"We need to do a better job in informing women about specific risk factors"

It is not uncommon for signs of heart disease in women to be misinterpreted or not recognised at all.

The phenomenon is well known, and the "gender data gap" is often mentioned as the cause. Heart disease is a particular focus of attention in this context. One example: in the case of a heart attack, a stabbing chest pain radiating to the left arm can be observed in both men and women. The latter also often complain of nausea, dizziness and shortness of breath. According to the European Society of Cardiology (ESC), however, the main symptom is acute chest pain.

What is the "gender data gap"?

How do diseases manifest themselves in women, what specific side effects do drugs cause, how high should the dosage be? Clinical studies provide answers to these and other questions. However, women have always been greatly underrepresented in these studies. The consequences are dramatic: today, cardiovascular diseases are the most common cause of death among women, while their proportion among men has fallen steadily since the 1980s. The proportion of women taking part in such studies is still only 24 per cent.

Cardiologists Dr Elena Tessitore and Dr Susanna Grego are confronted with the gender-specific symptoms of heart disease on a daily basis. In their interview, they point out that the lack of data from clinical studies must be seen as part of a larger problem:

Dr Susanna Grego is medical specialist in the Rare Cardiovascular Diseases Unit at the Istituto Cardiocentro Ticino in Lugano / Dr Elena Tessitore, Cardiologist in charge of the inpatient cardiac rehabilitation programme at the Hôpitaux universitaires de Genève (HUG)

Dr Susanna Grego: First and foremost, we have too few reliable results from clinical studies with female test subjects, so there is undoubtedly a gender data gap. However, researchers are also confronted with very practical problems. For example, rodents are often used in studies, but unlike mammals, they do not go through menopause, so the significance of the results is limited.

Dr Elena Tessitore: That certainly plays a role. But we have to be aware that women are much more difficult to recruit for clinical trials than men, especially in the 25 to 45 age group, where motherhood is the main focus for many women. Additionally, women are more concerned about the risks and complications that may be associated with participating in a clinical study.

Dr Elena Tessitore: If attention is paid to the specific concerns that women bring to the topic, I definitely see an opportunity. Women usually have more questions than men, whether about the possible effects of clinical trial participation on their health, about compatibility with other medications or about breastfeeding. The study nurses, who usually recruit women, have a key role to play. Therefore, they must take the time to address concerns.

"Women usually have more questions than men, whether about the possible effects of clinical trial participation on their health, about interaction with other medications or about breastfeeding."
Dr Elena Tessitore, MD

Dr Susanna Grego: I'm afraid not. Even when women are included in clinical trials, it is unfortunately often the case that researchers apply certain statistical analyses to the entire sample and eliminate the differences between the sexes. Why? It is simply more expensive to develop two drugs, one for men and one for women. Instead of taking into account the particularities of female physiology as a factor, these are often only noted in study results.

Dr Elena Tessitore: In women, myocardial infarction can manifest itself with atypical symptoms. Also, heart failure, and particularly heart failure with preserved ejection fraction [percentage of blood in a ventricle that is ejected per beat, ed.] is more present in women compared to men. This normally occurs at an advanced age. The pathophysiology is also different between genders, as women have smaller and stiffer ventricles, and the left ventricle has a somewhat different shape.

Dr Susanna Grego: Menopause, which in turn poses an additional risk for heart disease, and hormone replacement therapy add an additional layer of complexity to the diagnosis and treatment of heart disease in women.

Dr Elena Tessitore: Yes. Doctors are generally not very aware of the particularities of heart problems in women. Webinars and training courses such as those organised by GEMS help to counteract this, and specific study programs for medical students are also important.

"Menopause and hormone replacement therapy add an additional layer of complexity to the diagnosis and treatment of heart disease in women."
Dr Susanna Grego, MD

Dr Susanna Grego: Women can and should have high expectations of their doctors and should not hesitate to ask questions if they feel misunderstood, for example if palpitations are prematurely associated with anxiety. Both sides need to be willing to communicate. And anxiety should be diagnosed by a psychiatrist and not by a GP.

Dr Elena Tessitore: Women take part in cardiac rehabilitation programs less frequently than men. Some say they don't feel comfortable going to the gym, others don't have the time. In most households, it is still the women who do most of the housework and childcare, so it can be difficult to integrate secondary prevention exercises into everyday life. A lot could be achieved with women-focused exercise programs, offering alternatives to the gym, such as Zumba or yoga and flexible working hours.

Dr Susanna Grego: I can refer to the situation in Italy, which I know from personal experience. There are early screening programmes there, as we know them for breast cancer, and also for cardiovascular diseases. In Italy, you also need a medical certificate if you do sport or go to the gym. People at risk, both women and men, can therefore be identified early, informed about their risks and receive follow-up treatment. Such an approach would also be very beneficial for Switzerland.

Dr Elena Tessitore: Education is key. We need to do a better job in informing women about specific risk factors related to gestational diabetes, eclampsia, age at first menstruation and menopause, while not forgetting the "classic" risk factors, such as blood pressure, smoking, family history, stress, high cholesterol, lack of exercise and diabetes.

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