Systemic Blind Spot: Women's Heart Disease Diagnosis and Treatment Gaps
TL;DR
- Heart disease is the leading cause of death for women, yet cardiologists and primary care physicians lack confidence in treating it, indicating a significant systemic blind spot.
- Pregnancy complications like preeclampsia are not causes of future heart disease but rather unmasked indicators of pre-existing risk, necessitating long-term cardiology follow-up.
- Estrogen decline during perimenopause and menopause significantly increases women's heart disease risk by removing its anti-inflammatory and cardioprotective effects.
- Observational data strongly suggests hormone replacement therapy benefits cardiovascular health, but lack of large randomized trials creates a treatment conundrum for physicians.
- Lifestyle factors, including lack of movement and unmanaged high blood pressure, are preventable causes of 80% of heart disease, emphasizing personal choices.
- A baseline EKG and coronary calcium score are crucial preventive tests for women, providing vital historical data for future cardiac event risk assessment.
- Many women's heart disease symptoms are dismissed as "atypical" or anxiety, leading to delayed diagnoses and treatment compared to men.
Deep Dive
Heart disease is the leading cause of death for women, yet it remains a "missed women's disease" due to a systemic failure to recognize and address its unique symptoms and risk factors. This oversight, rooted in outdated medical training and a focus on reproductive health, leads to delayed diagnoses and preventable deaths, particularly as women navigate hormonal transitions like pregnancy and menopause.
The core of the problem lies in how cardiology has historically been taught and practiced, largely excluding women's specific physiological responses. Dr. Jayne Morgan highlights that symptoms like fatigue, jaw pain, nausea, and shortness of breath, often dismissed as anxiety or "atypical," are frequently indicative of heart issues in women. This dismissal is compounded by a lack of training among both primary care physicians and cardiologists, with surveys indicating significant discomfort among even specialists in treating women's heart disease. Pregnancy complications, such as preeclampsia and gestational diabetes, are critical early warning signs that a woman has an increased risk for future heart disease. However, this information is rarely followed up on, creating a missed opportunity for intervention. The transition into perimenopause and menopause further exacerbates this risk as estrogen, a cardioprotective hormone, declines. This hormonal shift can lead to increased blood pressure and cholesterol, but the lack of robust clinical trial data on hormone replacement therapy for cardiovascular health leaves many women without clear treatment pathways, despite strong observational evidence supporting its benefits.
The implications of this systemic blind spot are profound. Women are left vulnerable, with their risk factors often unaddressed until a cardiac event occurs. The lack of baseline EKGs on record for women means that when they do present with symptoms, there is no prior data for comparison, hindering accurate diagnosis. Furthermore, the focus on genetic predisposition often overshadows the significant impact of lifestyle choices, which account for 80% of preventable heart disease. This includes a lack of movement, which is often framed as daunting "exercise," and the critical management of blood pressure. The current medical system, siloed and slow to adapt, often fails to integrate knowledge across specialties, leaving women to navigate complex health landscapes with incomplete information. Proactive steps, such as advocating for specific tests like calcium scoring and Lp(a), monitoring blood pressure at home, and seeking out knowledgeable practitioners, are crucial for women to take charge of their cardiovascular health. Ultimately, a cultural and systemic shift is needed to prioritize women's heart health, ensuring that training, research, and patient care evolve to reflect the reality of their disease presentation and risk progression.
Action Items
- Audit pregnancy history: For 3-5 women, collect history of hypertension, preeclampsia, or gestational diabetes to identify elevated future heart disease risk.
- Implement EKG baseline: For 5-10 women, request an EKG during annual physicals to establish a baseline for future comparison.
- Track blood pressure trends: For all female patients over 40, establish a protocol for regular home blood pressure monitoring and trend analysis.
- Educate on subtle symptoms: Develop talking points for 3-5 common subtle heart disease symptoms (fatigue, nausea, jaw pain) often dismissed in women.
- Assess LP(a) levels: For 3-5 patients with family history of early heart disease, order lipoprotein(a) testing to identify genetic predisposition.
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View Episode Notes →Key Quotes
"Heart disease isn't a man's disease, it's a missed women's disease. There was a recent survey, cardiologists only 40% felt they may not be competent, felt comfortable enough in treating a woman with heart disease."
Dr. Jayne Morgan argues that heart disease is often overlooked in women, highlighting a concerning statistic where a significant portion of cardiologists feel inadequately prepared to treat female patients. This indicates a systemic issue in how women's cardiovascular health is perceived and managed within the medical field.
"If you are diagnosed with high blood pressure, as 54% of Americans are, we realize that for every 10 millimeters of mercury that top number goes up, that 120, if it goes to 130, increases your risk of heart disease by 20%. If it goes up by 20 to 140, your heart disease risk goes up by 40%."
Dr. Morgan emphasizes the critical link between high blood pressure and heart disease risk, explaining that even small increases in systolic blood pressure significantly elevate the likelihood of developing cardiovascular issues. She underscores the importance of managing blood pressure, as a 20-point rise can double the risk.
"The pregnancy did not cause the heart disease. The pregnancy unmasked it. It's telling you you are at higher risk, so the pregnancy is letting you know, and we don't have that handoff to the cardiologist."
Dr. Morgan explains that pregnancy complications like preeclampsia are not the cause of future heart disease but rather reveal a pre-existing higher risk. She points out a critical gap in healthcare, where this information is not consistently transferred from obstetricians to cardiologists for long-term preventive care.
"Estrogen protects the heart. Estrogen is a hormone that protects us. It decreases our risk of heart disease. Prior to menopause, our risk of heart disease is only half that of a man. On the other side of menopause, it's twice that of a man."
Dr. Morgan details the cardioprotective role of estrogen, explaining that its decline during menopause significantly increases a woman's risk of heart disease. She contrasts the risk levels before and after menopause, illustrating how the loss of estrogen's protective effects makes women more vulnerable.
"The biggest challenge I've seen with thyroid is the ranges too broad and then they're not doing a free t3, t4. Right? So I'm just going to do a shout out, I don't know if you've looked at Mark's, Dr. Mark Hyman's functional health because he'll do an LP little A, they've got TSH, they've got TPO, they've got the whole thyroid panel."
Dr. Morgan highlights a common issue in thyroid testing, suggesting that standard ranges may be too broad and that comprehensive testing, including free T3 and T4, is often overlooked. She references Dr. Mark Hyman's approach to functional health as an example of more thorough testing protocols.
"The normal score is zero. So here's a test where you actually want to miss every question. You want to just fail it and just get a zero. So the normal test, normal score is a zero. Anything really above a zero, even a one, is considered abnormal."
Dr. Morgan explains the interpretation of a coronary calcium score, emphasizing that a score of zero is ideal, indicating no calcium deposits in the arteries. She clarifies that any score above zero signifies an abnormal finding and suggests that this test serves as a 10-year risk indicator for heart events.
Resources
External Resources
Books
- "Well Beyond 40" by JJ Virgin - Mentioned as the title of the podcast episode.
Articles & Papers
- "The Importance of Understanding Your Cardiovascular Risk" (jjvirgin.com) - Mentioned as the location for full show notes.
People
- Dr. Jayne Morgan - Guest cardiologist discussing women's heart health.
- JJ Virgin - Host of the podcast "Well Beyond 40."
Organizations & Institutions
- Netflix - Mentioned as a sponsor offering live NFL games on Christmas Day.
- American Express Business Platinum - Mentioned as a credit card offering rewards points.
- Wayfair - Mentioned as a retailer for home goods.
- NFL (National Football League) - Mentioned in relation to live Christmas Day games on Netflix.
- Medical Association of Georgia - Mentioned for passing a resolution on cardiology training.
- American Medical Association - Mentioned as the body that will review a resolution on cardiology training.
Websites & Online Resources
- subscribetojj.com - Mentioned as the URL for an ad-free podcast subscription.
- megaphone.fm/adchoices - Mentioned as a link for ad choices.
- wayfair.com - Mentioned as the website to shop for home goods.
- amex.co/businessplatinum - Mentioned as a URL to learn more about the American Express Business Platinum card.
- americanexpress.com/businessplatinum - Mentioned as a URL to learn more about the American Express Business Platinum card.
- drjanemorgan.com - Mentioned as an Instagram handle.
- jane morgan md - Mentioned as a LinkedIn profile.
- whatshouldireadnextpodcast.com - Mentioned as the website for the "What Should I Read Next?" podcast.
Podcasts & Audio
- Well Beyond 40 - Podcast where the episode was featured.
- What Should I Read Next? - Podcast hosted by Anne Bogel.
Other Resources
- Coronary calcium score - Mentioned as a test to indicate heart disease risk.
- EKG (Electrocardiogram) - Mentioned as a test to assess heart health.
- Hormone Replacement Therapy (HRT) - Discussed in relation to managing perimenopause and cardiovascular health.
- Lp(a) (Lipoprotein A) - Mentioned as a genetic type of cholesterol to be monitored.
- Home blood pressure monitoring - Recommended as a tool for tracking blood pressure.
- Traditional healings - Mentioned in the context of Native American integrative medicine.