In Pakistan we have a high incident of rheumatic heart disease (RHD) which especially affects women belonging to the lower socioeconomic stratum

Heart disease is rampant in Pakistan as in the rest of the developed and developing world. Previously it was believed that heart disease did not affect women as badly as it affected men. But studies have now proved that heart disease does not discriminate between genders, particularly after one turns 40.

The phrase ‘heart disease’ generally means ischaemic heart disease, which claims maximum mortality. However, in Pakistan we also have a tremendous amount of rheumatic heart disease (RHD) which especially affects women belonging to the lower socio-economic stratum. Rheumatic heart disease generally implies chronic conditions which result in a lot of disability and may also cause death. RHD has virtually disappeared from the western world.

Ischemic heart disease is the leading cause of death in both men and women. Also, there exist some features that are generally found in women making the diagnosis and management somewhat difficult. Apart from other usual factors, women in our society are often neglected and are not given equal importance. This is perhaps due to their economic dependence on men and the prevalent social taboos. Therefore, international agencies are especially focusing on women’s health issues in the developing world.

Women of all ages who suffer heart attacks are more likely to die than men. According to one study that adjusted for age, size and other factors, the death risk for women was 1.7 times higher than the risk that men have.

Clustering of coronary risk factors is common among women. Though South Asians as a community are known to have low HDL (good cholesterol) and high triglyceride (T.G) in addition to raised LDL (bad cholesterol) it is more common in female gender.

In the past decade, heart attack survival has improved significantly thanks to thrombolytics (clot-buster medications). But how often do women get these drugs? In one study, of 1,078 subjects screened for clout-buster eligibility, 39 per cent of the women were too old, 59 per cent had nondiagnostic electrocardiograms and 30 per cent came to hospital too late. Overall, only 16 per cent of the women screened were eligible for thrombolytics, compared with 25 per cent of men. Of those eligible women, 55 per cent received medicine, compared with 78 per cent men. The situation in Pakistan is even worse.

One way women can get the benefit of clout-busting drugs is to get to the hospital quickly. Studies have shown that women with chest pain wait too long before heading to the hospital. But does clot-busting work better in men than in women?

Studies have found that women’s survival improves with these drugs, but that’s not the case with men, and it is not known why.

EXERCISE TOLERANCE TESTS (ETT): This is a most commonly used heart test. Treadmills as a screening tool for diagnosing heart diseases mostly prove accurate for men but not so for women. In one study comparing the accuracy of treadmill tests in women and men, misleading treadmill results occurred in 35 per cent of the women studied. When combined with nuclear imaging, using thallium, the accuracy rate improved in women.

Abnormal treadmill tests have been related to phases of menstrual cycle and oral contraceptive use, implicating sex hormones as a factor. It may be estrogen’s effect on the heart muscle.

Another explanation for the variations in test results may be the effect of ctecholamnes (stress hormones i.e. adrenaline) on the vasomotor tone and the higher prevalence of mistral valve prolapse among women.

PHARMACOLOGIC STRESS TESTS: Induced by drugs rather than by exercise, these may actually be preferable to women since many elderly women cannot endure the physical demands of treadmill-testing and suboptimal heart rates are achieved.

ANGIOGRAPHY: A dye study using the cardiac catheterisation procedure with X-rays to view blocked or narrowed vessels. It remains the gold standard for diagnosing coronary artery diseases, but unlike nuclear imaging, it has its risks. Women with heart attacks or unstable or stable angina are less likely to be referred for angiography. It is debatable whether this reflects the under-use of angiography in women or overuse in men.

SURGICIAL INTERVENTION: When it comes to balloon angioplasty, women should do as well as men but they usually don’t. Their complication rates are higher than men (the age adjusted heart rate of women is four times than that of men, according to the American Heart Association).

Though women undergoing angioplasty are generally older than men and more likely to have other conditions like diabetes and high blood pressure, gender remained an independent predictor of risk, according to a study by the National Heart, Lung and Blood Institute. The track record on bypass surgery isn’t any more encouraging. More women die from bypass than men and that’s not because they are older at the time of surgery. In one study of 6,630 subjects, the death rate for women was significantly higher in all age groups. In the 50 to 59 group, it was three women for every man. One possible explanation is women’s smaller size. In another study it was found that the death rates for women and men were nearly three to one.

Besides operative complication and less favourable results women often don’t do well in rehabilitation programmes. Post-surgery musculoskeletal syndromes are also more common in women than man.