Until recently, cardiac disease was defined by the symptoms that manifested in men. The classic expectation has been crushing or squeezing chest pain.

Until recently, cardiac disease was defined by the symptoms that manifested in men. The classic expectation has been crushing or squeezing chest pain. Other possible symptoms were arm, neck, or jaw pain; dyspnea; fatigue; nausea; sweating; and dizziness, according to the American Heart Association (AHA).¹

In women, however, the clinical picture often can differ substantially from what was considered the norm. Although chest pain remains the first symptom, that is not the case for many women. Importantly, among those with chest pain, the sensation may be different, in that women may describe it as pressure or tightness and therefore write it off as a passing anomaly other than a cardiac event.² Other symptoms that women experience include pain or pressure in the lower chest or upper abdomen; jaw, neck, or upper back pain; nausea or vomiting; shortness of breath, fainting; cold sweats; indigestion; and extreme fatigue.²

Several factors contribute to the differences in how cardiac disease affects men and women, according to the Cardiology Department at Brigham and Women’s Hospital in Boston, Massachusetts. In addition to variations in symptoms, structural and physiological differences between the sexes help explain why heart disease may present and progress differently in women.³

The cardiovascular systems of the two sexes differ: Women’s hearts are smaller, and the blood vessels are narrower. The Atherosclerosis Risk in Communities Study concluded that retinal arteriolar narrowing is related to the risk of coronary heart disease (CHD) in women but not in men, supporting a more prominent microvascular role in the development of CHD in women than in men. Future work is needed to confirm these findings.⁴

Cholesterol accumulates in different areas in men and women. In women, this accumulation is more likely to be in the microvasculature, whereas the buildup occurs in the largest arteries for men.

There are diseases that may mimic a heart attack in women, such as a coronary spasm, coronary dissection, and broken heart syndrome, the last of which is not characterized by blocked arteries.

Differences in risk factors for cardiac disease, such as preeclampsia, gestational diabetes, and endometriosis, exist in women.³ Regarding the last risk factor, a recent study reported, “…our data show that endometriosis is associated with higher risk of coronary heart disease independent of known and hypothesized confounders and coronary heart disease risk factors, especially among younger women. Moreover, we also observed that a portion of this association could be explained by treatment factors associated with endometriosis diagnosis, particularly hysterectomy/oophorectomy.”⁵

Different diagnostic heart care is needed for men and women. Troponin testing is done for both men and women to measure the serum levels of this protein. However, the threshold levels of the protein to detect a heart attack differ between men and women. One study showed that “using the common 99th percentile can lead to underdiagnosis of acute coronary syndrome in women, [as] their physiological levels of cardiac troponins are much lower. At the same time, the use of the 99th percentile, without considering the gender factor, leads to overdiagnosis of the acute coronary syndrome in men, which is due to higher physiological levels of cardiac troponins in the blood,” according to the authors.⁶

Cardiac catheterization is the gold standard for diagnosing a heart attack, but this test looks for blockages in large arteries. Because plaque buildup in women is more likely to develop in the smallest arteries, this test may not be the most appropriate to diagnose heart disease in women. Women are advised to seek further testing if the cardiac catheterization seems inconclusive, such as cardiac MRI to identify cardiac inflammation or intracoronary imaging to view the inner blood vessel walls in the heart.³

Different treatments for cardiac disease may be needed for men and women. Clinicians successfully treat plaque buildup with medications targeting the largest cardiac blood vessels. However, treating the microvasculature or cardiac inflammation is less well understood. Subtle calibrations in pacemakers or variations on angioplasty may be useful for women.

When those differences hit home

Case 1

Karen S. DeLoss, OD, FAAO, is a clinical associate professor of ophthalmology and visual sciences at the University of Michigan Medical School in Ann Arbor. Her case is illustrative of the scenarios that many women describe.

She is a practitioner aged 47 years with an unremarkable clinical history with no underlying cardiac issues. In June 2024, she experienced “very subtle” symptoms that included indigestion, mild discomfort that she considered tolerable, and mild chest pain—all so minor that they did not indicate a heart attack. She took an aspirin and reported that the symptoms persisted for about 2 hours. As a precaution, she presented to the emergency department (ED), where blood work was performed. She was not convinced that she was having a cardiac event and thought it was a panic attack. After about 5 hours in the ED, the blood work showed increasing troponin levels (approximately 200 ng/L). Normal troponin levels for women are below 10 ng/L. By later that evening, her troponin level was 700 ng/L.

The following morning, cardiac catheterization was recommended with the possibility of stent placement. Open heart surgery was also an option.

The catheterization identified a spontaneous coronary artery dissection (SCAD), which is common in women. In this case, the dissection was minimal and located in the distal left anterior descending artery. She was discharged from the facility with medications and cardiac monitoring.

“With research, I realized that this scenario is common in perimenopausal women under high stress. In this case, there is no major treatment, and the risk of recurrence is low,” DeLoss said.

Some women with this diagnosis have an underlying disorder called fibromuscular dysplasia or Marfan syndrome. She was followed by the SCAD specialist and treating cardiologist and underwent renal scans and echocardiography, which were negative. Evaluation of lipoprotein(a) (normal, < 40-50 mg/dL) returned an extremely high value (150 mg/dL), which is a risk factor for cardiovascular disease, especially heart attack and stroke, and linked to premature heart disease; lipoprotein(a) values are genetically determined. This factor might have been associated with her cardiac event. She will continue to be followed annually.

Case 2

This patient was a woman aged 75 years whose presenting symptoms included extreme anxiety, profuse sweating, and black spots in the visual field. The patient denied chest/jaw/arm pain, labored breathing, dizziness, and fatigue. The patient reported maintaining a healthy diet, eliminating red meat, weight control, and regular exercise because of a history of heart disease on both sides of her family.

After admission to the ED, an electrocardiogram (ECG) showed an ST-segment elevation myocardial infarction, which, in this case, was complete thrombotic blockage of the right posterior descending artery. Upon arrival in the cardiac catheterization laboratory, she was hypotensive and in cardiogenic shock and developed complete heart block that resolved with balloon angioplasty and placement of 3 stents. Following discharge, new-onset atrial fibrillation developed that was treated with infused amiodarone 150 mg. ECG demonstrated sinus rhythm with improvement of the previously seen ST elevations. Echocardiogram showed no evidence of heart failure. The patient is currently being followed 3 times annually.

Genetics was believed to have played a role in this case, because the patient’s mother died from a plaque rupture that affected the right posterior descending artery.

What is noteworthy in both patients is that there was no immediate recognition that a heart attack was occurring because they had taken such care to avoid one. “I gaslighted myself. I had uncomfortable pain but talked myself through it,” DeLoss said.

Patient advocacy

In light of this denial, DeLoss, a dry eye specialist, uses her clinical position to her advantage to educate her female patients about heart disease. In her practice, she believes in treating the entire patient over and above blood pressure and diabetes. For example, dry eye can be related to underlying Sjögren syndrome, lupus, or, in some cases, have no known cause as of today.

The event has changed her approach to patient care; she now takes the time to reach out to patients who may have significant ocular conditions and follows up personally with test results. She feels this may ease anxiety in her patients and lead to better adherence with their eye care in the future. It may be a small personal touch, but it could have a big impact on her patients, she explained.

In her case, she ultimately presented to the ED because she heard of another young woman who experienced a heart attack; the patient had exercised good eating and exercise habits, did not smoke, and believed that she could not experience a heart attack.

A great deal of research is now emerging about how women with cardiac issues present, DeLoss said. “The benchmark in the past was based on men’s presentations. The movement now is that the differences between men and women are being evaluated regarding reactions to cardiac issues,” she said.

She advises ophthalmologists and optometrists not to overlook young women when advising patients about cardiac health.

Read more: https://www.optometrytimes.com/view/what-the-eyes-reveal-cardiovascular-clues-in-women-hidden-in-plain-sight/?ekey=RUtJRDpGQ0FERjM4NC1GNDk3LTQyMzUtOTExQy0yOUNGM0ZEOUJGNkY%3D&utm_campaign=emailname&utm_medium=email&_hsenc=p2ANqtz-9jdNpao9-mUcfXaIi5HXGAlwgL1r8jlTIjI6iWNzMnOe2tuQxsudLjnT8-qs1hXAuWkz2Pb1I0gJlN1vxLKfUxUEY3CQ&_hsmi=384106391&utm_source=hs