There are many historical and practical reasons why women’s attitude to their risk of cardiovascular disease (CVD) may differ to men’s. Nurses can offer vital education and support to ensure women do not overlook potentially dangerous symptoms.
Cardiovascular disease (CVD) is consistently a leading cause of death worldwide across all demographics. However, a lack of understanding of the rates and presentation of CVD in women could be causing unnecessary morbidity and mortality from often preventable and treatable disease.
Practice nurses can support women in understanding their risk of CVD and promote equitable investigation and treatment across traditional barriers.
Barriers to women seeking care for CVD symptoms
As frontline healthcare professionals, we need to understand why women may or may not seek support for symptoms that could indicate CVD.
On the whole, women are more likely to seek primary care services than men are,1 for several historical reasons. Women have traditionally acted overwhelmingly as the main carer for children and other dependent family members. Women’s need for primary care interactions, from menarche to motherhood to menopause, and from contraception to conception and beyond, have meant they are simply more accustomed attending their local practice and specialist clinics.
On the other hand, unlike most other medical specialties, CVD is generally seen as a condition that mainly affects men. Media portrayals of heart disease tend to feature overweight middle-aged men clutching their chests and falling, grey and sweating, to the ground.
Certainly, gender plays a part in CVD risk. The average age of a woman having a first myocardial infarction (MI) is around 9-10 years higher than that of a man and there are various independent risk factors that affect men and women differently.2 Oestrogen seems to play a protective role against heart disease in women, so postmenopausal women should be aware of a sharp increase in their risk.3
Heart pain and CVD in women
In the past, in an attempt to raise awareness of CVD risk in women, public health programmes and medical education have placed specific focus on the idea that women might express the pain of an MI or angina in a different way to men; that women seem more likely to have ‘atypical’ pain from an MI, often describing pain in their shoulders, jaws, even teeth.4
Given that we consistently describe these sorts of pains as ‘atypical’ heart pain, perhaps we should stop considering them atypical, and start to treat them in the same way we would treat any other ‘query cardiac pain’.5
In fact, more recent research from the British Heart Foundation (BHF) has found women are actually likely to experience and describe heart pain in similar ways to men. The NICE guidelines6 for chest pain assessment specifically state sex should not influence the way chest pain is assessed. There should, in theory, be no gender disparity in the rate of investigations and treatment offered by professionals to anyone experiencing chest pain – this is not always the case, however.
It is absolutely right that healthcare professionals (and the public) should be cognisant of the incidence and nature of atypical symptoms but having preconceived ideas of the type and aetiology of symptoms experienced by different groups of people is unhelpful, and possibly harmful.7
‘Cardiac chest pain?’
Lists of differential diagnoses from junior and experienced medics alike assessing patients presenting with chest pain are often festooned with question marks and handed over with the word ‘query’ qualifying any suspicion. Any process or organ that exists within or without the thoracic cavity can cause symptoms that may resemble cardiac pain: respiratory tract infection; pulmonary embolism; exacerbation of COPD; costochondritis; psychogenic or musculoskeletal pain; upper GI symptoms; cholecystitis – the list is lengthy. This is why we order further investigations.
We have a good understanding of common and uncommon expressions of cardiac pain but they can be multitudinous and diverse, so we need to hone in on some of those classic descriptors: the tight band around the chest or the ‘elephant sitting on my chest’.
Cardiac symptoms can include:
- Chest pain that is tight, heavy, crushing, squeezing or burning
- Chest pain on exertion, possibly indicating angina
- Pain radiating to the neck, jaw, back, and one or both shoulders and/or arms
- Anxiety, even feelings of doom
- Dyspnoea
- Fatigue
- Nausea and vomiting
- Diaphoresis
Different people experience and describe cardiac pain in different ways. In addition, there are people who will always say no when they’re asked about ‘pain’, but on deeper questioning will admit to a dull ache or a tightness, or any other odd sensation that they wouldn’t describe as pain (but that other people certainly would).8
The crucial point to remember, based on the best available evidence, is that men and women can experience any of the typical or atypical symptoms of cardiac chest pain. There may be differences in the way it is described, differences in individual pain thresholds and even differences in a person’s perception of their pain depending on how high or low they believe their risk of heart disease to be.9
Consideration of a patient’s risk factors is also relevant when assessing potential cardiovascular disease; the likelihood of CVD increases in proportion to the number and nature of these factors.10 People with significant pre-existing risk factors like obesity, family history, hypertension and diabetes can be considered at higher risk. However, it’s important not to discount the possibility of CVD simply because someone is perceived to be at low risk.
While up-to-date healthcare professionals have decades of evidence on the incidence of heart disease across demographic divides and the symptoms and management of suspected or confirmed CVD, the general public may be influenced by misleading factors in their perception of risk. The challenge, then, is to change public understanding of the kind of symptoms that should prompt anyone of any gender to seek urgent medical attention, and the kind of response they should expect.
What can we do?
Women have been found to be more likely than men to think they are wasting their healthcare providers’ time and less likely to consider themselves to be at risk of heart disease.11 The way different people describe chest pain may also differ depending on the context of their lives and lifestyles: what is their current weight of responsibility? Are they meant to be picking up their grandchildren from school in half an hour? Do they need to go home to look after a family member, or are they worried that they might lose their job or driving license?
There are lots of reasons people may modify their response to medical examination, and while having a gender bias in our expectations of an individual’s external stressors can be harmful, a pragmatic awareness of a person’s responsibilities is important.
Women remain more likely than men to be informal carers12 or to have a primary parenting role.13 Add to that the belief that they are not at high risk of heart disease, and we find a group of people who may be unwilling to seek urgent care services for potentially cardiac symptoms. As noted, though, women are likely to have a closer connection with primary care services and this is where the role of the practice nurse is paramount.
Cardiovascular disease responds well to health promotion initiatives. As healthcare professionals, we have a unique opportunity to help our patients modify their disease risk, and that means education, education, education.
Interventions from primary care, including community pharmacists, practice nurses and GPs, could have a huge impact on the health of our communities.14 If we identify a risk in our patients, we should talk to them about modifiable factors, with reasonable emphasis on their overall risk.
We need women to know that they might not be as protected from heart disease as they think they are, based on their sex alone. There is no excuse for women to have worse outcomes for CVD than men.
Elaine Francis is a registered nurse working on a cardiology unit for the NHS in the north east of England
References
1 Wang Y., Hunt, K., Nazareth, I., Freemantle, N., & Petersen, I., Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open 2013; 3: 1-7. https://bmjopen.bmj.com/content/bmjopen/3/8/e003320.full.pdf
2 Campbell, D J. Why do men and women differ in their risk of myocardial infarction? European Heart Journal, 2008; 29(7): 835-836. https://doi.org/10.1093/eurheartj/ehn074
3 Maas, A. H., & Appelman, Y. E. Gender differences in coronary heart disease. Netherlands heart journal 2010; 18(12), 598–602. https://doi.org/10.1007/s12471-010-0841-y
4 Briggs, L. A. Deciphering chest pain in women. The Nurse Practitioner 2020; 43 (4): 25-33. https://doi: 10.1097/01.NPR.0000531071.96311.9f.
5 DeVon, H. A., Mirzaei, S., & Zègre‐Hemsey, J. Typical and atypical symptoms of acute coronary syndrome: time to retire the terms? Journal of the American Heart Association 2020; 9(7): 1-4. https://doi.org/10.1161/JAHA.119.015539
6 Steenblik, J., Smith, A., Bossart, C. S., Hamilton Sr, D. S., Rayner, T., Fuller, M., Carlson, M & Madsen, T. Gender Disparities in Cardiac Catheterization Rates Among Emergency Department Patients With Chest Pain. Critical Pathways in Cardiology 2021; 20(2), 67-70. https://doi.org/10.1097/HPC.0000000000000247
7 Clerc Liaudat, C., Vaucher, P., De Francesco, T., Jaunin-Stalder, N., Herzig, L., Verdon, F., Favrat, B., Locatelli, I., & Clair, C. Sex/gender bias in the management of chest pain in ambulatory care. Women’s health 2018; 14. https://doi.org/10.1177/1745506518805641
8 Hickam DH. Chest Pain or Discomfort. In: Walker HK, Hall WD, Hurst JW, (eds). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. https://www.ncbi.nlm.nih.gov/books/NBK416/
9 Løvlien, M., Schei, B., & Hole, T. Women with myocardial infarction are less likely than men to experience chest symptoms. Scandinavian cardiovascular journal 2006; 40(6): 342–347. https://doi.org/10.1080/14017430600913199
10 Pencina, M. J., Navar, A. M., Wojdyla, D., Sanchez, R. J., Khan, I., Elassal, J., Ralph B. D’Agostino Sr,, Eric D. Peterson & Sniderman, A. D. Quantifying importance of major risk factors for coronary heart disease. Circulation 2019; 139(13): 1603-1611. https://doi.org/10.1161/CIRCULATIONAHA.117.031855
11 Granot M., Goldstein-Ferber, S., & Azzam, Z. S. Gender differences in the perception of chest pain. Journal of pain and symptom management 2004; 27(2): 149-155. https://doi.org/10.1016/j.jpainsymman.2003.05.009
12 Foley, N., Powell, A., Francis-Devine, B., Foster, D., Ferguson, D., Danechi, S., Kennedy, S., Powell, T., Roberts, N., Harker, R., McInnes, R. Informal Carers. Commons Library Research Briefing 2021; June: 1-63. https://researchbriefings.files.parliament.uk/documents/CBP-7756/CBP-7756.pdf.
13 Office for National Statistics. Families and the Labour Market, UK: 2019 https://bit.ly/32nz1IO
14 Mc Namara, K., Alzubaidi, H., & Jackson, J. K. Cardiovascular disease as a leading cause of death: how are pharmacists getting involved? Integrated pharmacy research & practice 2019; 8: 1–11. https://doi.org/10.2147/IPRP.S133088
