Can’t We Do More to Care for Women’s Hearts?

Communities and countries and ultimately the world are only as strong as the health of their women.

– Michelle Obama

Each year, National Women’s Health Week, which began on 8 May 2022, gives us as clinicians an opportunity to assess in detail our efforts to deliver the best health care to the female patients we serve. In the field of cardiology specifically, it is vital that we revisit this conversation time and again.

The reasons for this are plentiful, as many well-known statistics demonstrate: few women are aware of the risks of heart disease, yet it is the No. 1 killer in women, accounting for 1 in 3 deaths. Compared to men, an adverse cardiac event in a woman is more likely to be fatal, and the care she receives is more likely to be suboptimal.

A recent publication highlighted how young (ages 18-55) women and minorities presenting to an emergency department with chest pain face longer wait times than do men and non-minorities. And when women are seen by physicians, they are less likely to be triaged for emergent care, undergo standard cardiac testing, or be admitted for care or even to observation. Furthermore, when an acute MI is diagnosed, women are less likely than men to undergo revascularization.

Clearly, we can and must do more to address the worse downstream outcomes related to heart disease that women experience.

Thankfully, many leading clinical voices have been calling for change. Among the most prominent of these efforts are the 2021 ACC/AHA Chest Pain Guidelines led by Dr. Martha Gulati. The very first “Take-Home Message” in this remarkable document is that “Chest Pain means more than Pain in the Chest”, a reference to the varying ways that heart disease manifests. Combining the learnings from many (often women-led) publications from trials such as PROMISE, VIRGO, YOUNG-MI, and BARI 2D, the Chest Pain Guidelines state that “[w]omen commonly presented with chest pain symptoms similar to men but also had a greater prevalence of other symptoms such as palpitations, jaw and neck pain, as well as back pain.” Being conscious of differing clinical presentations is a crucial step toward more appropriate care for women.

Spelling out what we can do differently in heart care, Dr. Patricia Rodriguez Lozano and colleagues published a review, in line with the Chest Pain Guidelines, calling for change. While each modality has strengths and shortcomings, the authors explain that a coronary CTA-first pathway is the most appropriate choice for women suspected of having coronary artery disease (CAD).

Coronary CTA:

• Delivers high diagnostic accuracy equally for women and men, unlike functional stress testing which overcalls CAD 4x more often in women than in men
• Informs a woman’s risk of downstream clinical events more effectively than stress testing
• Identifies coronary plaque which carries higher risk in women, even when non-obstructive
• Enables non-invasive FFR_CT to identify lesion-specific physiology and help guide treatment with no sex disparity

Additionally, the CTA + FFR_CT pathway has identified fundamental differences in the coronary anatomy and physiology of women that can provide insight when treating patients with INOCA (ischemia with nonobstructive coronary artery disease), a common reality in women, which is associated with worse outcomes.

The field of cardiology is learning how to provide better, precision heart care to the women patients we serve, and a coronary CTA + FFR_CT pathway is increasingly important in this work. Each patient deserves our best care, and the clinical voices leading the way to improve women’s cardiovascular care are helping all of us to do more today and every day to come.

— A perspective from HeartFlow Chief Medical Officer, Campbell Rogers, MD
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