We were delighted team up with the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), the American Society for Preventive Cardiology and the Global Heart Hub for the first NIPC Cardiology Series of 2021. We were joined by a panel of international leading female experts to discuss Women Heart Matters. We were overwhelemed by the volume of questions received during the Q&A session aat the end of the serie. Unfortuantely, we were unable to answer them each question during the live event. However, our fantastic line-up of speakers kindly agreed to answer all the questions asked via the post below.

Women & Heart Disease: Sex Differences in Heart Disease

Prof Martha Gullati
American Society for Preventive Cardiology

Q: Maybe the main problem of conducting studies with women, lies on the menstrual cycle, once for some acute studies, we need to run all the session in the same part of the menstrual cycle. I research with elderly and the major part of my study groups are women. What do You think about this issue?

A: I think it really depends what you are looking at. Certainly arrthymias, chest pain (related to SCAD) can be related to variations in hormonal levels for some but not all. It is interesting for sure, but it’s a difficult science because hormone levels fluctuate but there is no single value of normal for one person entirely.

Q: Why do doctors still misdiagnose cardiovascular disease in women? Are men showing symptoms early?

A: Women often, as I mentioned, report symptoms that are the same as men but often with additional symptoms. It is unclear if doctors and other healthcare professionals get lost in the “other” symptoms and miss the chest pain, or just underestimate risk in women. It is also an educational problem, sicne it is not always in medical school ciricculums to teach differences and also similarities. Additionally the pictures depicted of a heart attack often show men (see Netter diagrams and television etc)

Q: Does this overlooking of heart disease in women in general by healthcare providers include male healthcare providers or female healthcare providers, or there is no research on this issue?

A: There is some imperfect research in this area. In the past, older literature saw little difference based on sex of the doctor but more recently, women physicians have noted better care for women with heart attacks and heart failure (adhering to guidelines) more than men. But when male ER physicians work with more women, then they also take better care of women with myocardial infarctions.

Q: What is the aetiology and recommended treatment for left ventricular bundle branch block and is it more common in women?

A: LBBB is most often either due to atherosclerosis (CAD), aging, cardiomyopathies, aortic valve disease, induced due to a procedure or endocarditis or less often, idiopathic. It is not more common in women. But women with a LBBB and a dilated cardiomyopathy have been shown to do better with CRT therapy when they have a LBBB

Q: What cardiac monitoring for breast cancer patients post antracycline chemotherapy?

A: Intial cardiac assessment prechemotherapy, assessment of ASCVD risk and continued annual follow-up post chemo is needed because the risk can be both short term and long term.

Q: What is your opinion on a statin after SCAD and blood thinners?

A: No evidence of benefit for SCAD with statin unless they truly need it for hyperlipidemia (not because they had a MI with SCAD)

Q: Could you shed some light on why there is such little uptake of the clinical guidelins and why is there such low competency when screening women for CVD?

A: I wish we knew entirely! there is a lot of bias related to how we treat women- essentially women are second class citizens in the medical world. We need to do better in educating women AND the healthcare team about women being at risk I emphasize educating all physicians because there remains a lot of clinical interia and lack of knowledge of women’s risk. We respond to women’s complaints and problems differently than men. So we need to educate and be part of medical school cirriculums etc. I went to University of Toronto too, I hope we can connect and work together.

Q: Why do u think symptoms differ between men and women? What's the biology of that?

A: I am not sure they do differ. It is what we hear. they do have other symptoms with it so chest pain may not be the predominant symptom. but we need to ask. But certainly pain perception and biology is part of it.

Q: Are worse outcomes in women related to their older age compared with men?

A: Even after adjusting for age and comorbidities, women do worse, so it isn’t just age alone.

Q: Have you any numbers in the world related to women and CVD?

A: Heart disease is now the #1 killer worldwide. Every country has its statistics but some coutries, like Egypt for example, 53% of deaths are due to CVD (I just spoke there earlier today so I have that on hand!)

Q: There are various robust studies that highlight the high risk of pregnancy complications and future maternal CVD, therefore why is there this considerable gap in prevention? More recently such as the Agarwala et al. paper in Circulation 2020 - loads of papers are coming out, so why this gap?

A: The data is still relatively new. Although I will addmit that Graeham Smith from Queen’s University in Canada led this space. I think we are just realizing how high risk this population is and how it is in the near future, within 10 years of delivery. WE need to do better and we need clinics to address this.

Q: How do you ensure that women are correctly diagnosed with a heart issue instead of a mental health issue given the fact that heart problems are confused (most of the time) with mental health problems?

A: Good question and major issue. We must never attribute symptoms to anxiety or stress upfront. It can be a diagnosis of exclusion but not the first diagnosis. Too often women are labelled as anxious and they actually have a SVT. And we all have stress, so stress isn’t the cause we should jump to. It is why we need to change the educational system to make people understand the risk of women is high.

Q: Are there currently any known differences in cardioprotective strategies/treatments for women in comparisons to men?

A: Aside from risk stratification using sex-specific risk enhancers to guide our therapies, there isn’t specific therapies unique to women or doses unique by sex. probably to some degree that we didn’t study women well but to answer you, no.

Q: How can a clinic incorporate capturing APO's in screening women? Are there any tools available?

A: Aside from using EHR to create this for you, I am not aware of any, no.

Q: Is regular aspirin beneficial to prevent CVD?

A: Not for primary prevention. We don’t advocate ASA use for men or women, because the risk of bleed >>> benefit in primary prevention. I do use it in secondary prevention or documented CAC > 100

Q: What are the most important lifestyle changes to focus on to improve heart health?

A: Exercise, diet, tobacco cessation, and minding mental health.

Women and Cardiac Rehabilitation: Addressing Barriers

Prof Sherry Grace   
Immediate Past-Chair,
International Council of Cardiovascular Prevention and Rehabilitation

Q: How has your CR program been modified during Covid-19?

A: We have collated available policies and research on delivering CR during COVID-19 here. We also did a survey of CR programs globally to ask about delivering CR during COVID-19 (View here under revision in Global Heart); their suggestions were that for cardiac safety, with COVID screening, PPE and physical distance, some in-person contact at the beginning of CR was advocated. Programs are then using different functional capacity testing to inform exercise prescription and different means to monitor exercise. Respondents suggested loaning patients remote monitoring equipment where possible or exploiting smartphone apps. Then most CR components can be delivered through remote means, through videoconferencing where supports exist. Our program’s free online, evidence-based patient education program covering all modules is available here in many languages.

Q: What form of monitoring do you utilize for home or virtual exercise in CR programmes?

A: We educate patients about cardiac signs and symptoms at the beginning of the program, and how to respond to symptoms. We give patients a walking prescription with distance and time; they are to record in a diary and share with the program weekly. We talk to patients about target heart rate, and ensure they know how to assess theirs. We teach patients about the Borg scale of perceived exertion, and give them a recommended range. We also talk about the “talk test”. (pun intended!)

Q: How can we improve women's understanding of primary prevention risk factors and engagement in risk reducing behavior? For context, a lot of health promotion is on breast, cervical or ovarian cancer. Nothing on heart disease.

A: We are delighted with campaigns such as the America Heart Association’s Go Red for Women campaign, that is now in place in over 50 countries ( You can see what is happening in your country here). Studies of women’s awareness of their cardiac risk and leading causes of death show this is thankfully improving (e.g. Fifteen-Year Trends in Awareness of Heart Disease in Women), but yes we have a long way to go!

Q: What is the aetiology and recommended treatment for left ventricular bundle branch block and is it more common in women?

A: LBBB is most often either due to atherosclerosis (CAD), aging, cardiomyopathies, aortic valve disease, induced due to a procedure or endocarditis or less often, idiopathic. It is not more common in women. But women with a LBBB and a dilated cardiomyopathy have been shown to do better with CRT therapy when they have a LBBB

Q: Are there any heart disease in women vs men datasets (open source/research purposes) out there that we can leverage to apply AI and automate the process of early detection of a heart problem in women? Goal: Reduce bias and come up with a diagnosis early on.

A: Great question. This is not my area of expertise. There is a nice discussion of the issues around use of AI in CVD prediction here. And as you suspect, the majority of AI applications to date have ignored sex and gender, which we can only hope will be rectified (See here)

Q: Without resultant heart failure, is there any special approach needed for effective CR following diagnosis of SCAD? Or indeed with secondary heart failure?

A: Yes, a special approach to CR is needed for SCAD patients. Here is a link to the protocol for the SCAD CR program we discussed during the webinar Q&A. As we also discussed during the webinar, CR is shown in many randomized trials to reduce mortality in heart failure patients, so is highly recommended for that group.

Q: Do we need specialist psychology input embedded in services? What do we do if we can’t get that?

A: Psychosocial health is a core component of CR, and is very important for women, as they suffer two times the rates of depression than men. It is preferable a registered mental healthcare provider such as a psychologist is on a CR team to deliver this, so the evidence-based psychosocial care is delivered. View our global audit of CR programs here, however it showed that many CR teams don’t have this expertise due to resource constraints. Many programs do have nurses, but they may not have specialty training in mental health. In these cases, having a relationship with an external group of registered psychologists, social workers or psychiatrists is ideal. It is not recommended to screen for psychological disorders if there are no mental healthcare providers available. In this case, distress can be addressed using free meditation apps now available (e.g., Smiling Mind), and we know exercise itself can improve mild depression. The support from peers and providers in CR also helps. If no resources are available and you suspect a patient is suffering from depression or another psychiatric condition, engaging and collaborating with primary care would be helpful.

Q: That is an issue I find with the teams they may risk assess more on the thought of possible risks than the actual. What risk assessments do people use for this?

A: Risk assessment at the beginning of CR is needed to inform exercise initiation timing, prescription and program model (i.e., safety for unsupervised exercise in a home-based program). Here we are referring to risk assessment for an acute event during exercise (not long-term risk of another event, which will be lessened by CR participation itself). Here is the risk stratification by AACVPR and Framingham. We provide detailed, practical guidance on pre-PA assessment on page 305 of our consensus statement here.

Q: Can you provide a reference to the CR for SCAD's patients from Canada?

A: Here is a link to the protocol for the SCAD CR program we discussed during the webinar Q&A.

Q: Can you share the reference for the survey?

A: Here is the information about COVID-19 and CR. The study I mentioned is here.

Q: Can the slide on the CR program offered in 5 languages be shared?

A: Here is the link to the online course for inpatient cardiac care providers on how to encourage patients with regard to cardiac rehab. The 5 languages are there too. We have evaluated it and it is evidence-based. I hope you can share it widely.

Q: Have you been able to continue with cardiac rehab during Covid-19?

A: Yes, we have adapted our program. We do try to get them in for a first visit, and then offer the rest virtually. Here is our patient education available freely, with a focus on women.

My Story: The Lived Experience

Pauline O’Shea
Patient Advocate and Founder,
SCAD Ireland

Q: Can SCAD occur in all ages and is it more common in women than men?

A: SCAD is more common amongst women, than men, roughly 80% women to 20% men. More stats info is available here

Q: Pauline, your session was very informative. You mentioned other patients did not need surgery. How were they managed?

A: Thank you. Medical management of SCAD is possible in most cases, medication plus rest. Medications include beta blockers and ramapril, as I best understand it, although I am not a Cardiologist! A few need stent treatment. Rarely is open heart surgery required, sometimes depends on extent of tear, or location. Most SCAD patients, if given the appropriate medical intervention in a timely fashion, go on to make good recovery. Those with delayed diagnosis or misdiagnosis, at much greater risk of life time issues, like permanently reduced EF. For more info, would recomend visiting scadresearch.org

Q: How does Pauline think that cardiac rehabilitation could have met her needs better?

A: I believe cardiac rehabilitiation needs to be more conscious of the psychological forces at play for the patient. The average age of this condition is 42 so for anyone of that age you can guarantee they already feel like a fish out of water, relative to their peers and walking into crdiac rehab with seventy or eighty year olds compounds that sense of “difference” and indeed isoaltion, so age conscious cardiac rehab groups would be one thing to consider I think. Also younger cardiac patients with unexpected sudden cardiac events, may be suffering some kind of PTSD, so will be very senstitive to language and body language of staff in elevating fear factor, so if the staff look terrified, that patient’s terror will elevate, or if the staff say words like “weak” or “too much”, in relation to any exercise, the patient will likely read it as their being in danger and about to die! so positive language and approach vital. Finally, the patient needs hope, the promise of a better life lived less on a knife edge, not more problems that could happen, so probably best not to go through all the side effects of medication or the “lethal” as I was told foods to eat, or listing all the things they will “never do again”, so any cautions need to be delivered with a hope and possibility too. So that they have things to look forward and aspire to, I hope that helps. I could write on this for hours, but already a lot. 

You can watch the entire NIPC Cardiology Series on Women Heart Matters. To access the video, you will need to Log-In or Register for the NIPC Alliance.