Heart Failure: How It Affects Women Differently

Young women can get heart failure too

Heart attacks worse in women

Diabetes poses a risk

Heart failure in women occurs differently, compared to men. It often goes undetected, is less understood and there are no life-saving drugs for it.

More women than men get a type of heart failure that is less understood, less detected and has no cure yet.

Called heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure, it happens when the heart pumps normally but fails to relax or fill properly because it gets stiff.

"It often goes undetected because doctors have traditionally looked at the heart’s pumping function rather than the way it relaxes," says Professor Carolyn Lam, Senior Consultant, Department of Cardiology, National Heart Centre Singapore (NHCS), and Professor, Duke-NUS Cardiovascular Academic Clinical Programme, both members of the SingHealth group.

Prof Lam said the weakening of the pumping function – called heart failure with reduced ejection fraction or systolic heart failure – which more men than women get, has been better studied, more widely recognised, and has an array of effective drugs to treat it.

But there are no life-saving drugs for HFpEF – the type that many women get – even today. “There are no drugs to improve survival rates for it. That was my inspiration for studying it,” said Prof Lam, who set up Women’s Heart Clinic at NHCS to offer women comprehensive services catering to their specific needs.

Young women can get heart failure too

“One of the big myths is that heart disease does not happen to younger women, or that it is not a big problem for women,” said Prof Lam.

She said cardiovascular disease – which includes heart disease and stroke – is also a women’s disease and accounts for one third of all female deaths.

Women any age can get it, although fewer young women than young men suffer from it. But even those who are young, lean and look fit may have high blood pressure or high cholesterol, which are the beginnings of cardiovascular disease.

The incidence rises with age, and especially after menopause in women. In old age, the scales are tipped against them. “We not only catch up with men after menopause, we overtake them,” said Prof Lam.

She is concerned that women, while dutifully going for regular pap smears and mammograms, neglect to test their heart. “Take care of your heart. That’s the best thing you can do, not just for yourself but for your loved ones.”

Without an effective drug, doctors can only treat the symptoms and risk factors, and advise patients on preventive lifestyle changes in diet, stress and exercise – the latter being one of the best ways to reduce stiffening of the heart.

“We can manage their risk factors and the haemodynamics. If they have fluid overload, for instance, we give them diuretics. There are things we can do, but there is no magic pill to improve survival.”

Prof Lam added that the problem has been there all along, but women were underrepresented in cardiovascular clinical trials for a long time. However, there are now specific efforts aimed at enrolling representative numbers of women and minorities in clinical trials.

There is a glimmer of hope down the road. A new therapy targeting HFpEF is being tested in ongoing global trials, said Prof Lam, who is on a global committee running these trials in the United States, Europe and Asia, including Singapore. “These trials are at the forefront of research into HFpEF, and there are new drugs on the horizon that may help.”

Heart attacks worse in women

When it comes to heart attacks, women may fare worse than men. A study carried out by NHCS on heart attacks across Singapore showed that women who suffered these were older, had more advanced disease, and experienced more complications than men, resulting in a greater than twofold increase in long-term risk of death compared to men.

Heart attacks in men usually involve big coronary arteries. This can be treated using stents to open up the arteries for blood flow to the heart to resume.

However, women’s heart attacks can be due to:

Big arteries, it can also involve
Small arteries (microvascular disease)

These blockages cannot be seen on an angiogram, and no stent is small enough to be put inside them.

Another cause of heart attacks in women is stress-induced cardiomyopathy (broken heart syndrome or Takotsubo cardiomyopathy). Here, severe stress triggers a massive heart attack even when there are no blockages in the arteries. More prone to this are older, post-menopausal women receiving severe bad news.

“It’s pure stress. The adrenalin and stress hormones can be so strong that they cause the arteries to constrict. When there’s no blood supply to the heart muscle, it results in a heart attack.”

Symptoms of this disease may also be different in women than in men. These include:

Central chest pain
Jaw or neck tightness
Back pain
Gastric pain

Diabetes poses a risk

Diabetes and smoking have a worse impact on women than men, despite both genders having the same risk factors.

“We did a study on heart attacks in Singapore, and were shocked that so many of the women were diabetic. And diabetic women with heart attacks did badly and were more likely than men to die. So diabetes is particularly bad in women and a strong risk factor,” said Prof Lam, who was the co-first author of the study with Dr Gao Fei, Principal Biostatistician, NHCS.

She said diabetic women can prevent cardiovascular disease by taking their medicines as prescribed, controlling their diet and sugar intake, and exercising. “The saving grace is that exercise seems to protect women more than it does men.”

US guidelines advise women to get at least 150 minutes of moderate exercise a week, but those with heart disease should talk to their doctors before starting an exercise regimen, or be supervised when they do so.

Prof Lam also advises women with a family history of heart disease and those who are at menopause – or reaching it – to go for check-ups to ensure their heart is in good order.

“These problems are best picked up and managed at an early stage. If you have high blood pressure, high cholesterol or diabetes in the early stage, you can’t feel it. You have to test for it,” said Prof Lam.

Ref: N18

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