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No gender bias

Although more women than men die of heart disease each year, many doctors still believe that women are, by and large, immune to cardiac problems. DR. RAJAGOPALAN RAVI clears the misconceptions.

Women do develop heart diseases, but at an older age.

DURING the 10 years that I spent in Chennai as a doctor, in the 1990's, I was appalled at the incidence of vascular and cardio-vascular disease among women. I was, and still am, intrigued at the ignorance of the general public and some physicians in recognising this. Time and again, the women had said that their physicians had not taken their complaints seriously. When they experienced chest pain, their physicians give them Valium (diazepam), but when their husbands experienced identical symptoms, the same physicians ordered cardiac workups.

This extract from Women and Heart Disease, a book by Edward B. Diethrich, MD, and Carol Cohen, illustrates the problems many women face in getting early and appropriate treatment. Although more women than men die of heart disease each year, many doctors still believe that heart disease strikes men.

This attitude is the unfortunate, and lingering, the result of an error in medical research that occurred almost 40 years ago. In the 1950s, the Framingham Heart Study, the most thorough and long lived investigation of heart disease ever undertaken, concluded that women were, by and large, immune to coronary and other vascular diseases. Time — and reanalysis of this data in the 1980s and 1990s — showed that this conclusion is wrong. Women do develop heart and vascular diseases, but at an older age than men. A woman's natural estrogen may help protect her against heart disease until after menopause.


It is a progressive disease process that starts in childhood. There is a filler, called plaque, made up of fats, calcium, and scar tissue. When fully developed, plaque can cause bleeding, clot formation, and distortion or rupture of a blood vessel. Plaque can also obstruct the flow of blood through the arteries, depriving the organs of oxygen. Heart attacks and strokes are the most sudden, and often fatal, signs of the disease.

Atherosclerotic heart disease has specific gender characteristics. By 50, women are 15 times less affected than men and have first signs and symptoms 10 years later than men. Women have more non-typical types of chest pain and more silent heart attacks than men. Once the disease is established, women are at a higher risk for heart attacks, and have a higher death rate after heart attacks, a higher incidence of stroke after a heart attack, and a higher incidence of a second heart attack.

  • Risk factors

    These are the same for both sexes but the impact varies by gender. They are elevated cholesterol, cigarette smoking, hypertension (high blood pressure and family history.

    The factors especially pertinent to women are obesity, diabetes mellitus and hormonal status. Other secondary risk factors include level of physical activity, personality and stress.


    The major blood fats are cholesterol, triglycerides, and phospholipids. In analysis, total cholesterol is broken down into high-density lipoprotein (HDL) or "good" cholesterol and low-density lipoprotein (LDL) or "bad" cholesterol.

    The National Cholesterol Education Programme recommends a total cholesterol level of less than 200. In general, the higher the cholesterol in blood, the higher the incidence of coronary heart disease. Triglycerides — which is directly related to body weight, level of exercise, and presence or absence of diabetes — are independent of cardiovascular risk.


    It increases heart rate and blood pressure, decreases the oxygen carrying capacity of blood, and increases poisonous gases and elements in blood such as carbon monoxide and carbon dioxide, causing constriction of the blood vessels. Smoking enhances the process of atherosclerosis by direct effect on the blood vessel wall. It also causes a greater tendency for the blood to clot.

    The prototype of a wrist watch shaped health care device called "LifeMinder" which is equipped with a pulsemeter, thermometer, galvanic skin reflex (GSR) and Bluetooth module.

    Unlike in the West, although the incidence of smoking among Indian women is less, there is an increase in this habit among young women. The Framingham study showed that a 55-year-old woman who smokes is in more danger of having a heart attack than a 55-year-old man.


    Women who have undetected or uncontrolled hypertension have five times the risk of sudden death, heart attack, and chest pain than women with normal blood pressure. One in four adults has hypertension — and half of them are women. Hypertension tends to run in families. It is aggravated by obesity and is associated with diabetes.


    Between the ages of 30 and 55, the more overweight a women is, the greater her risk of coronary and vascular disease. Women who have more weight around their hips are less likely to develop coronary heart disease than women whose weight is around their waists.


    Diabetic women have a higher death rate with coronary disease than diabetic men. Diabetes negates the benefit of estrogen in a premenopausal woman and doubles her cardiovascular risk.

    Hormonal status

    Signs of atherosclerotic cardiovascular disease appear about 10 years later in women than men. Estrogen produced by a woman's own body is thought to confer some protection, which is then lost gradually over the period of menopause.

    Early studies in the 1990s reported less heart disease in postmenopausal women who had estrogen replacement, but more recent studies have not shown a benefit, particularly in women with existing disease. Further evidence is needed to place healthy women on hormone replacement after menopause on a regular basis.

    Physical activity

    Regular exercise causes better circulation; increases muscle tone and weight control. Brisk walking, jogging, swimming, and bicycling are very good. Always check with your doctor before starting an exercise programme. Personality and stress

    A type `A' personality displays hostility, aggressiveness and anger while a type `B' personality is essentially laid-back, more open and flexible. Although all the original research was done on men, an association between type `A' behaviour pattern in women and cardiovascular disease has been shown. Working women who are married and have children have been found to have a higher incidence of cardiac disease.

    The future

    Now that the truth about women and heart disease is beginning to be understood, national associations in many countries have initiated education programmes for both physicians and the general public. Early diagnosis and control risk factors will go a long way in curbing the incidence of cardiovascular disease in women.

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