‘For millennia, medicine has functioned on the assumption that male bodies can represent humanity as a whole.’
In Invisible Women, Caroline Criado Perez argued that women are systematically discriminated against in healthcare, as men are treated as the ‘default’ in biomedical research. But does this influence heart failure? And in what ways? As cardiovascular disease is responsible for half of all deaths of women in Europe, we look into how women are specifically affected.
Of the three types of heart failure, women are disproportionately affected by heart failure with preserved ejection fraction (HFpEF). The pathophysiology of HFpEF is different between men and women. However, as HFpEF remained under-studied for a long time, it is less well understood than other types of heart failure and there are fewer pharmacological treatments available.
A recent study found that a history of infertility in women was associated with an increased risk of HFpEF. While a deeper understanding of the mechanisms behind this association is needed, healthcare professionals should be particularly vigilant about women’s heart health and take their history of reproductive health into account when assessing risk of heart failure.
In spite of the differences in how heart failure affects men and women, women have been traditionally neglected in biomedical research. One study of global clinical trials from 2010 to 2017 found that fewer than 30% of participants in heart failure studies were women.
It is crucial that women have equal representation in clinical trials related to heart failure, and that research addresses the various knowledge gaps in how the syndrome affects women. We may learn, for instance, that different treatments may be more effective for women. We also need research into how factors such as socioeconomic position and race intersect with gender to affect heart failure risk and outcomes for women.
Differences in the presentation of heart failure in women could mean that different diagnostic criteria are needed. For example, ‘normal’ levels of natriuretic peptide are generally higher in women, and experts have proposed that left ventricle size should be indexed to body surface area to account for the fact that women are generally shorter than men.
In the UK, women are twice as likely as men to receive an incorrect diagnosis before being diagnosed with heart failure. Women wait on average 2 months longer than men to receive a diagnosis following their first GP visit. And women diagnosed with heart failure also tend to be older than men. This means they face a higher risk of comorbidities and require more complex treatment – and age-related discrimination may mean that the care women receive for heart failure is of a lower standard.
The problem is (at least) threefold. First, the exclusion of women from research has meant that both the public and physicians don’t always identify heart failure in women correctly, leading to delays in seeking treatment and a risk of misdiagnosis. Second, unconscious bias is likely at play, meaning that women’s symptoms are often taken less seriously than men’s. Third, healthcare professionals may lack training that would make them aware of how heart failure affects women.
We need to understand the differences in risk factors and types of heart failure affecting men and women, so we can better address them. Diabetes, obesity, stress and lower socioeconomic position appear to be stronger risk factors for heart failure in women than in men. Takotsubo cardiomyopathy, which is usually triggered by physical or emotional stress, can lead to heart failure and is much more prevalent among women. Postpartum cardiomyopathy can also lead to heart failure, so it is crucial that healthcare providers are aware of the condition when caring for pregnant women.
Women who have been treated for breast cancer have a higher risk than those who haven’t of developing heart problems, including heart failure. As different breast cancer treatments impact the heart in various ways, it is important that healthcare providers screen women treated for breast cancer for cardiovascular problems.
Evidence also indicates that prevention efforts need to specifically address the social and behavioural risk factors that put women at risk of developing heart failure. In all European countries, a greater proportion of women than men are insufficiently physically active. And although smoking remains more prevalent overall among men, smoking rates are falling more slowly among women – and in some countries are even increasing. As both inactivity and smoking are associated with heart failure, these are important areas for public health policy to address.
It is also worth highlighting that socioeconomic factors, such as a higher burden of childcare and household duties on top of paid labour, can lead to reduced time for exercise and increased stress. This is known as ‘time poverty’ and is understood to increase the risk of adopting unhealthy lifestyle behaviours.
It’s crucial to raise awareness of the symptoms of heart failure and cardiovascular disease in women among both healthcare professionals and the general public. We also urgently need to draw attention to the inequitable treatment that women receive and the unconscious bias they may face from healthcare professionals.
Health policy must ensure that knowledge gaps are addressed in EU-funded research (particularly regarding HFpEF), that women are equally represented in clinical trials, and that prevention of heart failure in women receives adequate investment.
Blog post by Francesca Butler, Project Officer, Heart Failure Policy Network