Cardiovascular diseases cause 1 in 5 women to die, while breast cancer causes 1 in 40 women to die, yet most people today think the biggest killer for women is breast cancer, when clearly that is not the case. There is more awareness about breast cancer and preventive screenings. Heart disease in women is still flying under the radar. In the US, women surpassed men in terms of deaths due to heart disease in 1984. In fact, many of them were already dying due to it, but were not diagnosed because screenings were focused on heart diseases in men, not women.
Why was that? Sometimes we have to look to fiction to get factual answers. In 1983 a Hollywood film called 'Yentl' was released. It was based on Isaac Bashevis Singer's short story, Yentl the Yeshiva Boy, set in Poland in 1904, in which the main character Barbra Streisand had to disguise herself as a man so that she could get an education and study the Talmud, the Hebrew Bible, which was otherwise forbidden to women.
In an editorial in the July 1991 edition of the New England Journal of Medicine, Bernadine Healy noted that being 'like men' has historically been the price women have had to pay for equality. She further stated that being different from men has meant being second class and less than equal most of the time and around the world.
For decades, all volunteers in heart disease studies were men. This led to the development of therapeutic strategies to address heart diseases in men, and women with heart conditions were undiagnosed or misdiagnosed, and untreated or mistreated, resulting in more women dying from their heart conditions than men. Healy coined the term 'Yentl syndrome' for women with heart diseases because they were being treated based on what was known about the disease in men, not women.
Even today, women make up less than a quarter of all heart research studies, while they make up more than half of all heart patients. As a result, women with heart disease are seven times more likely to be misdiagnosed than men. More than 40% of women do not experience chest pain. For these reasons, women wait longer than men to go to the hospital. As if that wasn't bad enough, women's heart attacks are twice as likely to be fatal than men's. If they survive a heart attack but already have diabetes, they have twice the risk of having a second heart attack compared to men.
Merz pointed out a fundamental difference between men and women. “The fatty plaque in men is lumpy—bumpy, as if they have a beer belly in their coronary arteries. Whereas in women, they are much smoother, as if they have kept it well-groomed and neat until it eventually completely blocks the artery. The fatty build-up of plaque in a coronary artery (the main blood supply to the heart muscle) that causes heart attacks usually bursts or 'explodes' in men. But in women, it will often be a much smaller, more subtle event, caused by 'erosion' rather than explosion. Often their symptoms can lead doctors off track leading to a misdiagnosis, and in many cases, women don't even realize they've had a heart attack until it's too late.” The problem with this is that these findings can easily be missed in women.
“So, I’ll tell you about the male-pattern heart attack first. The Hollywood heart attack. Uhhhh. Terrible chest pain. The EKG goes PBBRGH, so the doctor can see this extremely abnormal EKG. There’s a big clot in the middle of the artery. And they go to the cath lab and go bang, bang, bang to remove the clot. That’s a male heart attack. Some women have heart attacks like that, but most women have a different kind of heart attack where it’s a bruised, not completely clogged with clots, the symptoms are subtle, and the EKG findings are different – female-pattern. So, what do you think happens to these girls? They’re often not recognized and sent home. I’m not sure what it was. Maybe it was gas.”
“When we look at people getting fat, where do men get fat? Right here, it's just a focal point – right there (pointing to stomach). Where do women get fat? Everywhere. Cellulite here, cellulite here. So, we said, “Look, women look like they're really good at putting away the trash, putting it away easily. Men just have to throw it in one place.”
Has the story of heart disease been any different for women in India? According to the WHO's 2014 India report, based on death certificates, 349 deaths per 100,000 people were due to heart disease in men, while the number was 265 in women. This answers the question raised by Merz, is heart disease in women underreported because we don't know what to look for? Probably yes.
In India, the “cause of death” section on death certificates is written so late that it is doubtful whether it mentions the exact cause, since it is rare for heart disease to be associated with death in women. Even if we assume that this is not the case, these numbers are staggering. In the US, the death rate due to heart disease in men is 170 per 1,00,000 and in women it is 108.
In addition to constantly improving screening and treatment protocols, there is good news for women and even men. They can do some, in fact, a lot, for themselves. We have known for decades that heart diseases are lifestyle diseases. When we adopt better lifestyles, such as improving our eating, sleeping, physical activity and mental health and stopping smoking, this will reduce the chances of developing heart disease and even reversing it in those who already have heart disease.
In the February 2024 edition Journal of the American College of Cardiology A paper titled 'Gender differences in physical activity and all-cause cardiovascular mortality' concluded that compared to men, women benefit more from a reduction in cardiovascular mortality risk from the same dose of leisure-time physical activity. In other words, the study found that women only need to exercise for two and a half hours per week to achieve the same survival benefits as men who exercise for five hours per week. It is important to note that the benefits are similar for men and women at 15 minutes a day, i.e. 90 minutes a week, but then gender differences begin to emerge.
It's fun to wonder why this happens. Yes, we are different, but why does this happen? Are men really from Mars and women from Venus, or are there really physical and physiological differences?
One possible explanation is that men of all ages have measurably greater exercise capacity than women. One reason for this may be that men on average have proportionately larger hearts and blood vessels (arteries and veins), wider lung airways, greater lung diffusion capacity (the ability to move oxygen from each breath into the bloodstream) and larger muscle fibers. Men have one-third more lean body mass than women, so they need to do basically more work to achieve the same gains as women.
Women, on the other hand, need to put in less effort to increase their muscle strength. It may hurt men's egos even more that women have a higher density of capillaries per unit of skeletal muscle (muscles used for movement, posture, breathing, swallowing, stabilizing joints, etc.) than men. Effectively, an average woman may have less strength at baseline, but when they undergo strength training, they become stronger than men in less time and with less frequency, even if it doesn't look like it, because they don't build as much muscle as men. These gender differences were most pronounced between the ages of 40-59, so instead of saying 'Oh, I'm too old', this is the time when women can not only come at par with men, but also beat them into the dust.
Some people are discouraged by the idea that they need to do a lot to see these benefits, which is not true, but study co-author Martha Gulati says, “The public health message should be that exercise benefits everyone, and even a small amount goes a long way in reducing mortality. For women, we finally have some good news: they benefit slightly more from each minute of exercise than men do!”
Gulati highlights why women need less physical activity to reap the same benefits as men. “Women across all age groups report less physical activity than men, but it may be that they are active and just not calling it “exercise.” It’s really hard to know how much non-leisure activity might confound the results. Women tend to take on more household responsibilities and care for children and elderly parents, which can lead to a lot more physical work.”
Women with heart disease benefit from equal physical activity as men, but physical activity is still a big challenge for women in India. They are discouraged from being active right from birth. Most women who were active as school children stop being physically active after puberty due to physical changes. At every stage when they try to be active again, some obstacle comes up. The magic lies in doing little by little but consistently, not in doing complex things for just a few days.
Eventually, we will all die. The good news is that we can extend our healthy, active years by being alert to the signs of disease, which can look very different in men and women. But a healthy, physically active lifestyle improves the quality and quantity of life for everyone, regardless of gender and age.
Dr. Rajat Chauhan (drrajatchauhan.com) Sports Medicine and Musculoskeletal Medicine Physician, Author and Student of Running and Pain
Eva Bacon (evabacon.com) runner, roller blader, rock climber, urban hiker, translator and IT program manager
Eva and Rajat write a weekly column exclusively for HT Premium readers, analysing the art and science of movement and exercise.
Views expressed are personal.