Carolyn Lam, cardiologist: “With a heart attack, a woman has a higher risk of dying than a man”
Cardiovascular disease “is not sexy,” laments cardiologist Carolyn Lam (Singapore, 48 years old). It is not fashionable, it is not talked about. Despite being the first cause of death in the world, both in men and women, the population does not usually monitor or check their blood pressure or blood sugar level, variables that can influence cardiovascular risk, warns the specialist , who attends EL PAÍS during a symposium on Heart Failure organized by the pharmaceutical company Bayer in Barcelona.
Lam, who is director of Women’s Heart Health at the National Heart Center of Singapore, highlights the lack of awareness of these ailments, especially among women: the cardiologist explains that it often happens that they do not even accurately identify and agility the symptoms of a heart attack, on occasions other than men. Aside from chest pain, which they may or may not have, women also suffer from neck pain or jaw tightness.
Ask. We tend to associate cardiovascular diseases more with men.
Answer. Yes, and we must change that. It is also a disease of women. One in three women die from heart disease and stroke, and so does one in three men. It is the leading cause of death in both men and women, but we continue to ignore them and that must change.
Q. Is the scientific community well aware of the differences between sex and gender in this type of disease?
R. We don’t know everything, but we know a lot more (than before). And when you say sex and gender it’s exactly right. Sex is biological sex, hormones. And gender is our social role. And both play a role in differences in heart disease. First, there was a long-standing misconception that women are protected from heart disease because of estrogen, our sex hormones. That was thought because in the younger age groups, men have more heart disease, but as we go further, older women, especially after menopause, also get heart disease and may actually outnumber men. So if we only look at younger women and men, we have the wrong idea. We have learned, but based on assumptions.
And also, also, like in the movie Yentl, the woman, to be taken seriously, had to look like a man. And that’s the problem with symptoms: it’s like we need to experience him as a man and describe him as a man to be taken seriously. Dr. Bernadine Healy used the term Yentl syndrome in 2001 to draw attention to the paradox of adverse outcomes for women with ischemic heart disease, as well as underdiagnosis and undertreatment of women. Yentl’s syndrome It is the different mechanism of action that heart attacks usually follow in women compared to men. This is a problem because much of the medical research has focused primarily on the symptoms of heart attacks in men, and many women have died due to misdiagnosis because their symptoms present differently.
I wish doctors would remember that women can have heart disease and have different symptoms.”
Q. Are the symptoms not the same?
R. Our symptoms can be really different. Men often feel chest pain. Women may also have chest pain, but more often than men, it is not chest pain, but jaw pain or tightness. Many patients think that it is really a toothache or say that they are tired. Or they feel the pain in their stomach or back and rationalize it and instead of saying: “Oh, something is wrong”, they say: “It’s too hot”, “I ate too much”, “I’m stressed”. Instead, men will get chest pain and say, “Oh, it’s the heart,” and go to a doctor.
Q. Is it a problem of education, then? When faced with pain, there will be a bias and they will be told that it is anxiety or some mental health problem.
R. Yes, that’s the problem. Men will come (to the consultation) and say: “My chest hurts. Please check my heart.” The woman will come and say: “I’m sorry to bother you, I think I’m stressed because my son has an exam or blablabla…” and they apologize, they don’t say it’s from the heart.
Q. And what is the responsibility of the doctor regarding this?
R. I think we are all responsible. I would like doctors to remember that women can have heart disease and have different symptoms, but patients also have to feel that they are entitled to have heart disease and help the doctor understand that this is serious. And this starts from a young age: I grew up with my mother, who is a doctor, always chasing my father to control her cholesterol, her blood pressure… But she never checked it herself. We take care of everything and imagine that we are protected, but we are just as vulnerable.
Men will come (to the consultation) and say: “My chest hurts, check my heart.” The woman will come and say: “Sorry to bother you, I think I’m stressed…” and they apologize.
Q. The scientific community has long known of these gender differences. Has anything changed in recent years?
R. Yes, I think it has improved a lot. An attempt has been made to make women aware of our own risk. So that’s fine. But another thing that has impeded progress is that we don’t have enough women in clinical trials.
Q. And why does that happen?
R. They don’t prioritize themselves. Sometimes it is very difficult to get women to participate in trials, so they are always underrepresented. And our first trials were only in men: the mouse studies were in male mice because they didn’t want complications with the pregnancy or whatever, so they didn’t even study female mice. How can we continue like this, systematically excluding women? Now things have improved and we have trials on heart failure in which there are 40% or 50% women.
Q. Are there medical treatments or procedures where you don’t know if it works in women because the trials were done with men?
R. Yes, unfortunately there are quite a few examples where there is a difference. In heart failure there is a very old drug called digoxin that we didn’t realize until much later that there is a sex difference in response: the same dose gives you higher levels of the drug in women than in men. men and this is associated with toxicity and more deaths in women than in men. There are some drugs that we just give women in doses that we know for men.
Q. What is the consequence of this type of inequalities? Because I am a woman, am I more likely to die than my male partner, for example?
R. Yes. Our data still shows that with a heart attack, a woman has a higher risk of dying than a man. And a woman continues to receive fewer invasive therapies. And many of the medications that we have, they are less likely to receive than men. There are many reasons.
There are some medicines that we administer to women in the doses that we know in men, even though they are toxic to them.
Q. For example?
R. For example, a woman who has a heart attack might have disease of the small vessels, not the large ones. And with the small glass you cannot place a stent and sometimes it’s also overlooked (small vessel disease) and under-treated. Another reason is that women who suffer a heart attack may be older than men and that could explain many things, such as having more hypertension, diabetes… However, even adjusting for age, we found that women with a heart attack cardiac have worse results than men.
Q. What needs to be done to close this gap?
R. What we’re doing now, literally: trying to educate the public is extremely important. A woman must recognize her own risk, without excuses. Just as the boyfriend, the father, the brother and everyone else must take care of her and know her risks, we must know ours. Do you know what your blood pressure is? Your cholesterol? All of those are risk factors for heart disease.
Q. Cardiologist Valentín Fuster told EL PAÍS: “We live in a consumer society that deprives us of what is important, which is quality of life.” And he said that cardiovascular risk factors are a mirror of life. What do you think?
R. Yes, I think cardiovascular disease, if you will, is very much a lifestyle disease. And that is good and bad. The bad thing is that it is very sad that it is something that we do to ourselves, we clog our own arteries with grease, smoke and problems, we do not take care of what nature has given us. But the good part is that it’s modifiable: if it’s a lifestyle disease, it means we can try to do something about it. Stress management is very, very important. In fact, the connection between a woman’s heart and brain is even stronger: stress can trigger a heart attack, it’s called broken heart syndrome. And part of this is managing stress, which is why we need to have good mental health.
Sometimes it is very difficult to get women to participate in trials, they do not prioritize themselves”
Q. But does this only happen to women?
R. No, to men and women, but this connection between emotions, stress and heart disease is very strong in women. As I was saying, there is a broken heart syndrome in which a woman hears bad news and can have a heart attack: not because her arteries are full of grease, but because stress causes the arteries to constrict and she suffers heart damage. although the glasses are clean. It occurs predominantly in postmenopausal women, much more than men.
Q. Does sleep influence cardiovascular health?
R. Yes, good sleep is often overlooked, but it is a very important part of good lifestyle management. When we go hours without sleep, our entire body is in a state of adrenergic euphoria. And it greatly affects our metabolism and also our eating patterns. It’s a very bad downward spiral: your stress hormones are high and that makes you want to eat unhealthy things, it makes your blood pressure go up… Our rest, our mental health, are very important.
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