Research Identifies Gaps—and Opportunities—in Heart Disease Care Among Older Women.

Our research, published in Interventional Cardiology Clinics, revealed that women tend to present with coronary artery disease later in life and have worse outcomes following treatment.

Coronary artery disease (CAD) is the most common form of heart disease, the top cause of heart attack, and the leading cause of death among women. Women over age 75 have different symptoms of CAD than men and worse outcomes following percutaneous coronary intervention (PCI), a procedure to improve blood flow, reduce chest pain, and stop coronary arteries from narrowing more. 

Yet, there is too little data on the unique risks older women face.

That’s why our research, published in Interventional Cardiology Clinics, sought to answer important questions about why women are at the most significant risk from coronary artery disease after menopause and identify opportunities to improve diagnosis, treatment, and outcomes related to PCI.

Previous studies have shown that age increases the risk of CAD, partly because arteries become stiffer and more twisted and curved over time, known as “tortuosity.” And we know that hormones, especially estrogen and progesterone, can protect a woman from heart disease when she is younger. After menopause, levels of these hormones drop, and a woman’s risk of CAD increases.

This new research has identified further factors that can lead to delayed diagnosis and worse outcomes with PCI:
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• Women’s CAD symptoms can differ from men’s

• Women’s risk factors can complicate PCI

• Fewer women get PCI

• Risk assessment tools are lacking

• Older women are underrepresented in research
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Women’s CAD symptoms can be different from men’s.

While chest discomfort is the most common symptom among men and women, CAD in older women can often feel like:
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• Fainting (also known as syncope)

• Fatigue that gets worse

• Heart palpitations

• Nausea, vomiting, or dizziness

• Pain in the neck, jaw, or upper abdomen

• Shortness of breath

These are not symptoms that people typically associate with heart disease or heart attack. That’s why women are underdiagnosed with CAD, which is caused by plaque in the arteries (arteriosclerosis), and are less likely to receive treatment with PCI than men their age. Vague symptoms, underdiagnosis, and less access to evidence-backed treatment leads to worse outcomes for older women.  

Related reading: Research Aims for Definitive Answers on Coronary Imaging Guidance.

Women’s risk factors can complicate PCI.

To perform PCI, also known as angioplasty, an interventional cardiologist uses a thin tube called a catheter with a balloon at the tip to open arteries blocked by plaque. Guided by an X-ray, the cardiologist may use a stent to open the artery. 

Many challenges that make older women more likely to develop CAD can also complicate PCI, the procedure most often used to treat it. Older women’s blood vessels are:
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• More curved, and therefore more difficult to access

• Smaller in diameter than men’s

• Stiffer with age, which is often associated with more plaque and calcification in the arteries

• Less likely to receive PCI

• More likely to have complications

Among patients over age 70 undergoing PCI, women have an increased risk of major adverse cardiovascular events, including heart attack, stroke, heart failure, or death. Plus, extensive studies have shown that women have a higher risk of stroke and heart attack after PCI than men their age, especially in the first year after the procedure.

When it comes to the risk of bleeding complications, older women face two risk factors: their age and their sex. Data show that older women have a two-fold more significant risk of bleeding and vascular complications after PCI than men their age. Women over age 80 have the highest risk of bleeding complications. One study found that 12.8% of women required a blood transfusion after PCI compared to only 7.3% of men.

Risk assessment tools are lacking.

Guidelines for PCI are based on research involving men and younger people, so they often fail to consider older women’s unique needs, such as:
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• Cognitive impairment

• Frailty

• Medications for other conditions

Our team examined tools intended to help understand risk, including the SYNTAX, GRACE, and CRUSADE bleeding risk scores. Each has significant drawbacks that make them less appropriate for older women. SYNTAX  predominantly involved 78% of men, GRACE  is known to overestimate the risk of death by ignoring frailty, and CRUSADE  has limitations in its ability to assess bleeding risk in older patients and is less accurate for women than men. 

Closing research gaps can help reveal better tools to consider older women’s unique cardiovascular risks and needs.

Older women are underrepresented in research.

Older patients can have cognitive impairment challenges, making it difficult for them to consent to research activities. Research often requires rigorous follow-up appointments that can be hard to maintain, especially if mobility or transportation is limited. Due to these challenges, nearly 33% of CAD studies between 1996 and 2000 actively excluded anyone over age 75. 

Sometimes, older women decline to take part. One study found that they were more likely not to participate due to concerns that research activities could interfere with responsibilities such as caregiving for their spouses. 

Innovative research design strategies, including home care visits and telemedicine, can help expand access and improve participation in the long term. There are steps patients and providers can take today.

Related reading: Research Developing Solutions for Misdiagnosis of Heart Disease in Women.

What patients and providers can do.

The most important thing providers can do to help close this gap in care now is to be aware that older women have a higher baseline risk for CAD. Taken together with their higher burden of underlying conditions and traditional risk factors, this makes them more likely to experience complications.

This understanding suggests that more aggressive therapies and a higher degree of monitoring can help limit complications and improve outcomes.

Patients should be watchful for symptoms and remember that these can be different in women than men. Talk with a doctor about your risk for coronary artery disease. Communicate your goals with your doctor—whether extending your life, improving the quality of your life, or staying active—we will work with you to help you achieve your heart health objectives.