Every 80 seconds a woman dies from a heart attack or stroke. Once thought to be predominantly a problem of men, coronary heart disease remains the leading cause of morbidity and mortality for women in the US and worldwide. Gender differences have been recognized, but knowledge gaps in gender differences regarding pathophysiology, clinical presentation, diagnosis, and optimal acute and chronic treatment strategies for heart attacks and co-existing or resulting complications such as heart failure are still existing.
Despite stunning improvements in cardiovascular mortality in women in the last two decades, the annual coronary heart disease mortality rate has remained greater for women than for men. The observed narrowing of outcomes between women and men has been attributed to improved therapy for established cardiovascular disease and to primary and secondary preventive interventions. However, women are less likely to receive evidence-based care and have worse outcomes than men and the observed decline in heart attack event rates or heart attack associated deaths in the US in women remains significant higher than in men.
In addition to this unresolved gender gap, we are now facing a new phenotype of premature coronary heart disease. Recent evidence has shown the emergence of unfavorable trends in coronary heart disease and related mortality in younger individuals 35-55 years of age worldwide over the last decade.
While a substantial decline in AMI event rates or MI deaths in the US in the past decade is absent in young women.
Over the last decade, hospitalizations for acute coronary syndrome in women 40-49 years of age have increased all over the world.
Similar, as observed in the general population, young women are more affected than their male counterparts with more hospitalization for heart attacks, 2-fold higher crude 30-day hospital readmissions rate, and higher mortality rates. These unfavorable age and sex-specific trends in coronary heart disease may be attributable to distinct risk factors and an emerging cardiovascular phenotype of increasing obesity, diabetes mellitus, and high fat-salt-sugar consumption rates among young individuals.
Regardless of age, more women than men will die within the first year after they had their first heart attack. Young women who have their first heart attack in their 40s do worse than their male counterparts.
The mechanisms, likely multi-factorial, contributing to excess risk and inferior health among young women remain unclear. Young women are thought to have a different underlying gender-specific biology and disease manifestation and distinctive psychosocial stressors that interfere with health behaviors and interact with biology.
Racially/ethnically diverse young women are more affected by coronary heart disease and have their first heart attack at an even younger age than white women.
Further, ethnically diverse women are less likely to be referred to coronary arteriogram present with their incident AMI at an even younger age than white women, have a higher mortality.
Short-comings in evidence-based care, referral for coronary angiogram, reperfusion strategies, admission to intensive care units are more pronounced in diverse than white non-Hispanic women.
Trends of worse risk profile and higher mortality among younger women persist with continuing reports of excess in-hospital and early and late mortality compared with men.
Clinical and autopsy data point to a different pathophysiology in young women.
From a pathophysiological perspective, there are predominantly 3 major vascular events underlying thrombotic coronary occlusions responsible for myocardial infarction: plaque rupture, plaque erosion, and calcific nodule. Plaque rupture is by far the most common cause, responsible in three quarter of men and in half of women with fatal myocardial infarction.
Autopsy studies have shown that particularly in young women, plaque erosions rather than ruptures are more common. This is of particular interest given that myocardial infarction without obstructive coronary heart disease is more common at younger ages and among women. Further, nonatherosclerotic etiologies of acute coronary syndrome, such as spontaneous coronary artery dissection frequently affects younger women and a recent statement by the American Heart Association provides an overview of the Current State of the Science of Spontaneous Coronary Artery Dissection.
As a physician-scientist who encounters frequently young adults with cardiovascular disease, I am curious what future studies will reveal about this new phenotype of premature coronary artery disease regarding pathophysiology, optimal primary prevention, diagnosis and treatment strategies.
I am also wondering, despite stunning improvements in cardiovascular mortality in women in the last two decades, if we will be able to close the disparity gap in young women with cardiovascular disease and if Cinderella will make it to the ball.
1) Acute Myocardial Infarction in Women. A Scientific Statement From the American Heart Association. Laxmi S. Mehta, Theresa M. Beckie, Holli A. DeVon, Cindy L. Grines, Harlan M. Krumholz, Michelle N. Johnson, Kathryn J. Lindley, Viola Vaccarino, Tracy Y. Wang, Karol E. Watson, Nanette K. Wenger and on behalf of the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Circulation. 2016;133:916-947
2) Ghazi L, Oparil S, Calhoun DA, Lin CP, Dudenbostel T. Distinctive Risk Factors and Phenotype of Younger Patients With Resistant Hypertension: Age Is Relevant. Hypertension. 2017 May;69(5):827-835. PMID: 28348010 PMCID: PMC5402755
3) Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ; American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018 Feb 22.
Tanja Dudenbostel is an Internist, Hypertension Specialist within Cardiology at the University of Alabama at Birmingham where I divide my time as an Assistant Professor between clinical research and seeing patients in cardiology.