factors, but women seem to be more sensitive to those risks than men, says Paulsen. Women who smoke have their first heart attack about 19 years earlier than those who don’t, while men who smoke have their first heart attack about seven years earlier than those who don’t, she says. And women with diabetes are two to three times more likely to have heart attacks than men with diabetes, according to WomenHeart.
Unequal Treatment
At the same time, several studies indicate that women with heart disease are not treated as aggressively as men. “Women have higher mortality related to heart disease,” says Hayes. “But they are also undertreated. It’s hard to separate those two things.” She cites 2002 studies on acute coronary syndrome, in which women received the same early interventions as men. Investigators found the women did as well or better than their male counterparts when given the same treatments. “What that study suggested was, maybe women suffer more from undertreatment than men do,” Hayes says.
Women are also less likely than men to be referred for cardiac rehabilitation, according to University of Minnesota cardiologist Anne Taylor, M.D. They have more bone and joint disease, so rehabilitation is more difficult. “We need to make sure that physicians know that just because a woman is 75 and has osteoporosis, that doesn’t mean she shouldn’t exercise. Quite the contrary. It’s good for her heart and for her bones, provided there’s appropriate protection to vulnerable bones and joints,” says Taylor.
Symptoms differ in women as well. Women often have more subtle symptoms than men. Chest pain, for example, may not have the same correlations in men and women. “There’s plenty of data to show that while women might have typical chest pain, they may have more subtle symptoms as indicators for their coronary heart disease,” Taylor says. “We also know that women have very typical chest pain that’s not associated with heart disease.” She explains that a man with anginal pain in the middle of the chest has a 90 percent chance of having coronary disease, whereas a woman with that same symptom has only a 70 percent chance of having coronary disease. “Women have more chest pain, but it’s less specific.” Paulsen says that women may express feelings of discomfort, pressure, and heaviness rather than actual chest pain. And they may have less specific signs and symptoms, such as back pain, nausea, fatigue, and shortness of breath, to warn them about their heart.
Coronary artery disease also tends to be more diffuse in women than in men. Men are more likely to have a focal blockage in an artery. Women are more likely to have narrowing throughout the arteries, which is harder to detect with a stress test. Though there are gender differences in the accuracy of these tests, there are no “male” or “female” tests for heart disease. “You have to be looking for it in a different way,” Paulsen says. “Even the best noninvasive test misses one out of 10 people.”
Indeed, erroneous assumptions that have led to misdiagnoses and undertreatment have led many women patients to cry foul. A 2003 Mayo study co-authored by Hayes found that more than half of American women with heart disease were dissatisfied with their medical care. Although Hayes says one can’t extrapolate too much from the study, a subsequent analysis sponsored by the New York City-based Commonwealth Fund found similar results: Women are more likely to feel that they are not taken seriously, that their needs are not addressed, or that they are treated at least somewhat paternalistically. Their symptoms are more likely to be passed off as emotional or psychological, for example, in part because those symptoms may be different than men’s and, therefore, less recognizable.
It’s not that there has been a concerted effort to misdiagnose or undertreat women with heart disease, says Hayes. “Much of [women patients’] unhappiness may have been due to a really bad thing happening [the discovery of heart disease itself] that not much could have been done about. It’s topped off by a physician who may not have been sensitive to gender-related diagnostic and treatment issues or was dismissive or was not empathetic. The system isn’t quite prepared for women.”
A Woman’s Perspective
For many women, visiting a cardiologist can be an uncomfortable experience. In most clinics, one of the first things that happens to patients is that they are taken into a hall and made to step on a scale. Then they’re asked to undress, sit on a table, and wait in what’s often a cold exam room until the physician comes in. Having an EKG can be even more disconcerting. “Your heart is under your breast,” says Paulsen. “When you’re having an EKG, your breasts are exposed.”
Paulsen understands the importance of a respectful environment. At the North Memorial clinic, for example, women weigh in using a scale in a private bathroom. “They can just write down for us their weight,” she says. “We try to make people feel comfortable. They’re not undressed during their first contact with any of their providers.”
But effectively treating women with heart disease goes beyond comfort. “A good cardiologist can handle and will think of heart disease in women,” says Taylor, who sees both male and female heart patients in the University of Minnesota’s Cardiovascular Center. “[A women’s heart clinic] means that someone has really taken the time to understand what’s different about women with heart disease rather than what’s the same. You have to have a different index of suspicion. You have to ask the right questions.”
But sometimes even the best questions don’t have answers. “We’re getting clues that gender makes a difference, but we don’t have enough information,” says Hayes, who is pushing journal editors to require drug studies that do include women to report the data by gender. “If you’ve got 5,000 participants [in a study], of which 40 percent were women, but you lump them all together when reporting the results, you really have no idea whether there was a more beneficial effect in women. Was there no effect in women? Or did it actually harm one or the other, but you can’t tell because you lumped them? Now that more women are being included in trials, the next step is to report the sex-specific data.”
In other cases, the data simply raise more questions. “We have the raw data, but we don’t know why,” Hayes says, citing the example that women tend to have a higher risk than men for stroke when they take thrombolytics. Is that because we don’t dose them properly, she asks. Or is it because women have a higher prevalence of hypertension? We know that hypertensives have a higher risk of stroke when they receive thrombolytics. “Again, we don’t have enough information,” she says.
The first step in understanding the science seems to be to observe differences between men and women. “Then you have to sort through what the source of the differences is,” says Taylor.
The Social Advantage
Paulsen has observed that women are different not only hormonally and physiologically, but in the way they think and act. Women tend to be the caretakers, which may in part explain why men who have health problems have better outcomes. It’s often the man’s wife who drags him to the doctor and pulls out a list of questions and concerns about his health.
“But with women,” says Paulsen, “they don’t have anyone who’s making them come to the doctor’s office.”
In an emergency, men are more likely to call 911. Women, however, tend to delay their treatment, waiting until the end of the day and making sure their families are cared for before seeking care for themselves. This delay is one of the main reasons why more women than men die from their first heart attack.
But women have some social advantages over men. They tend seek support and advice. Paulsen jokes about how the waiting room in a men’s heart clinic would be silent, with the men sitting far away from each other. “They’re not going to admit to anyone that they’re even in that room, even though they’re all in there together,” she says. On the other hand, if a woman develops health problems, she immediately knows four or five people to call who can tell her who she should go see or what she should have done. “Women network,” says Paulsen. “Even in our women’s clinic, when they’re between parts of their stress test, in the little meditation room, women are exchanging recipes, talking to each other, comparing their stress tests.”
Despite their tendency to talk to other women, women are more likely to suffer from depression, which has been linked to poorer outcomes with heart disease, according to a study in the February 2004 issue of the Archives of Internal Medicine. The authors from the Albert Einstein College of Medicine in New York found that depressed women were 50 percent more likely to die within the four years of a heart disease–related event than women who were not depressed. “Depression is a huge barrier for healing,” says Hayes, who suspects depression also may exacerbate some of the risk factors for heart disease. “[If you’re depressed,] are you going to want to cook a healthy meal? Are you going to want to go out and walk for 30 minutes?”
An Ounce of Prevention
Gender-based medicine is part of a larger trend toward more personalized medicine. “So people have their personal risk factors addressed,” says Taylor. “They get treated with a combination of drugs that is most likely to be successful for them. The more we understand how we’re alike, the more we’ll understand how those small differences are meaningful. But we have a long way to go.”
Women’s heart clinics are a step in the right direction, says Taylor, although it is too soon to tell if they are making a measurable difference in women’s outcomes. But Paulsen is heartened by the stories she hears weekly of patients who were drawn to the idea of a women-centered heart clinic and began treatment for previously undetected heart disease. “When you hear those stories, it’s worth it,” says Paulsen, who adds that the next step is to survey patients a year from now and find out whether they are exercising more and eating right.
Technological advances in interventional cardiology coupled with the discovery that the heart can repair itself promise big improvements in mortality rates and quality of life for both men and women. Yet even in this high-tech world, prevention and early detection can make the biggest difference in outcomes. “If the first time that I’m seeing somebody is after a heart attack,” says Hayes, “then somewhere along the line, maybe there could have been something better done in terms of early detection or prevention, by the simple recognition that women get heart disease.” The doctors on the frontlines of women’s health care—ob/gyns, internists, and family practice physicians—can make the biggest difference.
“We’re playing catch up,” she says. “If we can move the medical profession so that all women are treated for their heart disease as promptly and as intensely as men, they would do as well or better. We could abandon the women’s heart clinic concept because we’d have reached our goal.” Until then, women’s heart clinics are keeping gender at the forefront of diagnosis and treatment, which Hayes hopes will not only improve care for women but push the entire science of cardiology into the future. MM
Susan Gaines is a freelance writer in Minneapolis.