Heart attacks in women

Why are women particularly at risk?

A heart attack (myocardial infarction) is caused by atherosclerosis of the coronary arteries and is one of the most common causes of death in developed countries. Men are affected more frequently than women, and the condition is also regarded as a typically male disease. However, an increasing number of women are also affected by myocardial infarction. They are more likely to die within the first year following a heart attack, and they also have a poorer prognosis following coronary bypass surgery. This is partly due to gender-specific differences, which have both biological and psychosocial causes. Statistically speaking, the condition tends to occur later in women – namely, only around ten years after the menopause – and there are numerous psychosocial reasons why women often do not receive timely treatment. Different patterns of distribution are also generally evident in risk profiles and in the presence of comorbidities. Furthermore, there are differences in symptoms, early diagnosis, acute care and treatment. Scientific studies have also shown that recommendations regarding drug therapy and the restoration of blood flow in women with acute heart attacks are less frequently followed. Early detection is also more difficult in women, and various diagnostic measures prove less sensitive in women than in men.

Causes and risk factors

The causes of a myocardial infarction in women are, in some respects, no different from those in men, but in other respects they are very different indeed. For example, there are biological causes that mean women suffer heart attacks later in life than men. Before the menopause, they benefit from the protective effect of oestrogen, which, amongst other things, influences blood clotting and has a vasodilatory effect on the blood vessels. In this way, oestrogen can help protect against the formation of atherosclerotic plaques and thus also safeguard the heart against coronary heart disease. However, this protection wanes after the menopause, and the risk of suffering a heart attack then rises more rapidly in women than in men. Furthermore, numerous psychosocial factors are now known to exist which can result in women, for example, not receiving timely treatment. Studies have shown, for instance, that women often hesitate for too long before calling the emergency services and are also frequently very reluctant or describe their symptoms in ‘atypical’ terms. This, in turn, can lead to doctors making misdiagnoses because they suspect a different illness is behind the symptoms described. Other causes of a myocardial infarction include:

• Obesity
• Smoking
• High blood pressure
• Elevated blood lipid levels
• high blood sugar
• psychosocial stress
• Stress
• Lack of exercise
• unhealthy diet

Symptoms of a heart attack in women

According to the World Health Organisation (WHO), a myocardial infarction is defined as occurring when: – biomarkers of heart muscle damage are detectable – symptoms of angina pectoris are also present (exception: silent heart attacks) – ECG changes occur or there are corresponding angiographic findings. – The main symptom is chest pain: This is a sudden, severe pain behind the breastbone or, less commonly, in the upper abdomen, which is more intense and persistent than that experienced during an angina pectoris attack and which is not relieved by physical rest or the administration of nitroglycerine preparations. The pain may radiate to the arms, the navel region, the back, the neck or the lower jaw, and is often accompanied by a fear of death. However, around 20 to 30 per cent of myocardial infarctions present without pain. These are referred to as silent infarcts. They occur primarily in patients with diabetes mellitus or in very elderly patients whose perception of pain is reduced due to nerve damage. Please note: in women, chest pain is often less pronounced than in men, in whom this symptom usually manifests very clearly. Women, on the other hand, frequently suffer from:

• stomach problems, nausea and vomiting
• pain in the upper abdomen
• non-specific back pain
• Shortness of breath or difficulty breathing
• Exhaustion, weakness and sleep disturbances

The dangerous thing about this is that these symptoms are often regarded as harmless, and a heart attack does not always spring to mind straight away.

Diagnosis of a myocardial infarction

To diagnose a myocardial infarction, an ECG is carried out, which enables the doctor to determine whether a heart attack has occurred. The condition can also be detected through a blood test. Following a heart attack, patients show elevated levels of troponin and creatine kinase. A heart ultrasound (echocardiography) allows the function of the heart chambers to be assessed and reveals any abnormalities in the way the heart contracts. Although the symptoms of a myocardial infarction often manifest differently in women than in men, there are no differences in terms of diagnostic procedures.

Heart attack: Treatment 

A heart attack is a medical emergency, and the first steps involve administering oxygen and painkillers. The next step is to attempt to remove the blood clot causing the blockage. Various treatment options are available for this: Medication: A fibrinolytic agent or antiplatelet medication is administered immediately. These are designed to inhibit blood clotting and the aggregation of blood platelets. Cardiac catheterisation: This involves inserting a thin, flexible tube through a puncture in the groin or arm, guiding it through the blood vessels to the heart. At the upper end of the catheter is a very small balloon, which is inflated as soon as the catheter encounters the clot (balloon dilatation). If rapid catheter treatment is not possible, thrombolysis using medication is carried out. Stent: This is a tubular mesh scaffold that is expanded within the blood vessel and provides permanent support to the narrowed section, ensuring that the blood vessel remains open even after the catheter procedure. Bypass surgery: This is used when several coronary arteries are narrowed. It involves a minimally invasive procedure to restore the blood supply to the heart by diverting the blood flow. The operation is carried out under general anaesthesia and takes several hours.

Prevention

It is important that every woman is mindful of the symptoms of cardiovascular disease and takes any unusual pain seriously. One way to recognise a heart attack early on is the so-called NAN rule: if unexplained pain occurs in the area between the nose, arm and navel (NAN) and lasts for more than 15 minutes, women should call the emergency services immediately. It is also important to be aware of risk factors and to take preventative measures. This applies to women before the menopause as well, particularly if they lead an unhealthy lifestyle or have a family history of the condition. Take steps to manage the following risk factors:

• Being overweight
• Smoking
• High blood pressure
• Elevated blood lipid levels
• High blood sugar
• psychosocial stress
• Stress
• Lack of exercise
• unhealthy diet

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