Note: Transcripts may contain errors. If you wish to re-use all, or part of, a transcript, please contact CBC for permission. Please check the corresponding audio before quoting in print. Copyright © CBC 2023

The Dose Transcript for June 1, 2023

Host: Dr. Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Heart disease is a leading cause of death in North America, both for men and women. But far too many of us still think of heart disease as a man's disease, despite lots of evidence to the contrary. Not knowing could cost women their lives. So this week we're asking: What do I need to know about heart disease in women? Hi, Dr. Beth Abramson. Welcome to The Dose.

BETH ABRAMSON: It's a pleasure to be here. Hi, Dr. Brian Goldman.

BRIAN GOLDMAN: It is a pleasure to be speaking with you as well. And I'm reminded -- This is a bit of a nostalgia trip for me. I did my first story on women and heart disease back in 1994. And my goodness, it's 2023. So I want to ask you, how common is it today for women to be shocked when you tell them they've had a heart attack?

BETH ABRAMSON: Unfortunately, it is still something that is new news to people when it shouldn't be. I also have been doing this for over two decades, and trying to make women, as well as men, but women, aware that their leading health threat for death and disability is coronary heart disease.

BRIAN GOLDMAN: And that's why we've come to you for the answers to the questions for our topic this week on The Dose. But before we begin, can you give us a Hi, my name is? Tell us what you do and where you do it. Just ad lib.

BETH ABRAMSON: Hi, my name is Dr. Beth Abramson. I'm a cardiologist at St. Michael's Hospital, University of Toronto, and I'm the Paul Albrechtsen Professor in Cardiac Prevention and Women's Health at the University of Toronto.

BRIAN GOLDMAN: OK, here we go. Dr. Beth Abramson, in round numbers, how big of an issue is heart disease for women?

BETH ABRAMSON: It is a woman's leading cause of death and disability in North America and Canada, bar none. And we need to be aware of our threat, and we need to take care of our health threats.

BRIAN GOLDMAN: Why aren't women as primed as men to think 'I could be having a heart attack'?

BETH ABRAMSON: That's a really good question. I often say that heart disease is no longer a disease of grey-haired, older men. The face of heart disease has changed, and it's changed over the decades because we're aware of it. And we understand that people coming to the emergency room -- for you and for myself when I'm on-call for cardiology -- are women. And there are younger women there as well. So I think there is a perception issue because women may be involved in other health issues and caring for others. I talk about Type B personalities. Women are everything to everyone except themselves. Women need to be aware that this is -- this could happen to them.

BRIAN GOLDMAN: So those -- that's some of the social factors that are really very important. But there is something else that I want to tease out with you, and that is that heart disease might be a different disease in women than it is in men. And that has all kinds of important implications, but can you talk about that?

BETH ABRAMSON: Sure. So when we talk about heart disease, I'm actually talking about coronary heart disease right now -- the main form of heart disease. There are other types of heart disease we can talk about specific to women. But it's a plumbing problem. Your pipes are clogged up and rusty, and if those get rusted too much it drops away the blood flow to your heart and you have a heart attack. And worse than that, you have a fatal heart attack. So, women tend to develop coronary heart disease five to seven years later than men, after midlife or menopause. And I say "tend to" because there are some exceptions to the rule. And women's risk factor profile can be different than men's, and we know there are some sex-specific risk factors as well. So if you're a woman who's gone through menopause or midlife early -- average age is 51, but if you went through menopause at 40 or 35, on the inside, when it comes to your coronary arteries, you're 10 to 15 years older. Also, if you've had high blood pressure or diabetes during a pregnancy, seizure disorders, pre-eclampsia, problems like that, we know these are young women we're starting to see in the emergency room, even in their 40s. So it is not the same. Women are not just smaller men. We are unique entities.

BRIAN GOLDMAN: Can you say more about the link to menopause? And of course, you know, by inference, the link to hormones.

BETH ABRAMSON: Absolutely. So, arteries are complex organs, and they react to various situations in their environment. And one of the situations they react to is the amount of estrogen, or estrogen to testosterone, in the body. And as a woman gets older and goes through midlife or menopause, average age 51, estrogen levels fall and estrogen to testosterone ratios change. And that puts a situation where the arteries are at greater risk for becoming unwell or unhealthy. We know, though, however, that menopausal hormone therapy is not the answer for that, unfortunately. There isn't a quick fix. But we realize that as women get older and their body composition changes, their risk factors for heart disease also change. You know, at menopause, a woman's body shape changes. Women when they gain weight when they're younger, often gain weight in a pear-shaped distribution. We call it a gynoid distribution. And that actually doesn't put you at great risk -- which is good for the young women listening if you've gained some weight -- for heart attack and stroke. But the exception is you can be a pear, but not a big pear. Because it's the weight across the belly -- the dangerous inner fat. And as women age and go through midlife, they go from the pear-shaped, gynoid fat distribution, to the apple-shaped, android or male distribution. We sometimes call that a 'beer belly.' Those sorts of things. It's that fat across the waist that is metabolically active and puts us at much greater risk for heart attack and stroke.

BRIAN GOLDMAN: Interesting. And you mentioned five to seven years later. And is that just based on the -- how long it takes for those hormone ratios to begin to change post-menopause?

BETH ABRAMSON: Probably that's one of the major factors. We don't have all the answers, but we have data that suggests that women are slightly older. But they're not old! As you and I get older, you know, after 51 is not an old individual, so we have to be careful of how we -- what we define as "old.".

BRIAN GOLDMAN: Yeah.

BETH ABRAMSON: But, you know, there's no doubt that this comes into play. The other thing is, is that I tell people heart disease is bad luck, bad living, bad genes. And although we can't change our genetic predisposition, we can change our living and then our luck, so we need to make sure that we're leading healthy and active and vibrant lives as we go through midlife and beyond. Doesn't mean we have to go to the gym and put on some spandex, but we all need to be active. And just because we're at a certain stage in midlife, does not mean that we should give up on healthy living.

BRIAN GOLDMAN: You started to say a little bit about hormone replacement therapy, but I know that there are a lot of people that are listening to our conversation that want to know what are the rules and what are the benefits and what are the risks.

BETH ABRAMSON: Absolutely. In fact, I was privileged to write guidelines for Canada with the Society of Obstetricians and Gynecologists this year, updating the use of menopausal hormone therapy and risks for cardiovascular disease. So one of the issues with hormones, by definition, is that a hormone has multiple effects on the body. And while estrogen would conceptually seem attractive to keeping our arteries healthy -- and in some ways it does -- it also allows the body to increase its clotting factors. And so clots are more increased. And blood clots, even fatal blood clots, can be increased if people -- and women, specifically -- go on hormone therapy. So we know that we have to look at the risk for women versus the benefit. And we no longer recommend menopausal hormone therapy just to prevent heart disease and stroke. Where we do use it in women, who are within ten years of the meno-- of menopause or midlife, and who do not have significant risk factors for cardiovascular disease, is for severe symptoms. If you're not sleeping -- Of menopause. If you're not sleeping at night, if you're irritable, if your sweating is uncontrollable, then it is a reasonably safe choice to make with your health care provider. And very, very much as we are in an era of patient-focused and informed decision-making, we need to know what the risk is and what the benefit is to that, to that woman. And we have data now. So we have longer-term data showing that menopausal hormone therapy, for short periods of time, do not put women at long-term cardiovascular risk.

BRIAN GOLDMAN: So, define short-term.

BETH ABRAMSON: Short term -- five years on average. Five to seven. Five if it's combination. So women who have not had a hysterectomy and have a womb, need progesterone so that they can have a sloughing so they do not have risk of cancer and uterine cancer. Women who've had hysterectomies and only need estrogen alone -- or we call it unopposed estrogen therapy -- the data is for about seven years, on average.

BRIAN GOLDMAN: OK, I want to pull back and get a little bit more general. What are the main risk factors for women when it comes to heart disease?

BETH ABRAMSON: Risk factors for heart disease are similar to men: high blood pressure or hypertension, diabetes, high cholesterol, smoking, and a family history of heart disease. And it doesn't go woman to woman or man to man. So if a woman has a father who had a heart attack in his 50s, her risk is double the average woman. Then there are sex-specific risk factors, which include high blood pressure or diabetes or pregnan-- of pregnancy, or pregnancy-related cardiovascular issues, and menopause. So those are the risk factors for women in addition to the traditional risk factors.

BRIAN GOLDMAN: What are the typical symptoms of a heart attack in women? I know they're different.

BETH ABRAMSON: Well, it's interesting you say that because there's been a lot of myth out there over the last few decades. And the commonest symptom for heart attack in women, as in men, is chest pain. And there's been lots of data out there since we've started thinking about this. The issue is, is that women may have some additional, less specific symptoms. Or other symptoms that you and I as health care providers would understand is potentially from the heart. So chest pain that is associated with jaw/arm/throat discomfort going into the back, those are all symptoms that we have to take seriously. That could be the heart. Certainly, if a woman wakes up in the middle of the night or out of the blue -- especially if she has risk factors for heart disease or is at midlife or older -- and becomes cold and clammy, short of breath, grey/ashen and has a chest discomfort, she needs to seek urgent medical attention. If she has something that's not quite right with her, she should talk to her doctor and say, 'Could this be my heart?' One of the issues is that we've had these non-specific symptoms about fatigue, for example. But I'd ask everyone listening to this, and yourself and myself as well, how many times we've been tired in the last week. We are all fatigued. So these are not sort of defining factors of heart attack. Heart attack for women is chest discomfort.

BRIAN GOLDMAN: OK, chest discomfort. Shortness of breath - how about that?

BETH ABRAMSON: Shortness of breath is a sign for heart attack, and is also associated with chest discomfort. But if you're out of the blue, something is wrong in terms of a severe shortness of breath, cold and clammy, absolutely one needs to seek medical attention. Chest pain with associated risk factors is actually common in both sexes. And, you know, I use the word sex, and I want to define sex and gender just for everyone. 'Sex' is the biological differences that we have -- XX versus XY chromosomes. Gender refers to how society influences us, and how we interact in society. I think there's a bit of both when it comes to women and heart disease -- why women are underdiagnosed and undertreated. And it's both sex and gender at play here.

BRIAN GOLDMAN: Can you say more about that?

BETH ABRAMSON: Sure. When we look at evidence-based care -- so the scientific knowledge that says this is the best treatment for you -- we do see that women receive less best care than men. Certainly, we look at this we don't have much data in Canada. But in the United States, in North America. And we have less data in Canada because we're not collecting that data, which is which is a shame. But that aside, women are less likely to receive life-saving treatments, or stay on medications a year out after heart attack, compared to men. In other realms of cardiology, we have certain patients who even need -- we call implantable defibrillators for serious rhythm problems. Beyond the scope of our conversation today, but women are less likely to receive defibrillators than men, even in this current era. So we need to we need to be proactive and say: Is there another treatment out there? Am I getting the best care? And it's OK for a women to ask that of their physician. Once you ask the question, you have to be provided with answers.

BRIAN GOLDMAN: Hm. And that may require a change in health services that are available.

BETH ABRAMSON: Yeah. We look at -- There's a desperacy or difference in care. Actually, if you are sitting in downtown Toronto in a big academic teaching hospital, fortunately, women are likely to get very similar care, data suggests, than men. When you move out into rural parts of the of the country -- and the same holds true for a lot of aspects of medicine -- there is regional variation to care. We have the potential to have access. We need to make sure that women, and anyone who is at risk and potentially marginalized, has an advocate out there to receive the best care.

BRIAN GOLDMAN: Now, is it my imagination, or, you know, maybe a bit of cognitive bias because of what I'm seeing in the emergency department, but, I'm getting the sense that I'm seeing younger women coming into the emergency department with what turns out to be a heart attack or a stroke, compared to to what I saw earlier in my career. Am I, am I right?

BETH ABRAMSON: You're right. You're absolutely right. The data is actually very concerning. We're starting to see younger women coming in with acute chest pain syndromes and heart attacks, and the reason for that is multiple. One of them is that, as I started to allude to, women who have high blood pressure or diabetes during their pregnancies, sort of have this pregnancy stress test that they're failing. And we're starting to see more of these women as women are slightly older as they're becoming pregnant and having children in society. We're seeing more high blood pressure and diabetes with pregnancy, and that becomes a risk for earlier heart disease. So that may be part of the part of the equation. The other thing is, is that we're all leading lives where we're becoming more and more overweight and out of shape, unfortunately, on average. And one of the things we didn't talk about is that the sex-specific risk factor of menopause, is out the window if you have diabetes. Which means if you're a younger woman with diabetes, you're not afforded the protection that many premenopausal women have. And you know that there is an explosion out there of diabetes related to obesity, related to exercising our brains and not our body, so, it's a problem.

BRIAN GOLDMAN: And not a reassuring one at that. I want to talk about a very specific diagnosis, and that is coronary artery dissection. So what is that, and what does it have to do with women?

BETH ABRAMSON: So I'm going to use the analogy of a pipe for your coronary arteries. And there's a tear in the pipe, so there's a tear in your arteries. And that, obviously, can be a life-threatening problem and a cause of a heart attack, as opposed to the traditional rust and a clot forming. And we know that arteries are sensitive organs and that there are estrogen receptors on arteries, and so we see this tear in the arteries, or coronary artery dissection, more commonly in women. And not trying to scare your listening audience because it is not common, but we see it often in high-estrogen states. So we will see it in someone who is pregnant, or who has just had a baby. And so the issue of estrogen and blood vessels is one that needs to be explored.

BRIAN GOLDMAN: Wow. And what are the typical symptoms of coronary artery dissection?

BETH ABRAMSON: Well, you can have chest pain and present with a heart attack. If you have a tear or dissection that goes up, straight up, to the top of your coronary artery. So sort of in a tube, and the tear goes all the way back to the top of the tube. It can be quite serious, and have severe discomfort and chest pain. You can have tears in your aorta, which can give you back pain. There are all sorts of symptoms that are -- sound scary out there and are not as common. But I do think if someone listening has a severe chest discomfort -- Or they say, actually, a tear in your aorta is one of the worst pains you will ever have. Worse than the pain of childbirth. If you have a searing pain in your upper back -- that's for younger women. And older women are at, actually, risk of what we call aortic dissection because they have high blood pressure. Those are things we need to take seriously.

BRIAN GOLDMAN: So what's the call to action for women?

BETH ABRAMSON: Women need to be aware that can happen to them. Women need to ask their doctors about their risk factors for heart attack and stroke, how can they lower their risk factors, and what can I do about making sure I don't develop risk factors in the future

BRIAN GOLDMAN: So let's take them one at a time. Let's talk about the risk factors -- what are the risk factors they need to know the most about and do as good a job as possible of trying to manage?

BETH ABRAMSON: OK, so the younger women who've had high blood pressure, diabetes, during their pregnancies, the most important thing to do, which is really, really hard, is to get back to your pre-pregnancy weight. And talk to your doctors about risk of heart disease in the long run, getting cholesterol checked intermittently, blood pressure and obviously blood sugar. For women before, at, and after midlife: checking blood pressure, checking cholesterol, talking to your doctor to see if you're at risk for diabetes or not, asking your siblings and parents about a family history. Because don't forget, risk factors for heart disease tend to run in families. So if you have a parent or a sibling with high blood pressure, you're at higher risk as you go through menopause and midlife. So it's really important to have a conversation with your family. Butt Out -- I say that for women, for men, for giraffes. For everybody. The highest risk for having a heart attack if you are younger and coming into the emergency room, is smoking. And although we're making great strides in Canada, there is still that misperception that the unhealthy, very slim fashion model who's smoking and unhealthy on the inside, somehow is at lower risk than the woman or young woman who is five to ten pounds overweight, is not smoking, is eating a heart healthy diet in fruits and vegetables and less saturated fats, who's out there and active. So you can be a little overweight, and healthier on the inside.

BRIAN GOLDMAN: And can we assume today that if a woman talks to her doctor or nurse practitioner about these issues, that she's going to get a good hearing? And that most primary care providers are well-versed in this, or are they going to sometimes encounter someone who is going to tell them that their risk is low because they're a woman?

BETH ABRAMSON: Yeah. The answer is I don't know, but I can tell you if you are told your risk is low because you're a woman, you are entitled to a second opinion. The other risk factor we didn't talk about is cholesterol in detail. But for many years we thought, because women can have good cholesterol -- HDL, which we want high, to be higher than the bad, lousy LDL cholesterol -- that that protects women. It does, but it's not the whole story. And so even if you have a good HDL, if your LDL or lousy cholesterol is up, that puts you at risk as well. So I think women are entitled to ask for another opinion if they've been told their risk is low because they are women. I think it behooves us as health care providers to think about the person in front of us, and make sure we assess risk. And that's what we need to do.

BRIAN GOLDMAN: Not just for women listening to this, but for everybody who cares about them. Because they are the linchpins of our families and we want them to stay healthy, and we want them to take care of themselves as much as they take care of everybody else. So this is great information and I'm so glad we got round to doing this topic. Dr. Beth Abramson, thank you so much for sharing your expertise and wisdom with us.

BETH ABRAMSON: My absolute pleasure.

BRIAN GOLDMAN: Dr. Beth Abramson is a cardiologist and the Paul Albrechtsen Professor in Cardiac Prevention and Women's Health at St. Michael's Hospital in Toronto. Here's your dose of smart advice: Heart disease is the leading cause of death for women, just as it is for men. Women's heart disease is somewhat different from that of men. In women, heart disease occurs in the smaller blood vessels of the heart, and less so the major coronary arteries. As a result, women may not get the crushing chest pain that men get, but they do experience chest discomfort, shortness of breath, fatigue, indigestion or nausea, back or neck pain. You can't talk about heart disease in women without talking about hormones. During childbearing years, estrogen and progesterone help protect against heart attacks. That protection lasts until five to seven years following menopause. When it comes to heart disease risk, hormone therapy helps relax arteries which is good for blood pressure, but also promotes clotting which can trigger heart attacks and strokes. Hormone therapy is therefore only recommended for temporary relief of menopause symptoms for up to five years. Heart disease is beginning to show up in younger women because of higher rates of obesity and older-age pregnancies, which put extra stress on the coronary arteries. Compared to men, women are at much higher risk of spontaneous coronary artery dissection, or SCAD -- a potentially lethal condition in which the coronary arteries are torn. Standard tests of heart disease, such as stress or treadmill testing and angiograms, are less sensitive in women than they are in men. Women of South Asian, Chinese, and Afro-Caribbean descent have higher rates of heart disease. They also have more high blood pressure and diabetes. Indigenous people in Canada have higher rates of heart attack and stroke. For some Indigenous groups, the death rate from heart disease and stroke are higher in women and younger age groups. Seek medical attention right away if you have pain or discomfort in the chest that may be dull and heavy or sharp; pain in the neck, jaw, throat, upper belly or back; nausea or vomiting; unusual fatigue; and shortness of breath during physical activity. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

Back To Top »

Provide Transcript Feedback

CBC would like to acknowledge the support of the Broadcasting Accessibility Fund.

What do I need to know about heart disease in women? - Transcript

More Stories Like This