The Mona Lisa by Leonardo da Vinci is perhaps the best-known and most famous work of art in the world.  It was painted in 1503 and still draws huge crowds to its home in the Louvre in Paris.  The Mona Lisa’s beauty stems from her eyes (which appear to follow the observer), her stately posture and her smile, about which many books have been written.  Most importantly, the Mona Lisa depicts the Renaissance ideal of womanhood. While the artist has been successful at portraying the ideal woman, cardiologists are less than ideal in diagnosing and treating heart disease in women. Cardiovascular disease is still the leading cause of death in women in the western world. Despite this, women are under-represented in cardiovascular research and women are less likely than men to be tested for heart disease and to receive appropriate heart treatments.

Women are built differently from men, especially when it comes to matters of the heart. Women usually present with heart disease, specifically blockages in the heart arteries, about ten years later than men. This is due to the fact that women are protected by their hormones until menopause and develop high blood pressure, diabetes, obesity and high cholesterol later in life than men. Men with blockages in the heart arteries present with classic, exertional chest pain.  Women, especially those older than 65, are less likely to have chest pain, but may have jaw pain, neck pain, shoulder pain, left arm pain, ear pain or tooth pain. Women will have shortness of breath with exertion or fatigue with exertion. Therefore, symptoms must be evaluated very carefully when a woman sees her cardiologist. In addition, cardiac testing is better suited for men than women. The exercise stress test is able to identify heart artery disease in men about 70% of the time, while in women it decreases to about 60%.  Even combining the stress test with nuclear images of the blood flow to the heart is less accurate in women compared to men.  In addition, women are much more likely than men to have false positive tests (an abnormal test but without blockages on the gold standard test for heart artery disease, the cardiac catherization) for both stress and nuclear stress testing. Overall, the lower ability of stress testing to pick out disease coupled with the higher false positive rate, makes noninvasive cardiac testing in women less accurate.

Even when women have chest pain the characteristics are different than men. In women who have chest pain, many (approximately 50%) will have no significant blockage after heart catheterization. Women with exertional chest pain, but without blockages in the major heart arteries, are felt to have microvascular angina. Microvascular angina is due to abnormal reactions of the small heart arteries to various stimuli (for example, anxiety). Much less is known about treating this entity, despite years of research. What is known is that microvascular angina is very disabling and women continue to have chest pain, continue to have heart testing and continue to be admitted to the hospital because of it. So, women with chest pain despite a normal heart catheterization should not be ignored and medications should continue to be adjusted to relieve symptoms.

Heart disease clearly is not a “man’s disease” as cardiac disease causes the death of one woman per minute in the US.  Risk factors, such as obesity and high blood pressure, are increasing for women, especially as they become older.  Women have a higher risk of dying from a heart attack than men, due to the fact that they are older, have other complicating diseases (for example diabetes) and they present with their heart disease later in its course due to vague symptoms.  Despite this, the picture has become rosier in recent years.  Cardiac disease in women has decreased significantly since 1980 due to improved risk factor treatment, major trials such as the Women’s Health Initiative and public heath campaigns by the American Heart Association (and others) raising awareness of heart disease in women. Hopefully this trend continues, the portrait becomes more ideal and we can all smile a bit more about the positive gains in women’s heart disease.