Heart disease often hits women hardest

More women are dying of heart attacks than men, but cardiologists still don’t understand why female patients have worse outcomes

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      Even though her father and grandfather both died of heart failure, Barbara Vance never imagined she’d one day end up in an operating room for open-heart surgery herself. But there she was in 2006, at age 66, having her chest cut wide open with a sternum saw at St. Paul’s Hospital for what she originally thought was going to be a valve replacement and a triple bypass.

      “When I woke up afterward, I found out I needed a quadruple bypass,” Vance says in an interview at her West Side home. “I didn’t like the idea of my heart being taken out and stopped for the surgery. That freaks you out….But I was really calm going into surgery. I have a lot of faith and believe that whatever will be, will be. Somehow there’s a peace that comes over you once you accept what’s happening to you. It comes last-minute, mind you: as you’re rolling onto the operating table.

      “I was shocked when I found out I needed surgery,” adds the grandmother of four. “I thought I could slip by it, that it wasn’t going to happen to me because it happened to my grandfather and my father. I didn’t have a role model who wasn’t male. A lot of women don’t take it [heart disease] seriously enough. I didn’t.”

      Vance represents the thousands of women across Canada who find themselves stunned by such a diagnosis, even though for females, heart disease is the leading cause of death. In 2008, cardiovascular disease (which includes heart disease and stroke) accounted for almost 30 percent of all female deaths in the country, according to the Heart and Stroke Foundation of Canada.

      “Many women mistakenly think that they have a greater chance of being diagnosed with breast cancer,” says Karin Humphries, who holds the UBC Heart and Stroke Foundation professorship in women’s cardiovascular health. (Operated in partnership with St. Paul’s, the position is a first for the province.) “Women under age 55 have a particularly hard time even relating to talk of heart disease, often downplaying their risk.”

      However, women with heart disease have poorer outcomes than men. Although the 30-day mortality rate after bypass surgery declined for both genders from 1991 to 2004, women still have a 42-percent higher mortality rate than men, according to a 2007 study Humphries headed that was published in the Journal of the American College of Cardiology.

      “From all the studies of any [type of] open-heart surgery—valves, bypasses—women don’t do as well, in terms of [having] a higher chance of dying, higher chance of complications; and their long-term survival is less, too,” says cardiovascular surgeon Anson Cheung—who’s also the director of cardiac transplantation for the province—in an interview at St. Paul’s Hospital.

      “There’s not a lot of difference [between men and women] from a surgical point of view, though women are slightly smaller, in general, so for bypasses, the blood vessels are smaller and so it’s slightly more technically challenging. Osteoporosis is also more common in women, so bone healing in the sternum is a potential problem. And because they have smaller blood volume, there’s a higher likelihood of needing a blood transfusion for the surgery.”

      One reason that heart disease isn’t as thoroughly comprehended in women as it is in men is that women have been largely underrepresented in clinical trials to date. Then there is the fact that, as caregivers, women tend to put others’ needs before their own, and health professionals often attribute women’s symptoms of heart disease to psychological causes.

      “For decades, this was considered a man’s disease, and that’s still so common,” Humphries says. “The reality is that more women are dying of heart disease than men. We still don’t understand why women have worse outcomes than men. Why, after a heart attack, are young women more likely to die than young men?

      “For many young women, odds are they have children, plus elderly parents, and they’re working,” she adds. “How do you balance all that and look after your own heart health? The importance of psychosocial factors is overlooked.”

      Low socioeconomic status is the primary indicator of heart disease and mortality in women and a greater risk factor for women than for men, according to the Heart and Stroke Foundation of Canada. Women are less likely to enroll in cardiac-rehabilitation programs and have higher dropout rates than men. Women also have poorer functional recovery and higher rates of depression than men after bypass surgery.

      Cardiovascular disease develops later in life in women than in men. It tends to take longer for women complaining of chest pain to be transferred to hospital than men. And women report experiencing more pain than men following 
      cardiac surgery.

      Older women, aboriginal women, South Asian women, and women with mental illness or addiction face higher risks of heart disease than their male counterparts.

      Women with stressful jobs are at risk too: a study published in the online medical journal PLOS ONE found that the risk of heart attacks was increased by almost 70 percent among women with great job strain (defined as having a demanding job that provides limited opportunity for decision-making or using one’s creative or individual skills).

      Like men, women can experience severe chest pain with the onset of a heart attack, as well as shortness of breath, shoulder or arm pain, sweating, and nausea. But women can have other symptoms, such as abnormal fatigue that gets worse with activity, heartburn that’s not relieved by antacids, overall weakness, and anxiety.

      Bypass surgery, known officially as coronary-artery bypass grafting (CABG), is typically performed after the heart is stopped and the patient is placed on a heart-lung machine. This machine performs the functions of the heart and lungs outside the body, allowing surgeons to manipulate a heart that is not moving.

      Cheung notes that women’s outcomes seem to be on par with those of men when their heart is still beating during open-heart surgery, a surgical approach that is in its early days. “It needs more research,” Cheung says. “The percentage of surgeries done on a beating heart is very small.”

      For those who do require open-heart surgery, the only thing worse than the idea of undergoing such a major procedure is waiting for it to happen. Vance found out in the fall of 2005 that she needed an operation, but she didn’t go under the knife until the following spring.

      “That was stressful: waiting for something like that when you don’t know when your last breath is going to be,” Vance says. “You need something to fill your time.”

      She started blogging and tweeting (@GramaBarb) and has gone on to write about her experience with open-heart surgery to provide encouragement to those who have to go through the same ordeal.

      Nancy Ward can relate. The Abbotsford department-store clerk had her first open-heart surgery 13 years ago, when she was 40, because of a congenital disorder called aortic stenosis, an abnormal narrowing of the aortic valve (which is found between the left ventricle and the aorta, the largest artery in the body). It’s gotten to the point where she needs surgery again, and the grandmother of 13 is anxious about what could happen in the meantime.

      “It was during a routine visit to St. Paul’s [Hospital] last March when I found out it had returned,” Ward says on the line from her home. 
      “I was devastated, absolutely devastated. Even in the last six weeks, my symptoms have greatly amplified. Before, it was tiredness and weakness; now I’m starting to get dizziness. I‘m starting to get pain [in my chest]. I have general flulike symptoms. I live half a block from the corner store, and when I walk there and back, I’m exhausted.”

      Ward says she was told to expect a call at the end of October to schedule her surgery.

      “November came and went,” she says. “The waiting is what’s difficult. The waiting… It plays with your mind. They told me, ‘If something bad happens, go to the hospital.’ This is something that will definitely kill me if I don’t have the surgery.”

      Surgeon Anson Cheung says open-heart surgery is riskier for women.

      To address wait lists for all types of treatments, the B.C. Ministry of Health implemented what’s known as the First Ministers Meeting (FMM) benchmarks, the title of which refers to a 2004 summit of provincial and federal leaders. The federal government also mandated that wait times for bypass surgery be reported and that patients receive surgery according to those defined benchmarks—the assumption being that meeting these benchmarks will improve patient outcomes.

      According to Cardiac Services B.C.—a Provincial Health Services Authority body that monitors cardiac care—the province has been largely meeting those targets.

      “For the past three quarters, more than 98% of isolated CABG cases have been completed within the FMM benchmarks,” the CSBC’s 2010 annual report (the most recent available) stated. “Priority III cases, those with the longest allowable wait time and generally the group who has the longest delay, were virtually all done within the FMM benchmarks.”

      However, the province is entering the 2013-14 fiscal year with longer waits than in the recent past because of a critical lack of perfusionists—the specialized medical technicians who keep blood flowing through a patient’s body during open-heart surgery and who operate the heart-lung machine.

      “It’s a nationwide shortage,” Cheung notes.

      David Babiuk, executive director of Cardiac Services B.C., tells the Straight in a phone interview that over the past few years, the average number of patients waiting for open-heart surgery has varied, ranging from 220 to 260. At the end of the 2012-13 fiscal year (ending on February 28), though, there were 352 people waiting.

      He says that to reduce wait lists, all the hospitals that provide open-heart surgery in the province (St. Paul’s, Vancouver General, Royal Columbian, Royal Jubilee in Victoria, and Kelowna General, which started offering the procedure this past December) are slated to increase the number of surgeries taking place in the coming months.

      “The five hospitals providing open-heart surgery procedures have performed, on average, 63 cases per week this past [fiscal] year. For the month of March, the hospitals are planning to perform, on average, 76 cases per week and continue at that rate until the end of June….That will assist us in bringing the wait list to a very manageable number so we don’t compromise care and can provide the highest quality of service.”

      Cheung says that so long as the benchmarks are still being met, the likelihood of someone dying while on the waiting list is “very low”. “In general, it’s safe to wait,” he says.

      For people like Ward, who had her first open-heart surgery at St. Paul’s in 2000, though, surgery can’t come soon enough.

      “I know I’m in very good hands [at St. Paul’s],” Ward says. “I can’t say enough good things about them, but I wish the wait wasn’t so absurd. I’m getting really, really worried.”

      Vance, meanwhile, still gets emails via her blog from people waiting for open-heart surgery who are looking for a little reassurance about the whole thing.

      “You need to be as peaceful as you possibly can, because it’s a big deal,” Vance says. “But the fear will pass.

      “And remember,” she adds, “to go for your checkups.” 



      Be the Change

      Mar 27, 2013 at 3:03pm

      I,too, has arotic stenosis and received a mechanical
      valve in August, 2011. I would have died without the surgery.

      I,however, waited 1 1/2 to have an echocardiogram before my first follow up, which ended up being in
      March, 2013.

      Abbotsford Regional Hosp. has a year wait time and
      I had my test done in Surrey, due to least wait time.

      I had my surgery done at RCH and the medical staff
      are incredible.

      We need preventative health care system and timely
      medical care reduces need for more extensive medical
      intervention in future.

      There, aslo, needs to be a reduction in administration
      and funds put towards health care.