The Heart of a Woman

For Washington Health Medical Group (WHMG) cardiologist Sangeetha Balakrishnan, MD, fitness and heart health go hand in hand, and the broad foundation she builds for her patients begins with education.

Dr. Balakrishnan first works with her patients to focus on risk factors for heart disease. Some can’t be changed, including age, gender, family history and race. Others can be modified or improved, including high blood pressure, high cholesterol, obesity, physical activity, smoking, diabetes, an unhealthy diet, chronic stress, sleep apnea and alcohol abuse. Educating her patients is the first step.

“First we work together with our patients to try to prevent or delay heart disease through education and recommendations for healthy living,” she said. “Then, if heart disease does develop, we work together to find the best plans for treatment.”

While that’s true for all her patients, it’s even more important for her women patients. Research shows women are less likely to seek treatment for cardiac issues compared to men.

“In my experience, women tend to focus more on other people rather than themselves,” Dr. Balakrishnan explained. They may not feel quite right or even have some symptoms that could indicate heart issues, but they put off seeing a doctor because they don’t have time or just have too many other things going on. But the truth is, if you delay evaluation or care, you end up having worse outcomes.”

For many years, women were underrepresented (or completely unrepresented) in cardiac research. The symptoms men presented with during heart attacks or other cardiac events were held up as the gold standard to initiate treatment in the emergency department. It’s only been in the last 35 years that heart disease in women has been studied independently of men. In fact, some health care providers still rely on diagnostic models based on primarily male data, failing to account for the physiological differences in how women experience heart disease. That has led to a great difference in how cardiac health in women is treated, Dr. Balakrishnan said.

“Women are more likely to have an atypical presentation including symptoms such as shortness of breath, nausea, and fatigue,” she noted. “Coupled with guidelines created for men along with societal stereotypes that associate symptoms like fatigue or shortness of breath with anxiety or stress rather than heart disease, this can lead to a missed diagnosis in women, or a misdiagnosis, with women's heart disease often categorized as gastrointestinal problems or anxiety. Because women's symptoms are often more subtle and varied, and they are more likely to downplay them, diagnoses are frequently delayed or missed.”

Follow the Signs

Heart disease is the leading cause of death for both men and women. Both can have a heart attack, but they may experience very different symptoms. The most classically recognized symptoms – nausea and shortness of breath, and chest pain radiating to the left arm, shoulder or jaw, – are generally more common in men. Women more often complain of feeling like they have indigestion or heartburn with pain in the upper back or neck, accompanied by fatigue and lightheadedness. Women are more likely to have what is known as a “silent heart attack,” or myocardial infarction (MI) without the typical heart attack symptoms. This can deter them from seeking treatment.

“I’ve had women come in, or be referred by their primary care provider, because they think they have indigestion and taking antacids isn’t helping, or they feel exhausted,” she said. “I always tell my patients if you start noticing that you’re more winded, or need to take more breaks during activity, it’s time to get checked out. Women tend to ignore these subtle changes, but they can be warning signs that something isn’t quite right with your heart.”

Dr. Balakrishnan shared that women have risk factors different from men. Women are at higher risk of heart attacks after menopause. Autoimmune disorders and pregnancy complications including gestational hypertension, preeclampsia and gestational diabetes can also increase their chances of developing heart disease. Other risk factors, such as high blood pressure, diabetes and obesity, are common in women and may also increase as they age. Women have smaller arteries and may have blockages in the smaller vessels of the heart. They are also more likely to have a type of heart disease called nonobstructive coronary artery disease, where blood flow is restricted to the heart without a clear blockage.

“I tell my patients to get regular checkups and teach them to pay attention to their numbers,” Dr. Balakrishnan explained. “Know your usual blood pressure range. Know what your cholesterol is. If you’re diabetic or pre-diabetic, know your blood sugar numbers, your A1C. I tell them what symptoms they should be watching out for.”

“We talk about what a healthy diet looks like for them, that being active doesn’t mean just doing 30-45 minutes in the gym, and that being healthy is a lifetime goal,” she continued. “The most important thing is to pay attention to your body. Recognize when something doesn’t feel right – and for women, that could be a small change – and see your primary care provider. Women need to take the time to take care of themselves so they can be around to take care of the people who rely on them.”

For more information about cardiology services at Washington Health, visit https://www.washingtonhealth.com/heart.