Women and cardiovascular diseases

Einthoven’s old string galvanometer, the ancestor of modern ECG

Over the last decade, cardiovascular disease (CVD) has remained the leading cause of death and disabilities worldwide. According to the latest WHO data published in June 2021, “17.9 million people died from CVD in 2019, representing 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke¹”.

Contrary to popular belief, CVD affects women as much as men. One woman out of 3 dies of CVD, half of which are heart attacks. Try it yourself and ask around: a large proportion of women are unaware that CVD is their #1 health problem. What makes it worse, this lack of awareness often predominates in communities most affected by the problem². In addition, there is a data gender gap which negatively affects women. Only a minority of women are enrolled in cardiovascular clinical studies³. Finally, women react more strongly to alcohol, tobacco or (sugar induced) type 2 diabetes than men; unfortunately, women are also increasingly exposed to these risk factors.

Epsidy's mission consists in empowering clinical science to fight this silent epidemic. In the long run, better predictions of risk factors will contribute to preventing sudden cardiac death and heart failure.

Electrocardiogram (ECG)

Electrocardiogram (ECG) was invented at the beginning of the 20^th century, by men and for men - this point will be covered later. At the time of its invention, ECG was a revolution: no need to open the chest and insert needles into the myocardium to measure the electrical activity of the heart. However, this was not the reason why the Nobel prize in Physiology or Medicine 1924 was awarded to Prof Willem Einthoven⁴. Prof Einthoven discovered the true significance of the electrical signal the medical community is familiar with, and demonstrated the significance of the ubiquitous P, Q, R, S and T waves.

Since then, clinical scientists have discovered most of what we know about the heart, from its disease mechanism to drugs and device therapies that work. In the 21^st century, it is possible to non-invasively map the flow of electricity inside the heart in 3 dimensions, a discipline known as ECG Imaging (ECGI). This in turn can be used to draw a roadmap to intervene inside the heart.

The bikini syndrome

For many years, the medical community has viewed women’s health with a bikini approach, focusing essentially on the breast and reproductive system⁵. Conventional risk factors impact women differently (and generally more adversely) than their male peers. Myocardial ischemia, commonly known as a 'heart attack' is more complex in women. In addition to physiological factors, social factors play a role as well. For instance, it is common in cardiology centers to ask women to bare their breasts, which is a barrier to diagnosis and/or therapy in some cases. Pain is often underestimated and managed more poorly in women compared to men.

To add insult to injury, ECG is not adapted to the female anatomy. Try googling "ECG Lead Placement" and you will be presented with a large majority of white Caucasian males: this is the population on which this essential technology was developed and tested. It starts in the labs or in the R&D departments: a large majority of staff are men, and abusively generalizes patient populations as male, and often, white. Diversity and women in 'STEM' (science, technology, engineering and math) is likely to change the status quo, but when?

The domino effect

The consequence of neglecting women in the clinical science of CVD is a sort of ”domino effect”. In most patients, CVD can be diagnosed with a simple ECG test, or some other inexpensive exams. However, when things get complicated – and things do get complicated more often in women, since most clinical science comes from research carried out on men – exams also get complicated. Patients can undergo several procedures before obtaining a definitive diagnosis. Cardiac MRI is the diagnostic imaging exam of last resort in cardiac diseases. It is also the reference when it comes to patient prognosis^6,7. Cardiac MRI technology, despite being a whopping 80 years younger than ECG, suffers from the same bias of being engineered by men for men. The same obstacles of ECG placement, modesty, and variations in women’s anatomy impair its wide-range efficiency in women populations.

This is a shame, because cardiac MRI would be a perfect tool for some female specific life-threatening conditions such as spontaneous coronary artery dissection and Takotsubo cardiomyopathy. There are also some uncommon heart attacks, known as MINOCA, found more often in women and which are perfect candidates for investigation with Cardiac MRI.

The trend is fortunately being reversed, and the scientific community has recently raised the awareness of CVD in women⁸. Yet, it is to be expected that many women with advanced CVD will require cardiac MRI, as the last step of the dominos, and for these patients the medical community should certainly do something to provide women with an easier, more reliable and more comfortable exam.

Sources and references

1. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds).

2. Circ Cardiovasc Qual Outcomes 2010 Mar;3(2):120-7. doi: 10.1161/CIRCOUTCOMES.109.915538. Epub 2010 Feb 10.

3. Circulation 2020 Feb 18;141(7):540-548. doi: 10.1161/CIRCULATIONAHA.119.043594. Epub 2020 Feb 17.

4. https://www.nobelprize.org/prizes/medicine/1924/ceremony-speech

5. Clin Cardiol 2018 Feb;41(2):171-172. doi: 10.1002/clc.22879. Epub 2018 Feb 15.

6. Cardiac Failure Review 2017;3(2):86–96. DOI: 10.15420/cfr.2017:19:1

7. JACC Cardiovasc Imaging 2021 Dec;14(12):2479-2481. doi: 10.1016/j.jcmg.2021.07.003. Epub 2021 Aug 18.

8. Lancet 2021 Jun 19;397(10292):2385-2438. doi: 10.1016/S0140-6736(21)00684-X. Epub 2021 May 16.