His and hers heart disease, Part 1

Published: February, 2010

Often said and probably true: matters of the heart affect men and women differently. And now medical research is confirming that, even in heart disease, while men and women share a lot of the same risk factors, there are some important differences:

Differences in risk

Smoking. A cigarette habit tops the list of lifestyle risk factors for men and women alike. But for women who take birth control pills, smoking increases the risk of heart attack and stroke even more.

Cholesterol. Levels of "bad" LDL cholesterol above 130 mg/dL are thought to signal even greater risk for men, while levels of "good" HDL cholesterol below 50 mg/dL are seen as greater warnings for women. High triglyceride levels (over 150 mg/dL) are also a more significant risk factor for women.

High blood pressure. Until age 45, a higher percentage of men than women have high blood pressure. During midlife women start gaining on them and by age 70, women, on average, have higher blood pressure than men do.

Inactivity. Only about 30% of Americans report getting any regular physical activity, but men tend to be more physically active than women, with the greatest disparities in the young (ages 18 to 30) and the old (65 and older).

Excess weight. Being heavy has long been thought to set one on the road to heart disease, but the location of the extra pounds may be more important than their number. Abdominal fat, which releases substances that interfere with insulin activity and promote the production of bad cholesterol, is more toxic than extra padding on the hips. Many health authorities consider a waist measurement of 35 inches or more for women and 40 inches or more for men a more precise indicator of heart disease risk than body mass index.

Diabetes. For both men and women, having diabetes more than doubles the risk of developing heart disease, but diabetes more than doubles the risk of a cardiac death in women, while raising it 60% in men.

Metabolic syndrome. Having any three of the five metabolic syndrome symptoms — abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and high blood sugar or insulin resistance — is riskier for women than for men, tripling the risk of a fatal heart attack and increasing the chance of developing diabetes 10-fold. The combination of a large waist and high triglycerides is especially toxic to women.

Psychosocial risk factors. The depth of the heart-head connection is still being plumbed, but there's enough evidence to implicate certain factors as contributors to heart disease, such as chronic stress, depression, and lack of social support. Neither sex fares better than the other over all, but research indicates that some factors predominate in men and others in women.

Stress is an equal-opportunity burden. Women are twice as likely to be depressed as men and to suffer more from emotional upheaval. In fact, the reported cases of "broken heart syndrome" — the sudden, but usually reversible, loss of heart function after an intense emotional experience — are almost exclusively in older women. Anger and hostility have long been cited as risk factors in men, but that's probably because most studies of heart disease excluded women. It's well documented that men are more likely to lack social support — especially after retirement — than are women.

Inflammation. Chronic inflammation is now thought to set the stage for the deposition of atherosclerotic plaque. Women have much higher rates of conditions that often lead to persistent, low-grade inflammation. For example, lupus more than doubles the risk of heart attack and stroke for women.

Heart disease differences

Women Men
Most important risk factors
  • Diabetes
  • Low HDL
  • High triglycerides
  • Waist measurement of 35 inches or more
  • Inflammatory disorders
  • High LDL
  • High blood pressure in young men
  • "Unconventional" symptoms — fatigue, malaise, shortness of breath, nausea, depression
  • First heart attack at average age 70 with higher fatality rate than men
  • More likely to have microvascular disease
  • Unstable angina warrants immediate attention
  • First heart attack at average age 65
Diagnostic procedures
  • ECG stress test less informative than nuclear test
  • When angiography shows no discrete lesions, IVUS and pressure flow studies also should be performed.
  • Stress tests more reliable than in women
  • Angiography more likely to be informative
  • Less likely to have bypass or angioplasty for coronary lesions
  • Longer hospital stays, higher complication rate
  • More likely to receive bypass surgery, angioplasty for coronary lesions
  • Shorter hospital stays
  • More likely to enter cardiac rehabilitation

In the upcoming His and hers heart disease, Part 2, we will discuss what women and men can do to reduce heart disease risk and how these approaches differ, why men and women experience different symptoms, and how physical differences between the sexes lead to diverse approaches to diagnosis and treatment. Stay tuned!

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