Heart diseases among women are on the rise. It is time for all concerned to get really concerned
HEART diseases have become a serious global issue. Pakistan Cardiac Society, in collaboration with World Heart Federation (WHF) has been celebrating the World Heart Day for the past few years. The aim of this exercise is to create awareness on this very serious public health problem, both in the profession as well as the public.
This year the World Heart Day is being celebrated on 28th September. And the theme for this year is Heart Disease in Women.
Up until a few years back, it was thought that the female gender, compared to the male specie, was at low risk for developing Ischaemic Heart Disease (IHD), especially during their pre-menopausal age.
But later data suggested that this is definitely not the case. IHD is equally prevalent in females and their incidence overshoots the male gender with advancing age. Approximately one-third of all death’s in women in the Western world are attributed to IHD. The clinical spectrum of IHD is showing such dynamic changes in all sections of the population that it has become very difficult to make any dogmatic statements as to who is not at high risk.
Not only is IHD quiet common in the middle aged and elderly females, the pre-menopausal women are also at great risk from the disease. An increasing number of young females are being seen in the hospitals with various clinical manifestations of IHD as well as strokes.
Therefore focusing on heart disease in women is not only logical, but need of the hour. As we know most of the initial research and attention was focused on IHD, hypertension and strokes in men, assuming these were the diseases of male gender. However, the profession has now rightly realized that IHD does not spare any gender, ethnic or social class. Age limits have also fallen consistently, especially in the Third world, and more particularly in South Asia. Whereas dramatic decrease in cardiovascular mortality in men has been achieved in the past two decades, there has been little improvement in the case of women.
As mentioned above, most of the epidemiological and diagnostic studies in IHD were carried with a gender bias. Hence the exact pathophysiology of IHD in women is even less clearly understood than the men. However, a number of factors can be identified that may play an important role. Perhaps the most important risk factor for IHD in women is the misconception that IHD is not a women’s disease or that it is somehow less serious in women than in men.
The National Health Survey of Pakistan, conducted by PMRC in 1997 provided sound basis for considering some of the risks in our community as below.
* High prevalence of obesity and diabetes mellitus in Pakistani women, especially those from the urban middle-class.
* High prevalence of high blood pressure in urban obese females.
* Total lack of physical exercises and recreational activities.
* Use of contraceptive pills in some section of the population.
* Diet rich in salt, sugar and saturated fats. (The three ‘S’).
* Familial and ethnic predispositions etc.
* In addition Hormel status are equally powerful predictors of IHD in women.
The American Heart Association (AHA) awards twice the weight to diabetes mellitus in women, in estimating IHD risks. The diabetes mellitus in the case of women dramatically increases the mortality of myocardial infarction, than that compared to in man.
Though cigarette smoking is not common in our females, tobacco consumption through other means like pan, naswar, huqqa chillam, etc., is widely prevalent in our women in different parts of the country.
More than two dozen epidemiological studies have examined the role of oestrogen (the female hormone) in the primary prevention of IHD and there is enormous evidence to support its significant benefits. The largest of these studies being the Nurses Health Study.
A smaller number of studies have also evaluated the role of oestrogen in the secondary prevention of IHD. Thus Hormone Replacement Therapy (HRT) is being recommended for post menopausal women under proper medical supervision and in the absence of any contra-indication.
However, these recommendations have been recently subjected to certain criticism and they certainly have some limitations.
On one hand, the disease is on the rise in female population while on the other hand, there are serious diagnostic and therapeutic difficulties in their clinical evaluation and overall management.
Firstly, the presenting symptoms in women can often be so variable, vague and misleading that a definite clinical pattern as seen in the case of men cannot be described.
This makes their initial evaluation difficult. Features of anxiety and non-specific complaints are very common in females which often confuse’s their initial presentation.
Thus a number of definite suffers of IHD may be missed by family physicians and junior doctors due to their atypical symptoms. Likewise the diagnostic work up in the females has significant limitations. Exercise Tolerance Test (ETT) is a very basic and most cost-effective tool in the initial assessment of chest pain.
COMMONEST PRESENTATION OF IHD: This is not only difficult to perform but difficult to interpret and conclude in female patients. Even the interpretation of resting ECG has serious limitation due to the presence of non-specific ST-T changes. These changes are influenced by hyperventilation, obesity, mitral valve prolapse and hormones. The final diagnostic yield after coronary angiography (the gold-standard diagnostic test for obstructive IHD), is often a surprise in females. The angiographic findings, in women with established IHD do not differ from man. However, non-obstructive IHD in particular coronary vaso spastic syndromes are much more common in females.
In addition to IHD, women suffer from various other heart conditions. Rheumatic Heart Disease (RHD) almost eradicated from the West is still to be found in abundance in our population both rural as well as urban. RHD affects more women than men.
RHD specially affects the lower socio-economic sections of the population. It has serious medical and economic implications. It is an irony that while we have not been able to get rid of the diseases of poverty and primitive living, we have been invaded by the diseases of affluence and modern living.
Heart muscle disease, Cardiomyopathies (CMP), of unknown origin and following pregnancy, (Post Partum Cardiomyopathy) are another major groups of condition confined to the female gender that result in serious heart muscle dysfunction. This leads to heart failure and arrhythmias which carries very high morbidity and mortality. The condition is further aggravated with frequent pregnancies, so common in our lower social classes.
Heart diseases in women have great significance in our society because women as a whole are a neglected section of the population. Poverty illiteracy, compounded with erroneous local customs, taboos and flourishing quackery makes the overall situation dismal. Everyone is affected with these menaces. But somehow women sustain the major blow and therefore need more protection.
Functional disorders affecting heart indirectly are also very common in females. Anxiety and depression has become very common in the society due to stresses resulting from rising unemployment and socio-economic disparities. Women are hit the most.
This year, the World Heart day demands from us, as a community, to recognize the fact that heart diseases are equally, if not more, common in females and that women also deserve the same preventive and therapeutic measures as the male gender. Educating women on preventive aspects related to quit tobacco, diet, exercise and general hygiene can play vital role in reducing the incidence of these disease in our fixture generations. The costs of heart disease treatment is becoming a nightmare for the nations, including the most affluent. Prevention therefore remains the only hope for us. It is a matter of satisfaction that the Pakistan Cardiac Society is working hard to highlight this problem.
The Society in collaboration with other medical societies like Pakistan Hypertension League, Pakistan Diabetes Association, Cholesterol Awareness Society and Pakistan Medical Association can play important role in creating awareness through media, personal contacts and publications.
Working groups on various aspects of heart disease needs to be set for local data collection. Basic research in this field is mandatory to fight the menace. The government also has a serious responsibility to help in this matter by patronizing such moves and providing legislative support. Women play a very important role in our lives. They deserve a lot of respect and care for the promotion of a healthy community and to ensure a healthy future generation.
Heart diseases among women are on the rise. It is time for all concerned to get really concerned 
