Women less likely to have heart disease and die from it than men

Women are less likely to develop heart disease and die from it than men, and those with no history of cardiovascular disease are more likely to use preventive medicines, control hypertension and to have quit smoking. 
 
Such are the findings of new research published in The Lancet.  
 
This is the first global, large-scale study to document the risk factors, use of treatment, incidence of heart attacks and strokes and mortality in people in the community, rather than only hospital patients. 
 
The information came from the Prospective Urban Rural Epidemiological (PURE) study, which recruited individuals aged 35–70 from urban and rural communities in 27 countries.  
 
More than 168,000 participants were then followed up prospectively for an average of 10 years for incident cardiovascular disease and death. 
 
‘There have been concerns that women with CVD [cardiovascular disease] are managed less aggressively than men, which could lead to women having poorer prognoses. Some have attributed this to a treatment bias against women,’ research fellow and first author Marjan Walli-Attaei said. 
 
‘In our global study we observed that while prevention strategies were used more often by women, invasive strategies such as percutaneous coronary intervention and coronary artery bypass surgery was used more often for men. 
 
‘But, overall, outcomes such as death or a new heart attack or stroke in women were lower than in men. This suggests there may be factors other than a treatment bias against women that contribute to the treatment differences.’ 
 
Co-author Professor Annika Rosengren said this study suggests the lower rates of coronary intervention in women are ‘appropriate’ as they have less extensive disease than men. 
 
Women’s Heart Clinic cardiologist and heart failure specialist Dr Monique Watts told newsGP she agrees that women with heart disease are not experiencing a treatment bias. 
 
Instead, she believes it is important to note that differences in presentation and pathophysiology leading to heart disease that may account for treatment differences between the genders. 
 
Dr Watts said men tend to present with occluded arteries and classic ST elevated myocardial infarctions (STEMI), whereas women tend to have more plaque erosion, and distal embolisation, which often leads to a more subtle presentation and causes more trouble with heart failure presentations in the longer term. 
 
‘We need to be mindful that the type of cardiac disease that affects women is often different to that that affects men,’ she said. 
 
‘Women don’t always present with an occluded artery, so it follows that we don’t always manage them as such. 
 
‘It doesn’t mean that we’re doing the right or the wrong thing by one sex or the other. 
 
‘We’ve got to treat the disease on its merits and appreciate that men’s cardiac disease and women’s cardiac disease is not the same.’ 
 
However, Dr Watts believes other results, such as the ‘perhaps surprise’ finding that women have fewer cardiac events and die less from heart disease than men, requires further analysis. 
 
‘I think we need to interpret that statement with caution,’ she said. 
 
For instance, Dr Watts said the mean age of the women in the study was 50 and that the follow-up period was only 10 years. 
 
‘That means the mean follow-up age was only 60, which is still quite young for a woman because their risk of coronary disease and cardiovascular mortality really doesn’t increase until post-menopause, so they’re about 10 years behind men,’ she said. 
 
Consequently, Dr Watts believes we need to be careful age-matching men and women when looking at cardiac outcomes. 
 
Another important factor to consider when analysing the study is that the risk factors did not include female-specific non-traditional issues, such as pre-eclampsia and pregnancy-related complications, Dr Watts said. 
 
Despite these issues, she still believes the research holds merit.
 
‘It’s a really interesting epidemiological piece and it throws us a lot to think about,’ Dr Watts said. 
 
One finding that particularly concerns Dr Watts is the differences noted in treatment between wealthier and poorer countries.  
 
The principal investigator of the PURE study, Professor Salim Yusuf said he also harbours significant concerns about this situation. 
 
‘The differences in outcomes in both women and men in low-income countries, where approximately 40% die within 30 days of a heart attack or stroke compared to the less than 10% in high-income countries, is matter of substantial concern,’ he said. 
 
‘This deserves major attention.’ 
 
While Dr Watts is cautious about the study’s findings, Australian statistics reflect a lower prevalence of heart disease in women than men. 
 
According to the Australian Institute of Health and Welfare (AIHW), the prevalence of coronary heart disease was around twice as high for men (3.8%) than women (1.9%) in 2017–18.
 
In 2016, the rates of acute coronary events in the form of a heart attack or unstable angina were also more than twice as high for men than women (468 and 215 per 100,000 population). 
 
Regardless of the difference in prevalence, Dr Watts said heart disease remains a significant issue in women that requires appropriate identification of disease and treatment.  
 
‘Women have a different presentation of heart disease than men and that’s why we need to be educating ourselves about it,’ she said. 
 
‘It is still a leading cause of death in Australian women.’

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