At the Heart of It

Women’s heart issues are often misdiagnosed. The effects of Covid-19 now add another level of concern.

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More than 840,000 people in the U.S. have died from Covid since the start of the pandemic, with that number still climbing daily, and now the virus ranks as the third-leading cause of death in the country. Cancer is second, and as for the number-one killer in the U.S., data point to heart disease. And that’s for men and women, despite the perception of heart disease as a “man’s disease.”

In fact, heart disease has been the leading cause of death for both men and women in America since 1921, according to the Centers for Disease Control and Prevention (CDC), and the direct and indirect effects of Covid could prolong heart disease’s stay at the top spot for both sexes.

“There could be some long-term issues from Covid, but we don’t know yet,” says Dr. Steven Gubin, president of Stern Cardiovascular Foundation. “We’ve seen some patients with Covid who’ve had arrhythmia and myocarditis, which people can have when the heart muscle becomes weak.

“But I think the biggest thing about Covid is that a lot of people have ignored their health,” continues Gubin, who has been with Stern since 1991. “We were saying for a while we haven’t been seeing as many heart attacks, but that was because a lot of people were scared to go to the hospital because they were scared of getting Covid.” The same reasoning holds for missed doctor visits for managing or diagnosing chronic conditions, such as high blood pressure, diabetes, or high cholesterol, all of which without proper treatment can increase the risk of a heart attack or stroke.

“The most common symptom is chest discomfort, but women a lot of times have more atypical symptoms.” — Dr. Steven Gubin

This is especially concerning for women, considering that women were less likely to seek treatment and be treated for heart disease, even before the advent Covid.

“If a husband has any type of problems, like indigestion or shortness of breath, the wife’s always like, ‘You need to go to the emergency room,’” Gubin says. “And in the past, when women would have indigestion or other symptoms, a lot of times the husband would say it’s just stress.” Because of thinking like this, as the healthcare system catches up with Covid-induced delays, researchers fear that women — especially women of color and lower-income women, who already are at greater risk for cardiovascular disease — will disproportionately shoulder the burden of heart disease without proper intervention and prevention.

“The most common symptom is chest discomfort, but women a lot of times have more atypical symptoms and that’s why a lot of women will present to the emergency room much later than a man,” Gubin says. “They may just have some neck, jaw, shoulder, or upper back discomfort and think it’s more muscular or skeletal, but that could possibly be a sign of heart issues. They might not have any chest discomfort; they may just have shortness of breath or they may have an unusual amount of fatigue, some nausea, vomiting, or indigestion.”

Not recognizing these symptoms as being possible symptoms for heart disease and delaying treatment can have severe outcomes. “We always say time is muscle,” Gubin says. “If you’re having a heart attack and get to the hospital within three to six hours of having symptoms, we can take you to the cath [catheterization] lab and open the artery and do something for you.” That was part of the initial appeal of his job as a cardiologist. “When people have cardiac issues, a lot of times they come on rapidly, and what I like about cardiology is that you can help these people. You can make a difference quickly.

“But if you wait a day or two,” he warns, “you could already have some damage that is not reversible.” In turn, this leads to women having higher mortality and morbidity rates when it comes to heart disease.

Despite this information, Gubin says, “If you ask women what they’re most afraid of, they’ll say breast cancer.” According to the CDC, only 56 percent of women recognize that heart disease is the number-one killer of women. He attributes this to the lack of heart health education geared towards women, in comparison to the abundance of breast health education, but physicians like Gubin, who serves as president of the Mid-South/West Tennessee chapter of the American Heart Association (AHA), are hoping to spread awareness about the seriousness of heart health as not being a “man’s disease” by “going red for women” and empowering women with education and awareness about heart disease.

“In my family, my grandmother and her two sisters lived until their 80s and were very active, and their husbands lived until their 80s, 90s. The men didn’t have much heart disease, but all three of [the women] — my grandmother and her two sisters — had heart disease and I saw that growing up, and that made me interested in heart disease, too,” Gubin says. “So unlike most people, I didn’t realize that heart disease was really thought to be a man’s disease because when I was growing up I thought females had a lot of heart disease.”

The classic “elephant sitting on the chest” might not appear in women facing heart problems, but if a woman is walking and suddenly feels fatigued or nauseated, Dr. Gubin warns, that may be a symptom of heart disease.

But not all those in healthcare are brought up with this awareness, and so for this myth to be dispelled for patients, those in healthcare must also work towards confronting their own preconceptions — not only so they can better educate their patients but also so they can improve their standard of care. Historically, women have been excluded from clinical research, which has been the basis for treatment guidelines and programs, and even prediction models, which have been based on male risk factors, neglecting how polycystic ovary syndrome, premature menopause, pre-eclampsia, or preterm birth giving birth pre-term can lead to a higher risk for heart disease for women.

In 2018, Women’s Health Issues journal published data that showed women with heart attack symptoms were less likely to receive aspirin, be resuscitated, or be transported to the hospital in ambulances using lights and sirens than were men. Plus, only 40 percent of routine care includes a heart risk check, the Journal of the American College of Cardiology wrote in 2017. Women have also reported being told to lose weight more often than having their cardiovascular disease risk factors addressed, and 26 percent of women found the disease embarrassing, assuming risk is solely linked to weight.

All in all, according to the AHA, heart disease and stroke cause 1 in 3 deaths among women each year, and the number of these deaths has risen each year over the past decade. But 80 percent of cardiovascular disease can be prevented, according to the AHA. “I really started being interested in preventing people from having the initial event,” Gubin says. “And if people do have something happen to them, I’m very interested in doing everything possible to make sure they don’t have a secondary event.”

As a noninvasive cardiologist, Gubin spends most of his days overseeing diagnostic testing, reading cardiac ultrasounds, doing nuclear studies, performing stress tests, and the like, so he recognizes that the first step in prevention is recognizing the patient’s personal risks for heart disease. “Women do develop heart disease about 10 years later in life than men because they’re somewhat protected until they go through menopause,” he says. “We think that estrogen may have a protective effect, and when their estrogen levels go down once they go through menopause, their risk of heart disease goes up.”

Family history can also predict the likelihood of heart disease. “If a male in your family had heart disease at less than 55, or a female at less than 65, then that’s considered a definite risk factor,” Gubin says. He also adds that women who have diabetes are more likely to develop heart disease than men with diabetes. “And if a woman was pregnant and developed high blood pressure or diabetes during their pregnancy,” he continues, “these conditions have been shown to make you have a high risk for developing heart disease later in life.”

Stress, depression, smoking, inactivity, rheumatoid arthritis, or lupus can also increase the risk of heart disease for both men and women. “The most prevalent place of heart disease is here in the Mid-South because of our diet, obesity rates, smoking, diabetes, and hypertension,” Gubin says. “The most common heart disease is coronary heart disease,” he adds, which is associated with the aforementioned risks in the Mid-South.

“We always talk about what we call nonmodifiable risk factors — for instance, you can’t change your family history,” Gubin continues. “And then there are modifiable risk factors that you can take care of. If you’re a smoker, it’s never too late to quit. You should exercise regularly. It’s nice to maybe do some light weights and resistance training. Have a healthy diet, with more whole grains, a variety of fruits and vegetables, and avoid lots of salt. Manage stress. It’s nice to get seven to nine hours of sleep a night. If you’re a woman, you shouldn’t have more than one drink a day. If you’re a man, you shouldn’t have more than two. Take your medications.”

But Gubin’s best advice, he says, is “Be proactive. If you’re not feeling well, don’t blow it off.”