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A Burning Problem

Heart disease affects women at all ages and is like in men the commonest cause of death. Despite this the perception is that coronary artery disease is a men’s disease. This notion largely stems from the fact the incidence of heart disease varies according to age. It is certainly lower in ages less than 50 years but increases steadily thereafter. Many women still don’t realise that after menopause their risk nearly equals that of men. In addition, younger ladies with several risk factors are prone to heart attacks even during their reproductive life and at times such episodes go un-noticed till a major complication has already arisen.

Polycystic Ovarian Disease and Cardio-Vascular Risk: Females with PCOS (polycystic ovarian syndrome) are prone to get cardio-vascular problems at younger ages. It is different from PCOD (Polycystic Ovarian Disease) which is common and is due to release of immature eggs in the ovaries leading to hormonal imbalances and swollen ovaries. These eggs produce more male hormones and leads to cyst formation. PCOS on the other hand is associated with weight gain, infertility, acne and menstrual irregularities. It in addition induces metabolic syndrome, which leads to heart disease, strokes and diabetes. It is also frequently associated with snoring and obstructive sleep apnoea (OSA). PCOS needs aggressive management consisting of cholesterol lowering, management of increased blood sugar and life style modification with exercise and heart healthy diet. PCOD however just needs counselling and adoption of healthy life style. In a study from Maharashtra, about 9.1% of menstruating women suffer from PCOS, while 22.5 % have PCOD. Both disorders can have infertility as a common feature. Although women have their first manifestation of involvement of the heart on an average 10 years after their male counterparts , but the death rates because of heart attacks are higher in women . This is in spite of improved medical facilities available for managing these patients. There are multiple reasons for this.

Non-Specific Symptoms at Presentation: Generally, ladies do not have the classical symptoms of a heart attack which are a hall mark in men. These tend to be vague like fatigue, shortness of breath, indigestion, back pain, light headedness and dizziness. These symptoms are often confused with other minor illnesses, often ignored and thus delayed in presenting to a physician or a cardiologist. Time is of utmost importance and if treatment is delayed by more than 6 to 12 hours permanent damage to the heart occurs with a high short-term mortality and those who survive get very weak hearts leading to heart failure. Even the electrocardiogram at times shows non-specific changes in females presenting with unstable angina and acute coronary symptoms and NSTEMI. Such changes can be present even without an acute cardiac problem in women, further complicating and delaying diagnosis even after presentation at a hospital.

Risk Factors for Heart Disease and their Effect (Women vs Men): High BP (Hypertension): It is more common in women than men after age of 45 years. It confers higher risk of getting a heart attack in females (four- fold) as compared to men (three- fold). It is more common in obese women and loosing more than 10 kgs of weight brings it down by around 8 mms Hg systolic. Poor control of BP is more common in females leading to higher chances of complications. Adult onset (Type 2) Diabetes: Diabetes is a stronger risk factor (at least 3-fold) for heart attacks in women than in men. It removes the protection in females of the oestrogens which are normally protective in pre-menopausal stage. Mortality in diabetic females with a heart attack is at least double than that in males. The chances of recurrence of a MI in women with diabetes is also double than that in men. Metabolic syndrome (Syndrome X): This is a conglomeration of hypertension, truncal obesity (excess body fat around the waist) high triglycerides and bad cholesterol. It is seen more often in South Asians especially women. These persons are more prone to get heart attacks and strokes and need an aggressive management of all the components of Syndrome X. Cholesterol and Triglycerides: Women show an increase in Triglycerides and bad cholesterol (LDL c) after menopause. Indian women have lower levels of good cholesterol (HDL c) than their western counterparts putting them at higher risk of coronary disease. An increase of triglycerides by more than 90 mgs/dl (beyond the upper normal limit 150 mg/dl) increases the risk of a heart attack by 75% as compared to 30% in men. It is often associated with hypothyroidism also. Obesity definitions in Indian women have been redefined. BMI (Body mass index ) of more than 25 is defined as the cut off for Indian females and BMI > 23 is defined as over-weight. BMI can be calculated by using a simple applications (meters and Kgs or pounds and feet)

Smoking Tobacco abuse because of its anti-oestrogenic effects increases the chance of getting a MI in pre-menopausal women. It is a strong risk factor in women than in men. Smoking in Indian women in general especially in urban areas is rather low (less than 4%), while in males as per the recent figures it is around 22%. However environmental tobacco smoke is an issue and vast number of ladies could be exposed to passive smoke and thus get accelerated fat depositions in arteries, increase coagulability of blood and events like heart attacks especially in those with multiple pre-existent risk factors. Psycho-Social Factors: An important reason for the delay in instituting treatment after a heart attack are the socio-demographic and psycho-social factors which are common in women, who give more priority to the health of their families at the cost of their health. It is not uncommon that females would wait for their husband or children to come back from work or educational institution and would avoid calling them urgently. These features of neglect are very common in our milieu and need to be addressed by the society in general. Poor educational status, depression, hostility in the family especially with the husband's parents and low social support are additional important risk factors. Unhealthy life style, low intake of fruits and vegetables which are protective risk factors are invariably additional features.

Conclusion: Heart diseases in women are often poorly recognized and is a major public health problem. Delayed recognition and treatment because of several factors lead to a high mortality. Post-menopausal protection by female hormones is lost. The clinical picture is often different and often non-specific as compared to their male counterparts. The risk factors like obesity, hypertension, diabetes and high lipid levels are very common yet often ignored. Health education and awareness campaigns are very important to mitigate this burning problem



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