Healthline
May 25, 2023
Written By: Meagan Drillinger
Fact Checked By: Jennifer Chesak, MSJ
Cardiovascular disease is the leading cause of death around the world, according to the World
Health Organization. While cardiovascular disease does not discriminate against gender, men
are more likely to have cardiovascular conditions than women.
But new research is showing that women may be more than twice as likely to die after a heart
attack than men.
“There are a lot of prior studies that have shown poor outcomes among women after heart
attacks, and we attributed those differences to the fact that we know women are older when
they present with heart attack and have more associated comorbidities,” said Dr. Anais
Hausvater, a cardiologist at NYU Langone Heart, specializing in women’s heart health who
was not involved in the study. “But in this study, they adjusted for those factors and compared
younger women. These findings tell us that there is more to it.”
The study, which was presented at Heart Failure 2023, a scientific congress of the European
Society of Cardiology, was a retrospective observational study. It included 884 patients with
an average age of 62 years. Twenty-seven percent were women.
As Hausvater indicated, previous studies have found that women with ST-elevation
myocardial infarction (STEMI) have a worse prognosis during their hospital stay compared to
men.
“A STEMI is the highest risk type of heart attack, where every minute counts. This is the type
of heart attack when you’re running the patient to the cardiac cath lab. Every minute of delay
can contribute to worse outcomes,” said Hausvater.
Those studies attributed those findings to older age and an increased number of comorbidities.
This study, however, compares short- and long-term outcomes after STEMI in women and
men and looked at whether the differences in gender were apparent in both premenopausal
women (55 years and under) and postmenopausal women (over 55).
The study followed patients admitted with STEMI and treated with PCI within 48 hours of
symptom onset over a five-year period. Adverse outcomes were defined as 30-day all-cause
mortality, five-year all-cause mortality, and five-year major adverse cardiovascular events
(MACE).
Of those studied, women had higher rates of high blood pressure, diabetes, and prior stroke.
Men were more likely to be smokers and have coronary artery disease.
The researchers compared the risk of adverse outcomes between women and men after
adjusting for other factors like diabetes, high cholesterol, hypertension, coronary artery
disease, heart failure, chronic kidney disease, peripheral artery disease, stroke, and family
history.
At the 30-day mark, 11.8 percent of women had died compared to 4.6 percent of men. At five
years, 32.1 percent of women had died versus 16.9 percent of men, and 34.2 percent of
women experienced MACE within five years, whereas 19.8 percent of men experienced
MACE.
“We know that there is some protective effect of estrogen and that postmenopausal women
tend to have higher risk,” said Hausvater. “But we’re seeing in the last 10 years heart attacks
among younger women, which is concerning. A lot of that likely has to do with the fact that
there are risk factors for heart disease unique among women that are under-recognized.”
Hausvater said that these potential risk factors can include premature menopause, pregnancy
complications, gestational hypertension, and delivering an infant that is premature.
“All of those increase risk but are not captured by doctors, and women don’t know that they
are risk factors for heart disease. We know from survey studies that women tend to be less
aware of their heart disease risk.”
According to the American Heart Association, women are frequently underrepresented in
research for cardiovascular disease, which can paint an incomplete picture when
understanding how the disease affects different genders.
According to the AHA, “Some risk factors for heart disease are specific to women, such as
risks related to menopause and treatments for breast cancer, and some, such as depression,
carry a different risk for cardiovascular disease in women than in men.”
“Psycho-social stress is another risk factor important for women and men, but especially
women,” said Hausvater. “Increased stress, depression, and anxiety is a factor of heart
disease that tends to affect women more.”
A lower recognition of symptoms of heart disease could be one of the contributing factors to
this study’s findings. Increasing women’s knowledge of heart disease symptoms could help
prevent adverse outcomes.
“Chest pain is the most common among men, but women tend to have multiple symptoms at
the same time. They may also have shortness of breath, fatigue, and nausea. But because
the symptoms are different, it can mean a woman delays in seeking out care. It can also delay
treatment when in the hospital.”
This study was an important step in understanding the unique risks of heart disease for
women. But more work is needed to understand the full picture.
“The other thing to consider is that we know a lot of the treatments we use for heart attacks,
like medication and other treatment options, have been studied in large trials predominantly
made up of men. Women are very much under-represented in all of these clinical trials. It’s
possible they are less effective in women, and we need proper representation of women in
these trials,” said Hausvater.
All of the traditional cardiac risk factors are equally important for women, such as a history of
diabetes, blood pressure, smoking, and family history. But for patients who are women, there
are additional specific risk factors.
“I would say both women and providers need to be aware of these risk factors to understand
their risk for heart disease,” said Hausvater.
“If I’m seeing a patient like this in the clinic, I would adjust my risk assessment, and it might
lower my threshold to start a cholesterol medicine. My recommendations for lifestyle
intervention would be much stricter if I felt they were at higher risk. It is important to understand
the risk.”
