An evolution in our culture has rightfully led to a blurring of differences between men and women.

A parallel progression in medicine has clearly shown a gender difference in health characteristics, especially over the past decade.

Heart disease is a prime example of such a divergence in knowledge and facts between men and women’s health, and this is starting to translate in a more gender-tailored approach to cardiac care.

In the USA, heart disease kills 500,000 women every year. Women develop cardiovascular disease about ten years later than men but it’s estimated that one in ten American women aged 45 to 64 has underlying heart disease. This increases to one in four women over the age of 65; a ratio similar to men of the same age group.

While only 24 per cent of men die within one year of their heart attack, 42 per cent of women do.

For women under 50 years, their first heart attack (or MI) is twice as likely to be fatal than for men.

In addition, it is estimated that less than 50 per cent of men die of a heart attack without a previous known history of chest pain, whereas 70 per cent of MI deaths in women occur with no such history.

Historically, studies that set the standard for detection and treatment of heart disease were done mostly on men. But researchers found the results didn’t always apply to women. Here are the major differences in heart conditions between women and men:

The ten-year age gap

Physiologic oestrogen secreted before menopause has shown to be protective against cardiovascular disease in women and explains the ten-year age gap or delay in CVD development between men and women.

For decades, post-menopause hormonal therapies, including oestrogen with or without progesterone, were prescribed and praised for their purported cardiac benefits until they were put to test and found to be harmful. The cause for that remains unclear.

Cardiac conditions and risk factors

While a high bad cholesterol [high LDL] is the main lipid parameter leading to vascular blockages in men, it appears that a low good cholesterol [low HDL] and high triglycerides are as important, if not more, in women.

Statins that gain their fame from reducing LDL, have been shown to be more effective in women than men.

Hypertension and diabetes are more significant in women as vascular risk factors than in men.

In fact, diabetes is the most powerful predictor of cardiovascular risk in women. Alone, diabetes erases the ten-year “gender gap” and predisposes women to premature CVD. Added to that, diabetes is more prevalent in women than in men over 40 years of age.

Atrial fibrillation causes more strokes in women than men with the same risk profile.

Mitral valve prolapse is three times more common in women than men. It is a condition where the mitral valve is baggy and balloons out, causing a backward blood flow called mitral regurgitation. However, when mitral prolapse does occur in men, it tends to be more severe than in women.

Heart failure with preserved cardiac performance is twice more common in women than men.

Takatsubo, or stress-induced cardiomyopathy, when seen, affects 90 per cent of women and ten per cent of men only.

Symptoms

Women with heart disease may have different symptoms than men. Women may experience the classic symptoms of gripping chest pain, sweating and shortness of breath, but they may also present with more non-specific complaints of generalised discomfort in the chest, breast, back, shoulders, jaw, neck or throat; indigestion; nausea; lightheadedness; palpitations; sleep disturbances and unexplained fatigue.

Testing

Tests that reliably pick up signs of coronary disease in men don’t always work in women.

Stress test: some women don’t have the strength to do a full exercise stress test and an incomplete one doesn’t work the heart hard enough to yield truly useful results. In addition, the electrogram portion of the test does not change in a clear way to rule in or out blockages (or more precisely “ischemia”).

Another fact: single-vessel heart disease, which is more common in women than in men, may not be picked up on a routine exercise stress test.

Angiogram: Women are more likely than men — 60 per cent versus 15 per cent — to have very small coronary blockages called microvascular disease, that would not show up on coronary angiogram, but can cause cardiac symptoms.

Treatment

Aspirin is less effective in women than men at preventing heart disease and is even less impactful, if at all, at preventing a stroke.

Because of the ten-year gap, women tend to have heart attacks later in life. As a result, they’re more likely to have other health issues that may make heart procedures, including surgeries, a riskier proposition for them. In addition, women have smaller hearts and arteries than men, and bypass surgery and balloon procedures may have higher complication and a lower success rate, though recent technical advances have significantly solved this issue.

• Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women’s Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients’ care recognition awards. The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article