Women and heart disease:

After the age of 55, women have just as many heart attacks as men do

surprising statistics:

Many think of heart disease as a man's disease. Five times as many women die from heart disease than from breast cancer. Women 55 and older have the same lifetime risk of cardiovascular disease as men (1). One gender difference is that for their first event, women tend to have slightly more strokes, whereas men tend to have more coronary heart disease (1).

Of heart attack survivors 45 and older, 1 of 4 women (23%) and 1 of 5 men (18%) of men will die within 1 year (2).

Within 5 years after surviving a heart attack at 45 or older, 1 of 2 women (47%) and 1 of 3 men (36%) will die (2).

Why are heart attacks more dangerous for women?

Women, who have smaller coronary arteries, may experience atypical symptoms of coronary disease more often than men. By atypical symptoms, we mean unusual types of chest pain or fatigue or shortness of breath or nausea, compared to the more typical left-sided crushing chest pain men have.

Women, who tend to have heart attacks older, are more likely than men to die within the first few weeks after a heart attack (3). Additionally, if heart symptoms are unusual, women may suffer from delayed diagnosis.

HeartDiseaseAndWomen.jpg

These factors may be a sign of increased risk:

  • A past history of miscarriages

  • Polycystic ovary syndrome

  • Past history of pre-eclampsia

  • Frequent menopausal hot flashes

  • Gestational diabetes

  • Past history of breast cancer

  • Mammogram calcium deposits in breast arteries (see below)

  • Caring for a spouse with cancer (4)

  • Dining out

  • Working long hours

  • Divorce increases risk, especially for women (5)

women and STATIN drugs:

Women have been under-represented in many statin trials. A recently published study showed that women benefit from taking statins just as much as men do. For every 40 mg/dl reduction in LDL, women and men get a 20% reduction in the risk of major CV events (6).

mammograms and heart disease:

Mammogram on the left, with orange arrows highlighting breast artery calcification, the red arrow highlighting a lesion which when biopsied, proved to be cancer. Heart coronary calcium scan is on the right, with orange arrows highlighting coronary artery calcium deposits. Picture from an excellent review article of the currently available scientific studies on breast calcium and heart artery calcium. © 2017 Wiley Periodicals, Inc. (see ref 9 below)

Mammogram on the left, with orange arrows highlighting breast artery calcification, the red arrow highlighting a lesion which when biopsied, proved to be cancer. Heart coronary calcium scan is on the right, with orange arrows highlighting coronary artery calcium deposits. Picture from an excellent review article of the currently available scientific studies on breast calcium and heart artery calcium. © 2017 Wiley Periodicals, Inc. (see ref 9 below)

In a study published in 2011, a woman's risk of developing coronary heart disease within 5 years was 3.5x higher in women who had calcium in breast arteries seen on a mammogram compared to woman without calcification. Other risk factors like hypertension (2.8x), high cholesterol (2.4x) and family history (1.7x) were not as strongly predictive as mammogram artery calcification (7). In a more recent study, 43% of women were found to have calcium in the breast arteries on mammography, and 67% of those also had calcium in the coronary arteries on CT scan (8). That's a picture of calcium in the heart arteries. Calcium in arteries shows up as white spots. Normal arteries have no calcium.

Currently there are no established guidelines for reporting artery calcification by radiologists who read mammograms. Guidelines will be necessary, because some breast arteries have more and some have less. If Dr. Margolies (8) method for quantifying breast artery calcification is validated in larger studies, then guidelines will be possible. And the published studies (9) are much to small for any scientist to recommend using mammograms to screen for heart disease.

So...in this moment in time between small studies that look promising and the larger studies that haven’t been done yet: Here's an idea: When you get your mammogram, ask the technician to write this note to the reading radiologist: "Please report any calcium deposits you see in my breast arteries."

If your mammogram shows calcium deposits in the breast arteries, what should you do? First, talk to your doctor. Secondly, consider getting a heart calcium scan to determine whether there is also calcium in your heart arteries. Calcium in arteries is not normal. It is a sign of inflammation and artery disease. We believe that it should be rigorously evaluated.

References:

  1. This prospective population-based study in the Netherlands followed 8400 adults for 21 years who were 55 and older with no baseline CV disease: Leening, et al. Sex differences in lifetime risk and first manifestation of cardiovascular disease: Prospective population based cohort study. BMJ 2014 Nov 17;349:g5992

  2. Benjamin, EJ, et al, Heart Attack and Stroke Statistics-2017 update. Circulation 2017 Mar 7; 135(10): e146-e603.

  3. Roger VL, et al. Heart disease and stroke statistics-2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-220.

  4. Caring for a spouse with cancer is associated with a 15% risk of heart attack and a 25% risk of stroke. Jianguang Ji, et al. Increased risks of coronary heart disease and stroke among caregivers of cancer patients. Circulation 2012; 125(14):1742-1747

  5. One divorce increases a woman’s heart attack risk by 30%. Remarrying increases risk by 40%. Having a second divorce doubles the risk. Dupre, et al. Association between divorce and risks for acute myocardial infarction, Circulation: Cardiovascular quality and outcomes. doi: 10.1161/circoutcomes.114.001291

  6. Cholesterol Treatment Trialists' Collaberation. Efficacy and safety of LDL-lowering therapy among men and women: Meta-analysis of individual data from 174,000 participants in 27 randomized trials. Lancet 2015 Jan 8. (epub: http://dx.doi.org/10.1016/S0140-6736(14)6138-4

  7. Schnatz PF et al. The association of breast arterial calcification and coronary heart disease. Obstet Gynecol 2011 Feb; 117:233

  8. Margolies, et al, Digital Mammography and Screening for Coronary Artery Disease, J Am Coll Cardiol Img. 2016;(9:350–60):. doi:10.1016/j.jcmg.2015.10.022

  9. Angela J. Ryan, et al, Breast arterial calcification association with coronary artery calcium scoring and implications for cardiovascular risk assessment in women. Clinical Cardiology. 2017;40:648–653 DOI: 10.1002/clc.22702