Heart attack mortality among women aged 18 to 55 years increases, points out SBC

The Brazilian Society of Cardiology (SBC) publishes, this May, a new position on cardiovascular diseases in women. Conducted by the Department of Women’s Cardiology, the document entitled “The woman at the center of self-care” proposes a specific approach to ischemic heart disease in female patients and presents epidemiological data that show an increase in early mortality due to infarction in women.

The publication is based on the assumption that social values, perceptions and different behaviors shape patterns and create different roles in society, which can generate differences in lifestyle and behavior, influencing epidemiology, clinical manifestation and treatment.

“The central message of the position is that mortality from ischemic heart disease, represented mostly by infarction, has been growing substantially among young women. One third of Brazilian women die from cardiovascular disease and most from heart attacks. And these women need access to adequate prevention, treatment and rehabilitation protocols”, says one of the coordinators of the document, the physician and member of the executive committee of the Department of Women’s Cardiology at SBC, Gláucia Maria Moraes de Oliveira.

From a statistical point of view, the position indicates that early mortality from infarction, between 18 and 55 years old, is increasing, especially in women. “We don’t always see that classic picture of a heart attack in women. The factors are in women, who have a greater impact due to traditional risk factors than in relation to men and evolve to a worse prognosis”, explains Gláucia.

Furthermore, the positioning shows that less than 10% of women have their risk factors controlled. Among these, the highlight is due to Hypertension. Less than a third of women know their blood pressure levels.

The majority of acute infarction in women, or a large part, is due to “Minoca”, which is myocardial infarction without obstructive disease. In these cases, outcomes are much worse in women compared to men, especially younger women.

The positioning also demonstrates that some states in the North and Northeast regions have much higher mortality than others due to infarction in women. “This phenomenon occurs due to lack of access to adequate treatment, recognition of specific symptoms and lack of knowledge about specific symptoms, which makes women delay the search for adequate treatment”, he concludes.

Check out more information present in the positioning “Women at the center of self-care”:

heart attack

Women’s ischemic disease is a spectrum that goes from angina, angina pectoris, which is precordial pain, to myocardial infarction. Statistics point to a consistent increase in acute myocardial infarction, which is the acute form of ischemic heart disease, among women, especially younger women, with rates equivalent to or even higher than in men, depending on the region of the country.

“Specificities in women such as manifestations of symptoms that are not always typical mean that women have their diagnosis of infarction underrecognized and undertreated, that is, they are not offered the best treatments, notably, for example, angioplasty. This is usually because women have thinner vessels and bleed more with procedures. Special care has to be taken and often this does not happen “,

explains cardiologist Gláucia.

Menopause

From a clinical point of view, ischemic heart disease occurs earlier in men. However, the incidence and prevalence in women increase markedly after menopause.

Studies also demonstrate that a greater proportion of women with anginal symptoms and acute coronary syndrome have non-obstructive ischemic heart disease.

Ischemic heart disease in women includes classic coronary atherosclerosis and comprises varied pathophysiology, such as coronary microvascular dysfunction, endothelial dysfunction, vasomotor abnormalities, and spontaneous coronary artery dissection.

In terms of anatomy, women have smaller epicardial coronary arteries than men and have a lower prevalence of obstructive coronary atherosclerosis and diverse plaque characteristics, albeit at comparable levels of ischemia.

Furthermore, women who have obstructive ischemic heart disease are generally older than men, have more cardiovascular comorbidities, and have a higher incidence of adverse cardiovascular outcomes, including mortality after acute myocardial infarction.

Women are also less likely than men to have plaque rupture and, in women, revascularization of the occluded artery may be more difficult due to bleeding at the access site and smaller, more tortuous coronary arteries.

Symptoms

Chest pain is the most prevalent symptom of acute myocardial infarction in both sexes. However, women are more likely to experience atypical symptoms, including upper back and neck pain, fatigue, nausea and vomiting.

Most women with an acute myocardial infarction have prodromal symptoms of shortness of breath, unusual fatigue, or arm/jaw discomfort in the preceding weeks. Stable angina is the most frequent clinical presentation in women with ischemic heart disease as opposed to acute myocardial infarction or sudden death.

Epidemiology

Ischemic heart disease remains the main cause of death for women and men in Brazil. There was a more pronounced decrease in the percentage of mortality rate in women between the years 1990 and 2019, -55.5 (II95%, -58.7; -52.3), than in men, 49.5 (II95% , -52.5; -46.6), in the same period.

This decline was unequal in the states of the federation for both sexes, being related to the aging of the population and the sociodemographic index.

The incidence and prevalence of ischemic heart disease have been decreasing in Brazil over the last 20 years in women and men, although there has been an increase in early mortality between 18 years and 55 years, especially in women. In women, there was a difference between Brazilian regions in age-standardized incidence, which was higher in the Southeast and South regions and lower in the North region.

Women had significantly lower rates of primary angioplasty and significantly higher rates of in-hospital mortality. The prevalence of myocardial infarction in the absence of coronary artery obstruction is higher in women, with mortality similar to that of obstructive IHD, associated with a risk of major events.

Disability

The study of Global Burden of Diseases (GBD) 2019 estimated standardized rate of DALYs (disability-adjusted life years) for IHD per 100,000 inhabitants of 1,088.4 (992.8; 1,158.9) in women and 2,116.5 (II95%, 1,989.9 ; 2,232.2) in men.

Ischemic heart disease was the second most common cause of DALYs in Brazil in women (after neonatal disorders) and men (after interpersonal violence) in 2019. These rates were heterogeneous across Brazilian geographic regions and the trend of DALY rates standardized by age from 1990 to 2019, in women, was similar to the mortality rates.

Risk factors

Women have a higher frequency of non-traditional cardiovascular risk factors, such as mental stress and depression, and suffer greater consequences from social disadvantages due to race, ethnicity and income. Women still have the risk factors inherent to sex, such as pregnancy, menopause and menarche, among others.

Less access to treatments

According to the document, women are less submitted to coronary angiography and surgical treatment, including mechanical circulatory support in cardiogenic shock. However, they have higher mortality and postoperative complications. In addition, less than 50% of patients undergo adequate drug treatment, in addition to low adherence to treatment and underutilization of cardiac rehabilitation.

*With advisory information

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