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More attention to the female heart

Majority of physicians do not alert women to the risk of a heart attack, even though mortality is close to that in men

ABIUROWomen’s hearts are getting badly treated. Studies carried out in Europe and the United States indicate that even today female cardiac health receives less attention that the male, although for years the heart attack has been considered one of the main causes of death all over the world – and not only amongst the men. Of the 7.2 million persons that each year lose their lives as a consequence of cardiac problems, about 3.4 million are women, according to data from the World Health Organization. Despite the figures suggesting that the difference is not that great, a good number of the physicians seem not to be convinced yet.

One of the most crushing proofs is a study published in the first half of this year in Circulation, the most important magazine in clinical cardiology. Part of the Women at Heart project, launched in 2005 by the European Society of Cardiology with the objective of calling doctors’ attention to women’s cardiovascular health and improving the treatment afforded them, the study involved the collaboration of 197 European cardiology centers and accompanied over one year the treatment given to 2,197 men and 1,582 women, between 50 and 72 years old and a diagnosis of angina pectoris: that intense pain in the chest that burns like hot coal and spreads over the neck and the back, causing a lack of air and leaving the left arm dormant – in general the first sign that the heart is not faring very well.

The work showed that in the initial consultation the probability of being given an indication to undergo a test in which the performance of the heart is monitored during physical effort – electrodes placed on the chest record the rhythm of the heartbeats while the patient is walking on a treadmill – was lower amongst women that amongst men. They also were given fewer recommendations for doing an examination called angiography, which investigates the state of the arteries of the heart, than the volunteers of the male sex. The physicians more frequently prescribe medicines to prevent the coagulation of the blood or to reduce the level of cholesterol for men that for the female participants in the study, even after confirming the diagnosis of cardiac disease. Amongst women, the chance of receiving an implant of blood vessels to reestablish the flow of blood to the heart was lower. As one might expect, the risk of suffering a heart attack – fatal or not – was twice as high amongst women as amongst men.

“The results of this study indicate a systematic underutilization of the diagnostic methods and treatments with women, when compared with men, although both groups had received the diagnosis from cardiologists and the women’s angina was more intense” wrote epidemiologist Viola Vaccarino, from Emory University, United States, in a comment about the study published in the same issue of Circulation. According to the epidemiologist, the lower use of noninvasive examinations in the initial stage of the disease translates into delay in the diagnosis and more serious damage to health. “It is important to fight the widespread belief that women do not develop cardiac diseases, except at an advanced age” wrote Sharonne Hayes, from the Mayo Clinic, United States, in an article published this month in Nature Clinical Practice.

Perhaps it may be early to say, but the work in Circulation may explain a discovery made by Viola Vaccarino at the end of last decade. Analyzing data on 380 thousand persons between 30 and 89 years old who had suffered a heart attack, she found that the prospects for recovery were worse amongst women than amongst men – the situation was even more critical for those in whom the problem had arisen before the age of 60. She also raised two possible explanations for this scenario: the diagnosis is very late amongst women, or only the serious cases are identified.

Except for this doubt that intrigues researchers from all over the world, the study leaves – or it should leave – more warnings for the cardiologists, gynecologists and other physicians who take care of female health in the developed countries, and in Brazil as well. After all, over here, heart diseases are also amongst those that most have been reaping lives since the 1960’s – they only lose to cerebral vascular accidents, also known as strokes. And the proportion between the sexes of death from heart problems is not as unequal as all that: for each two women that die from a heart attack, three men are lost, because the heart stops beating from one moment to the other. Records from the database of the Public Health System (DataSUS) indicate that women amount for 40% of the 80 thousand persons who died from a stroke in 2004 – and amongst them, cardiac problems are even ahead of cancer. In some Brazilian capitals, their mortality rate from heart problems, in the mid-1980’s, surpassed the male levels in countries like the United Kingdom and Finland, found epidemiologist Paulo Lotufo, the superintendent of the University Hospital of the University of São Paulo (USP).

It is a situation that has changed little in the last two decades. “In this period, there has been a reduction in the mortality rate for cardiac diseases, but it was small” explains cardiologist Antonio de Pádua Mansur, from the Heart Institute (InCor) of São Paulo, who seven years ago started the surveys about the risks of death from cardiovascular diseases in the country. Concerned with the lack of comprehensive information about our population, Mansur analyzed the death certificates of Brazilians of more than 30 years old who died from 1979 onwards. And he didn’t like what he saw: the deaths caused heart attack came down from 194 in each group of 100 thousand men in 1979 to 164 per 100 thousand in 1996. Amongst the women, the fall was less: from 119 to 105 per 100 thousand. The most recent survey, to be published before the end of the year, confirms the tendency of a slow and gradual fall observed since 1985: the mortality rate from cardiac diseases, this time amongst women more than 65 years old, went down from 857 to 522 per 100 thousand between 1981 and 2001 in the Southeast Region, probably because of the better control of hypertension and cholesterol levels, which contribute to blocking the vessels that carry blood to the heart.

The reduction, though, is not general. When the deaths recorded in the capitals are separated from those occurring in the cities of the interior, the growth of mortality from heart attack amongst women between 30 and 69 years old in the large urban centers, like São Paulo and Brasilia, becomes evident. “This increase is, in part, associated with the greater accuracy in filling in the death certificates in the Center-West and Southeast regions, but also to less healthy eating habits and to the sedentary way of life” says Mansur, the coordinator of InCor’s Women’s Hearts Study and Research Nucleus. Well-known to cardiologists, these figures are worrying, because they are a novelty for the majority of people, and even to doctors from other specialties. Although there is no data on what Brazilians – and in particular Brazilian women – know about cardiac problems, it is calculated that the situation is n better than in Europe and in the United States, where less than half of women say to have received some orientation from their doctors to prevent cardiovascular diseases.

Behind this almost general ignorance lie historical and social reasons. “Cardiovascular diseases have proved to be an important cause of male mortality after the Second World War” says Lotufo, from USP. “In those days, men used to smoke, and women didn’t.” In the following decades, the cigarette, the main trigger for cardiac problems in women, started to adorn women’s lips as well, at the same time that medical advances made it possible for people to live longer and longer.

“There was a certain neglect of women’s health until the end of the 1980’s” Lotufo says. That was when the cardiologists began to notice that cardiovascular problems were also common amongst women, with consequences for the whole of society: cardiovascular diseases are the second main cause of loss of healthy years amongst men, and the third amongst women.

“It was not rare for a middle-aged woman to arrive at the emergency department with pain in the chest, and the doctor not to think about a heart attack” recalls physician and epidemiologist Júlio Cesar Pereira, from USP’s Faculty of Public Health. “It used to be a vicious circle in which the dog is trying to bite its own tail” says Lotufo, “the doctor would not make a diagnosis, because he would not think of the possibility of women being victims of a heart attack, as they didn’t even imagine this hypothesis, they did not produce statistics on the problem, which, in turn, collaborated towards the lack of diagnosis.”

Fortunately, female health has begun to receive more attention in the last 15 years, including from women themselves, when the doctors noticed something odd: the probability of being given treatment for heart attack was about six times greater amongst the male public than the female public. Either women’s hearts were more resistant than men’s hearts, or there was something wrong. With this question in mind, the coordinators of major population studies started including women in surveys that investigated the emergence, evolution and therapy of various diseases. Until then, the idea in force was that the female organism functioned like men’s: it would be enough to investigate what was going on with the men to know what ought to be happening with the women – although it has been known since the days of Hippocrates of Kos, the father of medicine that the bodies of men and the bodies of women react differently to diseases.

ABIUROA new batch of studies that arose at the beginning of the 1990’s showed that the female heart was not so strong as all that, helping doctors and patients to review concepts and prejudices, like the one that heart attacks were a problem exclusive to the male population. Today, it is known that there are important differences: heart problems manifest themselves in men seven to ten years earlier than in women. This interval coincides with the period that starts with the end of the female reproductive life with the menopause, when the ovaries stop functioning and the level of female reproductive hormones falls a lot. This, by the way, was for a long time the biological justification for the neglect in relation to women’s health.

Until around the age of 50, the female organism produces the hormone estrogen, which facilitates the dilation of the blood vessels and the irrigation of the heart, even though the arteries that bathe it with blood may be partially obstructed by plaques of fat. “For this reason, it used to be believed that women were free of the problem” says Pereira, who recently calculated the probable duration of this natural protection. In collaboration with mathematician Laécio Carvalho de Barros, from the State University of Campinas, he analyzed the details of 3,350 persons from 54 Brazilian cities who had suffered a heart attack between October 1997 and November 2000. He found that at the age of 23 men two times more risk of suffering a heart attack than women. This probability, though, decreases slowly and progressively until around 61 years of age, when women find themselves just as inclined as men to be victims of clogging of the blood vessels of the heart, causing a stoppage, according to results published in April this year in the European Journal of Epidemiology. After the age of 61, a heart attack becomes a greater threat to the female sex than for the male sex: an 80-year old woman is twice as close to a heart attack that a man of the same age.

But this data needs to be interpreted with caution. “These figures are a measure of relative risk and indicate how many times the probability of a heart attack is greater in men than in women” Pereira explains. “What measures the seriousness of the problem is the number of deaths observed in the population.” Furthermore, there is a limitation in this study. Done on the basis of information on people who had suffered a heart attack, its results do not necessarily represent the state of Brazilians hearts. Even so, it gives an idea of how long the protective effect of the estrogen lasts.  “Doctors” says Pereira, “must become more attentive to the hearts of women over 61 years old.”

At InCor, Mansur and José Antonio Ramires, in collaboration with José Mendes Aldrighi, from USP’s Faculty of Public Health, confirmed the protective effect of estrogen in a study published in 2005 in the Archives of Medical Research. They observed that a variant of the gene responsible for making the protein to which the estrogen binds itself in the walls of the blood vessels was very common amongst women with premature cardiac disease, before the age of 55, than in healthy women.

But the protection of the estrogen is not everything. In another study, they evaluated the most frequent risk factors in 850 men and 468 women with poor vascularization of the cardiac muscle. Women generally showed more problems considered risk factors for a heart attack, such as high blood pressure, diabetes, increased levels of fat (triglycerides and cholesterol), besides a family history of heart problems. Amongst men, the risk factors that most contributed to heart disease were smoking and the previous occurrence of a heart attack.

“The larger number of risk factors may explain the higher frequency of sudden deaths amongst women, and the higher female mortality after the heart attack” Mansur says. “The positive side is that the risk factors are less intense amongst them.” This result suggests that many women can live better, merely by controlling the risk factors. Nothing very complicated. You just have to have access to a health center where the blood pressure and levels of sugars and fats in the blood are measured. “These measures do not prevent cardiac problems, but they possibly postpone them for a few decades, reducing the social cost and the deterioration of the quality of life associated with the disease” says Mansur.

A more precise idea of what is happening with the hearts of Brazilian men and women should appear in a few years, when, it is hoped, the initial results will be ready of the Adult Health Longitudinal Study (Elsa). This survey, which involves the participation of seven research institutions, should accompany for ten years the health of roughly 15 thousand people from six Brazilian capitals (São Paulo, Rio de Janeiro, Belo Horizonte, Vitória, Porto Alegre and Salvador).