This article originally appeared in the March 2004 Harvard Heart Letter and is provided courtesy of Harvard Health Publications.

Gender bender

Awareness that heart disease affects women in different ways than men can help women get the treatments they need and pay more attention to prevention.

Why can’t a woman be more like a man?” mused Henry Higgins in My Fair Lady. Cardiologists sometimes wonder the same thing, or its reverse.

A woman’s heart isn’t merely a scaled-down version of a man’s. It is built on the same basic plan, to be sure, and pumps blood along the same circuit. Yet the hormones that bathe it, along with a host of other physiological, psychological, and social differences, lead to indisputable disparities in the way heart disease affects women and men.

Over the years, the ways in which heart disease develops and makes itself known in men have become the standards. That wasn’t acceptable when heart disease appeared to be a man’s disease. It is even less tolerable today, when heart disease affects more women than men, and is by far the leading cause of death for women.

A growing body of research is turning the spotlight on just how women experience heart disease, whether they get the same care as men, and how they respond to the disease and its treatments.

Some sex differences protect women against heart disease or help them weather it. Others put women at a disadvantage compared with men. Here are some of the key differences:

Estrogen. This hormone helps direct how women’s hearts and blood vessels develop and function. It is probably a prime reason why heart disease tends to appear a decade or so later in women than men. It also favorably affects HDL (good) cholesterol and LDL (bad) cholesterol.

Smaller coronary arteries. Women’s hearts, and the arteries that nourish them, tend to be smaller than men’s. The smaller the coronary arteries, the harder they are for surgeons to stitch together during coronary artery bypass surgery or to keep open after angioplasty.

Better communication. Women tend to be better than men at describing their symptoms and talking about their health. They are also more likely to seek help when medical problems arise.

More intricate social networks. The ties that bind can be good and bad for the heart. Strong relationships with family and friends seem to somehow protect against heart disease. Stressful ones, though, affect women more than men, as does social isolation. Women also tend to feel responsible for the care and well-being of others; depending on the situation, this can be good or bad for the heart. Family or caregiving obligations can strengthen the intimate social connections that bolster some women. They can also leave little time or energy for healthy eating and exercise and may generate unhealthy stress.

Call to action
Genes, hormones, lifestyle, stress, relationships, and culture make heart disease much more than a simple plumbing problem. Sex differences in each of these areas translate into significant variation in the appearance and impact of heart disease. Continuing research on the diversity of this disease should sound a wake-up call to women. The loudest and most urgent alarm warns that heart disease is a 50-50 flip of the coin, not a remote hazard. Softer but no less insistent signals alert women that they may need to be more assertive about heart attack symptoms and treatment, and may also need to pay more attention to prevention.

In 2004, the American Heart Association launched the “Go Red for Women” campaign to make women more aware that heart disease and stroke are by far the leading causes of death and disability in women. We’ll continue to do that, and more, in the pages of the Heart Letter.

Compared with men, women:    tend to have more “unusual” symptoms of a heart attack, such as lower back pain, nausea, and fatigue    take longer to get to the hospital when having chest pain or other signs of a heart attack    when having heart attack warning signs, are less likely to be admitted to the intensive or cardiac care unit and to get electrocardiograms, clot-busting drugs, or cardiac catheterization    are more likely to die from a heart attack or have another one after recovery    tend to be older and sicker (more diabetes, high blood pressure, other chronic conditions) when undergoing bypass surgery or angioplasty    are more likely to die in the hospital after bypass surgery or angioplasty    are less likely to have better quality of life after bypass surgery    are less likely to be directed to a cardiac rehabilitation program, or to finish one, after a heart attack    are less likely to get counseling about nutrition, exercise, and weight loss to prevent heart disease