Heart Disease in women: Recognizing and addressing genetic differences

By Jen Radin, US Health Care Advisory Sector leader, Deloitte and Touche LLP, and Heather Nelson, managing director of Life Sciences and Health Care, Deloitte Consulting LLP

Heart disease is the leading cause of death among men. But it is also the leading cause of death among women—more so than breast cancer, ovarian cancer, and other gender-specific diseases—and can affect women at any age.^¹ In Part 1 of this Q&A series, we spoke with Nina Goodheart, president the Structural Heart and Aortic Operating Unit at Medtronic. We discussed the importance of recognizing the biologic differences between men and women when diagnosing and treating heart disease (see What is being done to help keep women, and their hearts, healthy?).

Part 2: A conversation with cardiologists Stacey E. Rosen, MD, the executive director of the Katz Institute for Women’s Health, senior vice president of Women’s Health at Northwell Health, Partners Council professor of Women’s Health and professor of Cardiology at the Zucker School of Medicine, and volunteer President-elect of the American Heart Association; and Jennifer H. Mieres, MD, senior vice president for equity of care at Northwell, associate dean for Faculty Affairs and professor of Cardiology at the Zucker School of Medicine. This two-part series seeks to highlight heart-disease symptoms that are unique to women and explore what is being done to improve their health outcomes.

Here is an excerpt from our conversation with Drs. Mieres and Rosen:

Jen: The medical community generally recognizes that heart disease symptoms are often different for men and women, but women sometimes still wind up being misdiagnosed. Why is that? Is it changing?

Stacey: It's an important question, and it is at the core of the challenges we have been working to address over the last several decades. Health care—and medicine in general—was created with a male model. It was assumed that men and women are biologically the same.^² In medical school, Jennifer and I were taught that heart disease is a man's illness…so, we studied men. We studied what we call ‘typical presentations’ that were based on men. The thinking was that women only get heart disease when they are very old. Women who developed heart disease—in different ways and at different stages of life—didn't fit that paradigm. As a result, many women were developing heart disease but were not receiving the same type of preventive strategies and treatments that helped reduce death rates among men. As a result, women were having worse outcomes.^³ Eventually, [the medical community overall] began to view heart disease as an illness of both men and women. I think there is still research to be done, and more education is needed for women and the clinicians who treat them.

Jen: So, heart disease both presents and behaves differently in men and women because of biological differences?

Stacey: Yes. Optimizing heart health starts with biology. At a cellular level, men and women are different. We use the term, ‘Sex as a Biologic Variable’ or SABV. If you have XX chromosomes, your arteries, muscles, tendons…all of it, will behave differently than someone with XY chromosomes. Every cell in your body has a chromosomal makeup. Women also tend to take care of their family members first and often minimize their own health care needs.^⁴ The Go Red for Women movement focuses on educating and empowering women to expect better care and to not be minimized when they present with symptoms. It also supports critical research to better understand some conditions that are unique to women when it comes to heart disease.^⁵

Jen: A little more than half of US women recognize heart disease as their biggest health threat, according to the Centers for Disease Control and Prevention.^⁶ What are some ways to educate women about heart disease in women and how it's different from heart disease in men?

Stacey: Heart disease is predominantly preventable. Women often make the health care decisions for their families. If their families are healthier, communities can be healthier. Empowered, educated, and knowledgeable patients can be better prepared to recognize and prevent heart disease. Knowledge is power. Educating our primary care clinicians is also a priority, as they can begin prevention strategies earlier in a women’s life.

Jen: What is the role of the community in educating women about heart health?

Jennifer: The American Heart Association and the Go Red for Women Movement recognize the power of partnerships. I think they have been instrumental in educating the medical community to effectively diagnose and treat heart disease in women. The movement has helped empower women to take action to prevent heart disease. Between 80% and 90% of the women who joined the movement made lifestyle changes after having conversations with their doctors.^⁷ Getting women involved with community-based organizations can be important in customizing that message. Translating the science into actionable steps is a huge component.

Heather: Where you live can be more predictive of heart disease risk than genetics, according to the American Heart Association. A person’s ZIP code can influence their access to healthy food, exercise options, and overall quality of life.^⁸ How does that impact cardiovascular health?

Jennifer: Socioeconomic status is an essential determinant of cardiovascular health, encompassing economic, educational, and occupational status. It plays a fundamental role in shaping an individual's health trajectory. Not having optimal access to health care, a diet that does not include fruits and vegetables, and limited safe areas to walk outside can all impact the physiology that underlies the causes of heart disease. This is not seen as a soft science anymore. We have studied the biology and the adverse health effects of chronic stress and the social determinants of health. Food insecurities, where you live, and other socio-economic factors can all contribute to activating the inflammatory process. People who stay in this state of chronic stress have a higher risk of endothelial dysfunction, a higher incidence of stroke, and a greater risk of kidney disease, cardiovascular disease, and heart attacks. There is a connection between social determinants of health and cardiovascular disease.^⁹

Heather: What are some ways to reach more communities and engender trust?

Stacey: Information should come from a place of mutual respect. And when you partner with a community, you start by listening. You shouldn’t go into a community as the clinician who knows best. It is important to develop and sustain relationships of trust with the community. We also try to emphasize the power of storytelling. When a leader in the community talks about a personal experience with heart disease, people tend to listen.

Jen: You have both authored books and co-produced documentaries about women and heart disease. Do you think film is an effective way to get your message out?

Jennifer: Film can be a critical medium because it focuses on storytelling. In our first documentary, we found women and leaders across the country who were willing to tell their stories. The idea was to provide tools needed to take actionable steps. It discussed simple steps like stocking your refrigerator with heart-healthy choices so that you're not tempted by processed foods and sugar. It also explained the importance of moving every day…walking just 10 minutes a day can help reduce the risk of heart disease. The film also discussed ways to interact most effectively with a physician and care team. Creating a sustainable strategy for heart-healthy living is the ultimate mission.

Stacey: The theme of our most recent film is that optimizing health requires knowledgeable and open clinical expertise. We learned that people often feel disconnected when clinicians use medical jargon, talk down to them, don’t speak in their preferred language, or are not respectful of their culture and related eating habits. We also learned that brain health and heart health are uniquely attached. The same steps that help reduce the risk of heart disease can also help reduce certain forms of dementia and unhealthy aging. The film focuses on several women who were misdiagnosed or had their symptoms minimized. Some were led to believe that their symptoms were all in their head. Our hope was that the film would motivate viewers. The women in this film, and their families, are intended to be relatable and their stories can be impactful. We went to doctor's visits with them. We also interviewed some of the most illustrious cardiologists and cardiac scientists in the country.

Jen: More than 60 million women in the US live with some form of heart disease, and they often have different symptoms than men.^¹⁰ What can the health ecosystem do to move the needle?

Stacey: We have learned so much over decades, but we still have so much to do. The triumvirate of opportunities is in the academic and clinical health spaces. We need better science. We need better and more specific data. We need to fund it. We need to support it. And we need to share it. In the private sector, ensuring women’s health is a critical and financially important opportunity.

Jennifer: In terms of the education, it is important to use storytelling to demystify heart health and to support women as they work with their care team as partners in this journey. We also need more research into sleep and how it affects the cardiovascular system. More research is also needed to further understand the gender-specific aspects of cardiovascular diseases.

Jen: What would you say to biopharmaceutical companies to address the risk of heart disease in women?

Stacey: I would urge them to populate their clinical studies with enough women. Some cardiovascular diseases—pulmonary hypertension, for instance—are more prevalent in women. Data and findings should be separated for men versus women. They should also consider the hormonal times in women's lives. What is the relationship between heart disease risk and puberty, pregnancy, and menopause? Understanding hormones could be an important opportunity to improve science for pharmaceutical development and medical device development.

Conclusion:

Addressing heart disease in women involves a multifaceted approach that encompasses education, research, and community engagement. The historical bias in medical research toward male models has led to gaps in understanding and treating heart disease in women. By recognizing the biological differences between men and women, promoting community-based education, and fostering trust through respectful partnerships, the medical community can better diagnose, treat, and prevent heart disease in women and men.

The executive’s participation in this article is solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the companies mentioned, nor does Deloitte advocate or endorse the services or products provided by these companies.

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Endnotes:

^{¹ _{About women and heart disease, Centers for Disease Control and Prevention, May 15, 2024}}

^{² _{30-year cardiovascular outcomes in women, New England Journal of Medicine, August, 31, 2024}}

^{³ _{Recognizing, addressing unintended gender bias in patient care, Duke University Health System, January 14, 2020}}

^{⁴ _{Why US women skip or delay health care, Deloitte Center for Health Solutions, September 10, 2024}}

^{⁵ _{Go Red for Women, American Heart Association}}

^{⁶ _{About women and heart disease, Centers for Disease Control and Prevention, May 15, 2024}}

^{⁷ _{Go Red for Women, American Heart Association}}

^{⁸ _{Your home – and where it's located – may affect your health, American Heart Association, August 1, 2023}}

^{⁹ _{Association of psychosocial stress with risk of acute stroke, Journal of American Medicine, December 9, 2022}}

^{¹⁰ _{About women and heart disease, Centers for Disease Control and Prevention, May 15, 2024}}

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